Inspection Results » St Francis of Bellingham

Health Inspection on December 4, 2018 ^[1]

1. Pattern: Immediate jeopardy to the resident health or safety

   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-02-13)

2. Isolated: Actual harm that is not immediate jeopardy

   • Provide enough food/fluids to maintain a resident's health. (Corrected 2019-02-13)

3. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-02-13)
   • 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. (Corrected 2019-02-13)

4. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. (Corrected 2019-02-13)
   • Provide and implement an infection prevention and control program. (Corrected 2019-02-13)
   • Implement a program that monitors antibiotic use. (Corrected 2019-02-13)
   • 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 (Corrected 2019-02-13)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-02-13)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2019-02-13)
   • Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. (Corrected 2019-02-13)
   • 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. (Corrected 2019-02-13)
   • Observe each nurse aide's job performance and give regular training. (Corrected 2019-02-13)

5. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-02-13)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-02-13)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2019-02-13)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-02-13)
   • 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. (Corrected 2019-02-13)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2019-02-13)
   • Assess the resident when there is a significant change in condition (Corrected 2019-02-13)
   • Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. (Corrected 2019-02-13)
   • Provide activities to meet all resident's needs. (Corrected 2019-02-13)
   • Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. (Corrected 2019-02-13)
   • 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 (Corrected 2019-02-13)