A list of the most recent deficiencies for St Francis of Bellingham. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-08 | 2024-02-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-01-08 | 2024-02-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-11 | 2024-02-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-11 | 2024-02-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-11 | 2024-02-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-01-11 | 2024-02-01 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-01-11 | 2024-02-01 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-01-11 | 2024-02-01 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-01-11 | 2024-02-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-06-27 | 2023-07-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-27 | 2023-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-27 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-27 | 2023-07-28 | 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 | 2023-06-27 | 2023-07-28 | 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 | 2023-06-27 | 2023-07-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-27 | 2023-07-28 | Y |
| 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. | Health | 2023-06-27 | 2023-07-28 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Develop a communication plan. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-06-22 | 2023-07-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-31 | 2023-07-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-06 | 2023-04-28 | Y |
| 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. | Health | 2023-04-06 | 2023-04-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-06 | 2023-04-28 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-06 | 2023-04-28 | Y |
| 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. | Health | 2023-04-06 | 2023-04-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-08 | 2023-04-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-08 | 2023-04-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-08 | 2023-04-28 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-03-08 | 2023-04-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-08 | 2023-04-28 | 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 | 2023-03-08 | 2023-04-28 | Y |
| 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. | Health | 2023-01-03 | 2023-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-03 | 2023-02-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-13 | 2023-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-13 | 2023-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-13 | 2023-02-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-02-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-01-13 | 2023-02-03 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-13 | 2023-02-03 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-01-13 | 2023-02-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-13 | 2023-02-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-13 | 2023-02-03 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-01-11 | 2023-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-11 | 2023-01-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2023-01-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-29 | 2022-09-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-29 | 2022-09-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-29 | 2022-09-08 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-05-25 | 2022-06-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-01-26 | 2022-04-26 | Y |
| 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. | Health | 2022-01-26 | 2022-04-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-26 | 2022-04-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-26 | 2022-04-18 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-01-26 | 2022-04-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-26 | 2022-04-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-26 | 2022-04-18 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-01-26 | 2022-04-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-26 | 2022-04-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-04-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-02-02 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-02-02 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-11-10 | 2022-01-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2022-01-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-10 | 2022-01-25 | Y |
| Report COVID19 data to residents and families. | Health | 2021-11-10 | 2022-01-25 | Y |
| 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. | Health | 2021-11-10 | 2022-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-10-12 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-05 | 2021-10-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-05 | 2021-10-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-10-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-19 | 2021-08-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-19 | 2021-08-26 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-07-19 | 2021-08-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-05-20 | 2021-06-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-23 | 2021-05-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-04 | 2021-04-02 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-03-04 | 2021-04-02 | Y |
