A list of the most recent deficiencies for Mission Healthcare at Bellevue. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-02 | 2023-12-12 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-11-02 | 2023-12-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish methods for sharing information. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-07-17 | 2023-08-21 | N |
| Respond appropriately to all alleged violations. | Health | 2023-07-21 | 2023-08-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-08-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-14 | 2023-08-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-07-14 | 2023-08-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-07-14 | 2023-08-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-14 | 2023-08-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-07-14 | 2023-08-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-14 | 2023-08-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-14 | 2023-08-14 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-14 | 2023-08-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-14 | 2023-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-14 | 2023-08-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-13 | 2021-10-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-15 | 2021-10-15 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-15 | 2021-10-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-23 | 2021-08-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-23 | 2021-08-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-23 | 2021-08-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-23 | 2021-08-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-23 | 2021-08-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-23 | 2021-08-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-23 | 2021-08-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-06-23 | 2021-08-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-23 | 2021-08-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-06-23 | 2021-08-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-06-23 | 2021-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-23 | 2021-08-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-23 | 2021-08-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-23 | 2021-08-04 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-06-23 | 2021-08-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-16 | 2021-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-16 | 2021-07-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-26 | 2021-04-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-26 | 2021-04-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-02-07 | 2019-03-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-07 | 2019-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-07 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-07 | 2019-03-15 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-07 | 2019-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-13 | 2019-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-13 | 2019-03-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-13 | 2019-03-07 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-02-07 | 2019-03-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-02-07 | 2019-02-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-02-07 | 2019-02-08 | N |
