Deficiency Records for Wellspring Health and Rehabilitation of Cascadia
Updated as of March 01, 2024
A list of the most recent deficiencies for Wellspring Health and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-15 | 2019-12-18 | 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 | 2019-11-15 | 2019-12-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-15 | 2019-12-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-15 | 2019-12-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-15 | 2019-12-18 | N |
| Post nurse staffing information every day. | Health | 2019-11-15 | 2019-12-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-15 | 2019-12-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Meet other general requirements. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Ensure that anesthesia apparatus are tested after any adjustment, modification or repair. | Fire Safety | 2019-09-04 | 2019-10-07 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-03-01 | 2019-04-05 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-03-01 | 2019-04-05 | 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 | 2019-03-01 | 2019-04-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-01 | 2019-04-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-03-01 | 2019-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-01 | 2019-04-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-01 | 2019-04-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-02-12 | 2019-03-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-02-12 | 2019-03-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-12 | 2019-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-12 | 2019-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-02-12 | 2019-03-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-12 | 2019-03-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-10 | 2018-09-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-10 | 2018-09-25 | 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 | 2018-08-10 | 2018-09-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-10 | 2018-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-10 | 2018-09-25 | N |
| 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 | 2018-08-10 | 2018-09-25 | 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 | 2018-08-10 | 2018-09-25 | 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 | 2018-08-10 | 2018-09-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-10 | 2018-09-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-10 | 2018-09-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-08-09 | 2018-09-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-09 | 2018-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-09 | 2018-09-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-09 | 2018-09-12 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2018-08-09 | 2018-09-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-08-09 | 2018-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-09 | 2018-09-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-09 | 2018-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-09 | 2018-08-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-08-09 | 2018-08-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-08-09 | 2018-08-27 | N |
