SHUKSAN HEALTHCARE CENTER

Nursing Home Inspector

1530 JAMES STREET
BELLINGHAM, WA 98225
Whatcom County
Phone: 360-733-9161
Provider Number: 505098
Last Inspection: 02/21/2017

About the Nursing Home

Number of Beds: 52
Number of Residents: 44
Beds Available: 8
Percent Occupancy: 85%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

92

Facility
58

County
36

WA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

92

2017
77

2016
15

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

2/21/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Potential 4 4/20/2017
 
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 4/20/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 4/20/2017
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 4/20/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 4/20/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 4/20/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 4/20/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Immediate 5 4/20/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3  
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 4/20/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/20/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3  
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 4/20/2017
 
Failed To: Develop policies and procedures for influenza and pneumococcal immunizations. Pattern : Minimal 4 4/20/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Potential 3  
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4  
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Actual 4 4/20/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4  
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Actual 4 4/20/2017
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Pattern : Actual 5  
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Pattern : Minimal 4 4/20/2017
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 4/20/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/20/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Actual 5 4/20/2017
 

4/4/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 7/12/2016
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 7/12/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 7/12/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 7/12/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 7/12/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 7/12/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/12/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 7/12/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 7/12/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 7/12/2016
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 7/12/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 7/12/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 7/12/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 7/12/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 7/12/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 7/12/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Potential 3 7/12/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 7/12/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 7/12/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 7/12/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 7/12/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 7/12/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 7/12/2016
 

2/12/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/25/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/25/2015
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 3/25/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/25/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 3/25/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

6/3/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Minimal 4 7/12/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Pattern : Minimal 4 7/12/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 7/12/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg WA State Avg
Number of Residents 44 74.00 74.34
Registered Nurses 1.45 1.25 1.07
Licensed Practical / Vocational Nurses 0.48 0.46 0.66
Certified Nursing Assistants 2.55 2.48 2.50
Total Staff Hours 4.47 4.18 4.23

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% WA State Avg%
of high risk long-stay residents with pressure ulcers 0 2 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 96 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96 97 95
of long-stay residents experiencing one or more falls with major injury 6 3 2
of long-stay residents who have depressive symptoms 0 10 9
of long-stay residents who lose too much weight 1 7 6
of long-stay residents who received an antianxiety or hypnotic medication 17 16 15
of long-stay residents who received an antipsychotic medication 4 16 15
of long-stay residents who self-report moderate to severe pain 4 10 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 21 21 17
of long-stay residents whose need for help with daily activities has increased 11 15 13
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 50 43 52
of short-stay residents assessed and appropriately given the pneumococcal vaccine 92 89 85
of short-stay residents who had an outpatient emergency department visit 9 8 11
of short-stay residents who made improvements in function 70 78 70
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 18 22 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 87 87 84
of short-stay residents who were rehospitalized after a nursing home admission 13 15 16
of short-stay residents who were successfully discharged to the community 68 60 60
of short-stay residents with pressure ulcers that are new or worsened 0 0 0