Care Citations

BELMONT TERRACE

560 LEBO BOULEVARD, BREMERTON, WA, 98310 · 3604791515

On the CMS record

Overall rating (CMS)
3 / 5
Health inspection rating
2 / 5
Staffing rating
4 / 5
Certified beds
102
Ownership type
For profit - Corporation
Chain
THE ENSIGN GROUP

Inspection findings on record (78)

Quoted exactly as CMS published them. We do not rewrite findings.

— Resident Rights Deficiencies

Tag 0582 · scope/severity E · potential for more than minimal harm

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0628 · scope/severity E · potential for more than minimal harm

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0688 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity E · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0730 · scope/severity E · potential for more than minimal harm

Observe each nurse aide's job performance and give regular training.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity E · potential for more than minimal harm

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity D · potential for more than minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0803 · scope/severity D · potential for more than minimal harm

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0660 · scope/severity D · potential for more than minimal harm

Plan the resident's discharge to meet the resident's goals and needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0697 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate pain management for a resident who requires such services.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0881 · scope/severity D · potential for more than minimal harm

Implement a program that monitors antibiotic use.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity D · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0887 · scope/severity D · potential for more than minimal harm

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0578 · scope/severity E · potential for more than minimal harm

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0585 · scope/severity E · potential for more than minimal harm

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity E · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity E · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity E · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0688 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity E · potential for more than minimal harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0725 · scope/severity E · potential for more than minimal harm

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0804 · scope/severity E · potential for more than minimal harm

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0808 · scope/severity E · potential for more than minimal harm

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0809 · scope/severity E · potential for more than minimal harm

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Recorded as corrected on .

— Administration Deficiencies

Tag 0849 · scope/severity E · potential for more than minimal harm

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity E · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0908 · scope/severity E · potential for more than minimal harm

Keep all essential equipment working safely.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0561 · scope/severity D · potential for more than minimal harm

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0645 · scope/severity D · potential for more than minimal harm

PASARR screening for Mental disorders or Intellectual Disabilities

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0676 · scope/severity D · potential for more than minimal harm

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity D · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0694 · scope/severity D · potential for more than minimal harm

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0887 · scope/severity D · potential for more than minimal harm

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0553 · scope/severity D · potential for more than minimal harm

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0660 · scope/severity D · potential for more than minimal harm

Plan the resident's discharge to meet the resident's goals and needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0687 · scope/severity D · potential for more than minimal harm

Provide appropriate foot care.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity F · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity D · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0887 · scope/severity D · potential for more than minimal harm

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0565 · scope/severity E · potential for more than minimal harm

Honor the resident's right to organize and participate in resident/family groups in the facility.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0657 · scope/severity E · potential for more than minimal harm

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity E · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity E · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity E · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity E · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0550 · scope/severity D · potential for more than minimal harm

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0638 · scope/severity D · potential for more than minimal harm

Assure that each resident’s assessment is updated at least once every 3 months.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0641 · scope/severity D · potential for more than minimal harm

Ensure each resident receives an accurate assessment.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity D · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0676 · scope/severity D · potential for more than minimal harm

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0688 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0692 · scope/severity D · potential for more than minimal harm

Provide enough food/fluids to maintain a resident's health.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0744 · scope/severity D · potential for more than minimal harm

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity D · potential for more than minimal harm

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 505290