Deficiency Records for St Francis of Bellingham
Updated as of June 01, 2021
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? |
|---|---|---|---|---|
| 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 |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-01-19 | 2021-02-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-01-19 | 2021-02-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-01-19 | 2021-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-19 | 2021-02-18 | Y |
| Report COVID19 data to residents and families. | Health | 2021-01-19 | 2021-02-18 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-01-19 | 2021-02-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-09-01 | 2020-10-06 | 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 necessary and PRN use is limited. | Health | 2020-09-01 | 2020-10-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-03-16 | 2020-07-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-16 | 2020-05-06 | N |
| 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 | 2020-03-16 | 2020-05-06 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-03-16 | 2020-05-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-16 | 2020-05-06 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2020-03-16 | 2020-05-06 | N |
| Post nurse staffing information every day. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2020-03-16 | 2020-05-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-16 | 2020-05-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-03-16 | 2020-05-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-16 | 2020-05-06 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-16 | 2020-05-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-16 | 2020-05-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-03-16 | 2020-05-06 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-03-16 | 2020-05-06 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-16 | 2020-05-06 | Y |
| Provide activities to meet all resident's needs. | Health | 2020-03-16 | 2020-05-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-16 | 2020-05-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-16 | 2020-05-06 | Y |
| 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 and maintain the bed rail. | Health | 2020-03-16 | 2020-05-06 | 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 | 2020-03-16 | 2020-05-06 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-06 | 2020-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-26 | 2020-01-14 | Y |
| 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 necessary and PRN use is limited. | 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 |
| 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 and maintain the bed rail. | 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 necessary and PRN use is limited. | 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 |
| 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 |
| 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 |
| 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 | N |
| Allow residents to self-administer drugs if determined safe. | Health | 2017-09-06 | 2017-10-03 | N |
| 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 | N |
| 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 | N |
| 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 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-06 | 2017-10-03 | N |
| 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 | N |
| 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 | 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 | 2017-09-06 | 2017-10-03 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-09-06 | 2017-10-03 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2017-09-06 | 2017-10-03 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-06 | 2017-10-03 | N |
| 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 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-06 | 2017-10-03 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-06 | 2017-10-03 | N |
