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Deficiency Records for Sequim Health and Rehabilitation

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.

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?
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 2024-06-06 2024-06-25 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-04-26 2024-05-16 Y
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 2024-04-12 2024-05-08 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 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
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

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