Deficiency Records for Sequim Health and Rehabilitation
Updated as of January 01, 2020
This is not the most recent data for Sequim Health and Rehabilitation. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-25 | 2019-12-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-10 | 2019-12-04 | 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 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 ne | 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 |
| 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 | 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 | 2019-10-09 | 2019-12-04 | Y |
| 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 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-04-05 | 2019-05-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-05 | 2019-05-08 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-14 | 2018-12-19 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-11-14 | 2018-12-19 | 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 | 2018-11-14 | 2018-12-19 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-14 | 2018-12-19 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-14 | 2018-12-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-11-14 | 2018-12-19 | 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 | 2018-11-14 | 2018-12-19 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-11-14 | 2018-12-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-14 | 2018-12-19 | 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 | 2018-11-14 | 2018-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-14 | 2018-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-14 | 2018-12-19 | N |
| Provide appropriate foot care. | Health | 2018-11-14 | 2018-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-14 | 2018-12-19 | 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 | 2018-11-14 | 2018-12-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-11-14 | 2018-12-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-11-14 | 2018-12-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-11-14 | 2018-12-19 | 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 | 2018-11-14 | 2018-12-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-14 | 2018-12-19 | 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 | 2018-11-14 | 2018-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-14 | 2018-12-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-14 | 2018-12-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-14 | 2018-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-14 | 2018-11-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-14 | 2018-11-15 | 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 | 2018-01-26 | 2018-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-01-26 | 2018-03-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-26 | 2018-03-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-01-26 | 2018-03-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-26 | 2018-03-14 | 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 | 2018-01-26 | 2018-03-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-01-26 | 2018-03-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-01-26 | 2018-03-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-26 | 2018-03-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-01-26 | 2018-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-26 | 2018-03-14 | 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 | 2018-01-26 | 2018-03-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-01-26 | 2018-03-14 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-01-23 | 2018-02-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-23 | 2018-01-24 | N |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-06-09 | 2017-06-19 | 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 | 2017-06-09 | 2017-06-19 | Y |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-03-15 | 2017-04-12 | 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 | 2017-03-15 | 2017-04-12 | Y |
