Deficiency Records for St Francis of Bellingham
Updated as of January 01, 2020
This is not the most recent data for St Francis of Bellingham. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-14 | 2019-09-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-14 | 2019-09-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-14 | 2019-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-14 | 2019-09-24 | 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 | 2019-08-14 | 2019-09-24 | Y |
| 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 ne | Health | 2019-08-14 | 2019-09-24 | 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 | 2019-08-14 | 2019-09-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-08-14 | 2019-09-24 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-07-08 | 2019-09-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-30 | 2019-05-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-30 | 2019-05-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-13 | 2019-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-13 | 2019-04-16 | 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 | 2019-03-13 | 2019-04-16 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-01-25 | 2019-02-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-25 | 2019-02-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-04 | 2019-02-13 | N |
| 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 | 2018-12-04 | 2019-02-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-12-04 | 2019-02-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-04 | 2019-02-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-12-04 | 2019-02-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-12-04 | 2019-02-13 | 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 | 2018-12-04 | 2019-02-13 | N |
| Provide activities to meet all resident's needs. | Health | 2018-12-04 | 2019-02-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-12-04 | 2019-02-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-12-04 | 2019-02-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install | Health | 2018-12-04 | 2019-02-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-12-04 | 2019-02-13 | 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 ne | Health | 2018-12-04 | 2019-02-13 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-12-04 | 2019-02-13 | N |
| 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 | 2018-12-04 | 2019-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-04 | 2019-02-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-12-04 | 2019-02-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2018-12-04 | 2019-02-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2018-12-04 | 2019-02-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-04 | 2019-02-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-04 | 2019-02-13 | Y |
| 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 | 2018-12-04 | 2019-02-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-04 | 2019-02-13 | 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 | 2018-12-04 | 2019-02-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-21 | 2019-02-13 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2018-12-21 | 2019-02-13 | Y |
| 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. | Health | 2018-12-04 | 2019-02-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-05 | 2019-02-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-11-05 | 2019-02-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-05 | 2019-02-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-11-05 | 2019-02-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-05 | 2019-02-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-05 | 2019-02-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-05 | 2019-02-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-11-05 | 2019-02-13 | 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 | 2018-11-05 | 2019-02-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-11-05 | 2019-02-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-11-05 | 2019-02-13 | Y |
| Meet other general requirements. | Fire Safety | 2018-11-19 | 2019-01-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-19 | 2019-01-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-08-29 | 2018-09-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-08-29 | 2018-09-24 | 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 | 2018-08-29 | 2018-09-24 | Y |
| 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 | 2018-08-29 | 2018-09-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-29 | 2018-09-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-29 | 2018-09-24 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-08-29 | 2018-09-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-29 | 2018-09-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-01-24 | 2018-01-25 | Y |
| 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. | Health | 2017-11-01 | 2017-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-01 | 2017-11-16 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2017-09-06 | 2017-10-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-09-06 | 2017-10-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-06 | 2017-10-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-09-06 | 2017-10-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-09-06 | 2017-10-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-09-06 | 2017-10-03 | Y |
| Allow residents to self-administer drugs if determined safe. | Health | 2017-09-06 | 2017-10-03 | Y |
| 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. | Health | 2017-09-06 | 2017-10-03 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-09-06 | 2017-10-03 | Y |
| 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. | Health | 2017-09-06 | 2017-10-03 | Y |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-06 | 2017-10-03 | Y |
| 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. | Health | 2017-09-06 | 2017-10-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-06 | 2017-10-03 | Y |
| 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. | Health | 2017-09-06 | 2017-10-03 | Y |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-09-06 | 2017-10-03 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-09-06 | 2017-10-03 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-06 | 2017-10-03 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-06 | 2017-10-03 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-06 | 2017-10-03 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-06 | 2017-10-03 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-07-13 | 2017-07-31 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2016-06-11 | 2016-10-24 | N |
| Try to resolve each resident's complaints quickly. | Health | 2016-06-11 | 2016-10-24 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2016-06-11 | 2016-10-24 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2016-06-11 | 2016-10-24 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-06-11 | 2016-10-24 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-06-11 | 2016-10-24 | N |
| Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. | Health | 2016-06-11 | 2016-10-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-06-11 | 2016-10-24 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2016-06-11 | 2016-10-24 | N |
| Provide housekeeping and maintenance services. | Health | 2016-06-11 | 2016-10-24 | N |
| Review or revise the resident's care plan after any major change in physical or mental health. | Health | 2016-06-11 | 2016-10-24 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-06-11 | 2016-10-24 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-06-11 | 2016-10-24 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-06-11 | 2016-10-24 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-06-11 | 2016-10-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-06-11 | 2016-10-24 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-06-11 | 2016-10-24 | N |
| 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. | Health | 2016-06-11 | 2016-10-24 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-06-11 | 2016-10-24 | N |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | Health | 2016-06-11 | 2016-10-24 | N |
| 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. | Health | 2016-06-11 | 2016-10-24 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-06-11 | 2016-10-24 | N |
| Ensure that residents are safe from serious medication errors. | Health | 2016-06-11 | 2016-10-24 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-06-11 | 2016-10-24 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-06-11 | 2016-10-24 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-06-11 | 2016-10-24 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-06-11 | 2016-10-24 | N |
| Keep all essential equipment working safely. | Health | 2016-06-11 | 2016-10-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-06-11 | 2016-10-24 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-06-07 | 2016-06-08 | N |
