Deficiency Records for Regency Coupeville Rehab and Nursing Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Regency Coupeville Rehab and Nursing 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-22 | 2024-01-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-22 | 2024-01-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-22 | 2024-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-22 | 2024-01-17 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-22 | 2024-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-22 | 2024-01-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-22 | 2024-01-17 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-22 | 2024-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-22 | 2024-01-17 | 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 | 2023-11-22 | 2024-01-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-22 | 2024-01-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-22 | 2024-01-17 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-20 | 2024-01-01 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-11-20 | 2023-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-20 | 2023-12-12 | 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 | 2022-11-18 | 2022-12-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-18 | 2022-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-18 | 2022-12-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-18 | 2022-12-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-01 | 2022-09-13 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-28 | 2022-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-08-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-01 | 2022-08-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-07-01 | 2022-08-10 | 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 | 2022-07-01 | 2022-08-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-01 | 2022-08-10 | 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 | 2022-07-01 | 2022-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-01 | 2022-08-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-01 | 2022-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-08-10 | 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 | 2022-07-01 | 2022-08-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-01 | 2022-08-10 | 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 | 2022-07-01 | 2022-08-10 | N |
| Post nurse staffing information every day. | Health | 2022-07-01 | 2022-08-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-01 | 2022-08-10 | 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 | 2022-07-01 | 2022-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-01 | 2022-08-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-06-28 | 2022-07-28 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-05-10 | 2022-06-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-10 | 2022-06-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-10 | 2022-06-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-10 | 2022-06-07 | 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 | 2022-05-10 | 2022-06-07 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-05 | 2022-01-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-28 | 2021-08-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-08-17 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-27 | 2021-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-17 | 2021-04-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-14 | 2019-05-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-02-27 | 2019-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-27 | 2019-04-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-27 | 2019-04-04 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2019-02-27 | 2019-04-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-02-27 | 2019-04-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-02-27 | 2019-04-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-02-14 | 2019-04-02 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-02-14 | 2019-04-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| 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 | 2019-02-14 | 2019-04-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-02-14 | 2019-04-02 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-02-14 | 2019-04-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-02-14 | 2019-04-02 | N |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2019-02-14 | 2019-04-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-02-14 | 2019-04-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-14 | 2019-04-02 | N |
| Respond appropriately to all alleged violations. | Health | 2019-02-14 | 2019-04-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-02-14 | 2019-04-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-02-14 | 2019-04-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-02-14 | 2019-04-02 | N |
| Provide activities to meet all resident's needs. | Health | 2019-02-14 | 2019-04-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-14 | 2019-04-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-02-14 | 2019-04-02 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-02-14 | 2019-04-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-14 | 2019-04-02 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-02-14 | 2019-04-02 | N |
| 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. | Health | 2019-02-14 | 2019-04-02 | 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 | 2019-02-14 | 2019-04-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-14 | 2019-04-02 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2019-02-14 | 2019-04-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-14 | 2019-04-02 | N |
