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Deficiency Records for Gig Harbor Health and Rehabilitation
A list of the most recent deficiencies for Gig Harbor 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 Gig Harbor 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-17 | 2024-08-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-30 | 2024-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-23 | 2024-05-08 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-28 | 2024-04-09 | 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 | 2024-02-28 | 2024-04-09 | 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 | 2024-02-28 | 2024-04-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-28 | 2024-04-09 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-28 | 2024-04-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-28 | 2024-04-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-28 | 2024-04-09 | 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 | 2024-02-28 | 2024-04-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-28 | 2024-04-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-28 | 2024-04-09 | N |
| Post nurse staffing information every day. | Health | 2024-02-28 | 2024-04-09 | 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 | 2024-02-28 | 2024-04-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-28 | 2024-04-09 | 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 | 2024-02-28 | 2024-04-09 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-02-28 | 2024-04-09 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-28 | 2024-04-09 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-28 | 2024-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-28 | 2024-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-28 | 2024-04-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-28 | 2024-04-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-02-28 | 2024-04-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-28 | 2024-04-09 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-02-28 | 2024-04-09 | N |
| Keep all essential equipment working safely. | Health | 2024-02-28 | 2024-04-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-28 | 2024-04-09 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-28 | 2024-04-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-02-28 | 2024-04-09 | 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 | 2024-02-28 | 2024-04-09 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-27 | 2024-04-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-27 | 2024-04-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-27 | 2024-04-04 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-02-27 | 2024-04-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-02-27 | 2024-03-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-27 | 2024-03-27 | 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 | 2023-08-21 | 2023-09-08 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-08-21 | 2023-09-08 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-24 | 2023-08-25 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-07-24 | 2023-08-25 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-07-24 | 2023-08-25 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-05-24 | 2023-06-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-05 | 2023-06-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-05 | 2023-06-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-02-24 | 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 | 2023-01-20 | 2023-02-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-02-24 | 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 | 2023-01-20 | 2023-02-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-01-20 | 2023-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-20 | 2023-02-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-20 | 2023-02-24 | Y |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-18 | 2023-02-22 | 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 | 2023-01-18 | 2023-02-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-01-18 | 2023-02-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-06 | 2022-11-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-23 | 2022-10-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-03 | 2022-08-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-21 | 2022-08-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-06-21 | 2022-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-21 | 2022-08-05 | Y |
| 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 | 2022-04-25 | 2022-06-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-25 | 2022-06-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-13 | 2021-11-15 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-10-03 | 2019-12-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-03 | 2019-12-30 | 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 | 2019-10-03 | 2019-12-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-03 | 2019-12-30 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-10-03 | 2019-11-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-10-03 | 2019-11-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-03 | 2019-11-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-03 | 2019-11-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-03 | 2019-11-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-03 | 2019-11-15 | 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 | 2019-10-03 | 2019-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-03 | 2019-11-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-03 | 2019-11-15 | N |
| Post nurse staffing information every day. | Health | 2019-10-03 | 2019-11-15 | 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 | 2019-10-03 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-03 | 2019-11-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-24 | 2019-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-24 | 2019-10-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-24 | 2019-10-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-24 | 2019-10-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-24 | 2019-10-28 | N |
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