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 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 | 2024-02-09 | 2024-03-18 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-02-09 | 2024-03-18 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-09 | 2024-03-18 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-09 | 2024-03-18 | 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 | 2024-02-09 | 2024-03-18 | Y |
| 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 | 2024-02-09 | 2024-03-18 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-02-09 | 2024-03-18 | Y |
| Provide or obtain dental services for each resident. | Health | 2024-02-09 | 2024-03-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-09 | 2024-03-18 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-02-09 | 2024-03-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-09 | 2024-03-18 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-23 | 2023-11-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-23 | 2023-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-23 | 2023-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-23 | 2023-11-17 | N |
| 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 |
| 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 |
