Deficiency Records for Tacoma Nursing and Rehabilitation Center
Updated as of October 01, 2020
This is not the most recent data for Tacoma Nursing and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Tacoma Nursing and Rehabilitation Center. 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 enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-15 | 2019-11-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-08-29 | 2019-09-20 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-04-30 | 2019-06-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-04-30 | 2019-06-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-30 | 2019-06-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-04-30 | 2019-06-10 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-30 | 2019-06-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-30 | 2019-06-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-30 | 2019-06-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-30 | 2019-06-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-30 | 2019-06-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-30 | 2019-06-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-30 | 2019-06-10 | N |
| 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 | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-30 | 2019-06-10 | 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 | 2019-04-30 | 2019-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-30 | 2019-06-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-04-30 | 2019-06-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-30 | 2019-06-10 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-04-23 | 2019-05-28 | 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 | 2019-04-23 | 2019-05-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Be properly staffed | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-04-23 | 2019-05-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-06-28 | 2018-08-13 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-06-28 | 2018-08-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-28 | 2018-08-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide appropriate foot care. | Health | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-28 | 2018-08-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-06-28 | 2018-08-13 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | N |
| Provide or obtain dental services for each resident. | Health | 2018-06-28 | 2018-08-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-06-28 | 2018-08-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-28 | 2018-08-13 | 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 | 2018-06-28 | 2018-08-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-06-28 | 2018-08-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-06-28 | 2018-08-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-06-26 | 2018-07-31 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-06-26 | 2018-07-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-06-26 | 2018-07-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-06-26 | 2018-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-26 | 2018-07-31 | N |
| Be properly staffed | Fire Safety | 2018-06-26 | 2018-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2017-08-01 | 2017-09-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-08-04 | 2017-09-05 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-08-04 | 2017-09-05 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-04 | 2017-09-05 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-08-04 | 2017-09-05 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-08-04 | 2017-09-05 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-04 | 2017-09-05 | N |
| Provide or obtain dental services for each resident. | Health | 2017-08-04 | 2017-09-05 | N |
