A list of the most recent deficiencies for Shaw Mountain of Cascadia. 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? |
|---|---|---|---|---|
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-21 | 2022-11-14 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-10-21 | 2022-11-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-14 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-21 | 2022-11-14 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-24 | 2022-10-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-23 | 2021-07-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-12 | 2021-07-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-12 | 2021-05-27 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-12 | 2021-05-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-12 | 2021-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-12 | 2021-05-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-03-12 | 2021-04-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-12 | 2021-04-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-12 | 2021-04-15 | Y |
| 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 | 2021-03-12 | 2021-04-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-11-09 | 2018-12-13 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-11-09 | 2018-12-13 | 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 | 2018-11-09 | 2018-12-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-09 | 2018-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-09 | 2018-12-13 | N |
| Provide activities to meet all resident's needs. | Health | 2018-11-09 | 2018-12-13 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Use approved construction type or materials. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-09-04 | 2018-10-24 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-04-06 | 2017-05-10 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-06 | 2017-05-10 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-04-06 | 2017-05-10 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-06 | 2017-05-10 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-04-06 | 2017-05-10 | N |
| Signs that state that exit doors are to be kept closed. | Fire Safety | 2016-06-22 | 2016-08-23 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-06-22 | 2016-08-23 | N |
| Portable fire extinguishers. | Fire Safety | 2016-06-22 | 2016-08-23 | N |
| Exits that are free from obstructions and can be used at all times. | Fire Safety | 2016-06-22 | 2016-08-23 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-06-22 | 2016-08-23 | N |
