A list of the most recent deficiencies for Teton Healthcare 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-30 | 2022-10-04 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-08-30 | 2022-10-04 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-30 | 2022-10-04 | 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 | 2022-08-30 | 2022-10-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-30 | 2022-10-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-30 | 2022-10-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-30 | 2022-10-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-30 | 2022-10-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-08-30 | 2022-10-04 | 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 | 2022-08-04 | 2022-09-02 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-23 | 2021-07-27 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-23 | 2021-07-27 | 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 | 2021-06-23 | 2021-07-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-23 | 2021-07-27 | 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 | 2021-06-23 | 2021-07-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-23 | 2021-07-27 | Y |
| 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 | 2019-01-18 | 2019-02-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-18 | 2019-02-18 | 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 | 2019-01-18 | 2019-02-18 | N |
| 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 | 2019-01-18 | 2019-02-18 | 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 | 2019-01-18 | 2019-02-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-18 | 2019-02-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Meet other general requirements. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Ensure proper storage of liquid oxygen. | Fire Safety | 2018-01-31 | 2018-03-02 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-04-10 | 2017-05-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-04-10 | 2017-05-17 | N |
| Provide written records when a resident is transferred or discharged. | Health | 2017-04-10 | 2017-05-17 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-10 | 2017-05-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-10 | 2017-05-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-10 | 2017-05-17 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-04-10 | 2017-05-17 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-04-10 | 2017-05-17 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-10 | 2017-05-17 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-10 | 2017-05-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2016-11-15 | 2016-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2016-11-15 | 2016-12-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2016-11-15 | 2016-12-20 | N |
