A list of the most recent deficiencies for Sequim Health and Rehabilitation. 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-23 | 2024-03-26 | 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 | 2024-02-23 | 2024-03-26 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-31 | 2024-02-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-31 | 2023-09-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-07-31 | 2023-09-01 | 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 | 2023-07-31 | 2023-09-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-31 | 2023-09-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-07-31 | 2023-09-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-31 | 2023-09-01 | N |
| Provide activities to meet all resident's needs. | Health | 2023-07-31 | 2023-09-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-31 | 2023-09-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-31 | 2023-09-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-07-31 | 2023-09-01 | N |
| Post nurse staffing information every day. | Health | 2023-07-31 | 2023-09-01 | 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 | 2023-07-31 | 2023-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-31 | 2023-09-01 | 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 | 2023-07-31 | 2023-09-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-31 | 2023-09-01 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-01 | 2023-09-01 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-01 | 2023-08-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-14 | 2023-08-09 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-27 | 2023-05-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-17 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-27 | 2023-05-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-04-07 | 2023-05-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-14 | 2023-03-31 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-02-23 | 2023-03-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-23 | 2023-03-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-12-07 | 2022-12-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-07 | 2022-12-28 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-12-07 | 2022-12-28 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-07 | 2022-12-28 | 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 | 2022-12-07 | 2022-12-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-15 | 2022-12-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-15 | 2022-12-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-15 | 2022-12-20 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-15 | 2022-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-04 | 2022-12-09 | 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 | 2022-10-26 | 2022-11-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-10-26 | 2022-11-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-26 | 2022-11-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-26 | 2022-11-17 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-05-07 | 2022-06-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-07 | 2022-06-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-07 | 2022-06-20 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-05-07 | 2022-06-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-07 | 2022-06-20 | 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 | 2022-05-07 | 2022-06-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide activities to meet all resident's needs. | Health | 2022-05-07 | 2022-06-20 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-07 | 2022-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-07 | 2022-06-20 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-07 | 2022-06-20 | 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 | 2022-05-07 | 2022-06-20 | N |
| Post nurse staffing information every day. | Health | 2022-05-07 | 2022-06-20 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-05-07 | 2022-06-20 | 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 | 2022-05-07 | 2022-06-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-07 | 2022-06-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-07 | 2022-06-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-07 | 2022-06-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-02 | 2022-05-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-03-23 | 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 | 2022-02-16 | 2022-03-23 | 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 | 2021-11-03 | 2021-11-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-04 | 2021-11-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-04 | 2021-11-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-07 | 2021-10-06 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-09 | 2019-12-04 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-10-09 | 2019-12-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-10-09 | 2019-12-04 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-10-09 | 2019-12-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-09 | 2019-12-04 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-09 | 2019-12-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-09 | 2019-12-04 | 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 | 2019-10-09 | 2019-12-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-09 | 2019-12-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-09 | 2019-12-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-09 | 2019-12-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-10-09 | 2019-12-04 | 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 | 2019-10-09 | 2019-12-04 | 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 | 2019-10-09 | 2019-12-04 | N |
| Post nurse staffing information every day. | Health | 2019-10-09 | 2019-12-04 | 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 | 2019-10-09 | 2019-12-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-09 | 2019-12-04 | 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 | 2019-10-09 | 2019-12-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-09 | 2019-12-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-09 | 2019-12-04 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-10-09 | 2019-12-04 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-10-09 | 2019-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-09 | 2019-12-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-09 | 2019-12-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-02 | 2019-12-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-02 | 2019-10-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-02 | 2019-10-02 | N |
