A list of the most recent deficiencies for Mountain View 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-05-22 | 2023-06-30 | 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 | 2023-05-22 | 2023-06-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-22 | 2023-06-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-01 | 2023-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-22 | 2023-06-16 | 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 | 2023-05-22 | 2023-06-13 | 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 | 2022-06-23 | 2022-08-01 | 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 | 2022-06-23 | 2022-08-01 | 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 | 2022-06-23 | 2022-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-23 | 2022-08-01 | 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 | 2022-06-23 | 2022-08-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-13 | 2022-07-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-13 | 2022-07-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-13 | 2022-07-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-13 | 2022-07-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-13 | 2022-07-19 | N |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-06-23 | 2022-06-23 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Develop a communication plan. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-01 | 2022-01-15 | 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 | 2021-12-01 | 2022-01-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-01 | 2022-01-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-24 | 2021-12-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-24 | 2021-12-20 | 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 | 2021-11-24 | 2021-12-20 | 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 | 2021-11-24 | 2021-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-24 | 2021-12-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-24 | 2021-12-20 | N |
