Deficiency Records for Bainbridge Island Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Bainbridge Island Health and Rehab 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? |
|---|---|---|---|---|
| Assess the resident when there is a significant change in condition | Health | 2023-09-29 | 2023-11-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-29 | 2023-11-14 | 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 | 2023-09-29 | 2023-11-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-29 | 2023-11-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-29 | 2023-11-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-29 | 2023-11-14 | 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 | 2023-09-29 | 2023-11-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-11-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-29 | 2023-11-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Meet other general requirements. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-26 | 2023-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-03 | 2023-01-04 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-23 | 2022-08-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-26 | 2022-07-28 | 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 | 2022-06-26 | 2022-07-28 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-26 | 2022-07-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-26 | 2022-07-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-26 | 2022-07-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-26 | 2022-07-28 | 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 | 2022-06-26 | 2022-07-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-26 | 2022-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-26 | 2022-07-28 | 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 | 2022-06-26 | 2022-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-26 | 2022-07-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-06-26 | 2022-07-28 | 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 | 2022-06-26 | 2022-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-26 | 2022-07-28 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-06-26 | 2022-07-28 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-23 | 2022-07-28 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-06-23 | 2022-07-28 | 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 | 2019-06-26 | 2019-08-03 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-26 | 2019-08-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-26 | 2019-08-03 | 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 | 2019-06-26 | 2019-08-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-26 | 2019-08-03 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-06-26 | 2019-08-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-06-26 | 2019-08-03 | 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 | 2019-06-26 | 2019-08-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-26 | 2019-08-03 | 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 | 2019-06-26 | 2019-08-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-26 | 2019-08-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-26 | 2019-08-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-26 | 2019-08-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-26 | 2019-08-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-06-26 | 2019-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-18 | 2019-07-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-18 | 2019-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-18 | 2019-07-12 | N |
