Deficiency Records for Bainbridge Island Health and Rehab Center
Updated as of January 01, 2022
This is not the most recent data for Bainbridge Island Health and Rehab Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2019-06-26 | 2019-08-03 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-06-26 | 2019-08-03 | Y |
| 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 | Y |
| 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 |
| Respond appropriately to all alleged violations. | Health | 2018-05-04 | 2018-06-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-04 | 2018-06-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-04 | 2018-06-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-04 | 2018-06-04 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-05-04 | 2018-06-04 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-05-04 | 2018-06-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-04 | 2018-06-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-04 | 2018-06-04 | 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 | 2018-05-04 | 2018-06-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-04 | 2018-06-04 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-05-04 | 2018-06-04 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2018-05-04 | 2018-06-04 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-05-04 | 2018-06-04 | N |
| Use approved construction type or materials. | Fire Safety | 2017-03-27 | 2017-05-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-03-27 | 2017-05-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-27 | 2017-05-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-03-27 | 2017-05-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-03-27 | 2017-05-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-03-27 | 2017-05-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-03-27 | 2017-05-22 | 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 | 2017-03-24 | 2017-04-20 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-03-24 | 2017-04-20 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-24 | 2017-04-20 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-24 | 2017-04-20 | N |
