Deficiency Records for St Francis of Bellingham
Updated as of September 01, 2022
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? |
|---|---|---|---|---|
| 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 | N |
| Respond appropriately to all alleged violations. | Health | 2022-07-29 | 2022-09-08 | 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 | 2022-07-29 | 2022-09-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-29 | 2022-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-29 | 2022-09-08 | N |
| 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 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-29 | 2022-09-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-07-29 | 2022-09-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-07-26 | 2022-08-26 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-07-26 | 2022-08-25 | N |
| Develop a communication plan. | Fire Safety | 2022-07-26 | 2022-08-25 | N |
| 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 |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-26 | 2022-04-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-26 | 2022-04-29 | N |
| 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 a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-26 | 2022-04-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-26 | 2022-04-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-26 | 2022-04-18 | N |
| 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 | 2022-01-26 | 2022-04-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-26 | 2022-04-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-26 | 2022-04-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-26 | 2022-04-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-26 | 2022-04-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-26 | 2022-04-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-26 | 2022-04-18 | N |
| 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 | 2022-01-26 | 2022-04-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-01-26 | 2022-04-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-26 | 2022-04-18 | 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 | 2022-01-26 | 2022-04-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-26 | 2022-04-18 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-26 | 2022-04-18 | 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 | 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 |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-06 | 2022-01-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-06 | 2022-01-26 | 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 | 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 |
| 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 |
