Deficiency Records for Las Cruces of Cascadia, LLC

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Updated as of March 01, 2024

A list of the most recent deficiencies for Las Cruces of Cascadia, LLC. 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 each resident receives an accurate assessment. Health 2023-10-30 2023-12-01 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-10-30 2023-12-01 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-03-14 2023-04-24 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-03-14 2023-04-24 N
Respond appropriately to all alleged violations. Health 2023-03-14 2023-04-24 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-03-14 2023-04-24 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 2023-03-14 2023-04-24 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2023-03-14 2023-04-24 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-03-14 2023-04-24 N
Provide activities to meet all resident's needs. Health 2023-03-14 2023-04-24 N
Provide enough food/fluids to maintain a resident's health. Health 2023-03-14 2023-04-24 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2023-03-14 2023-04-24 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 2023-03-14 2023-04-24 N
Ensure medication error rates are not 5 percent or greater. Health 2023-03-14 2023-04-24 N
Ensure that residents are free from significant medication errors. Health 2023-03-14 2023-04-24 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 2023-03-14 2023-04-24 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-03-14 2023-04-24 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-03-14 2023-04-24 N
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. Health 2023-03-14 2023-04-24 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-03-14 2023-04-24 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-03-14 2023-04-24 Y
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-03-08 2023-04-19 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-03-08 2023-04-11 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-10-31 2022-12-09 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-04-29 2022-06-06 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-04-29 2022-06-06 Y
Ensure staff are vaccinated for COVID-19 Health 2022-04-29 2022-06-06 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-12-21 2022-02-21 N
Reasonably accommodate the needs and preferences of each resident. Health 2021-12-21 2022-02-21 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2021-12-21 2022-02-21 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2021-12-21 2022-02-21 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2021-12-21 2022-02-21 N
Provide activities to meet all resident's needs. Health 2021-12-21 2022-02-21 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-12-21 2022-02-21 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2021-12-21 2022-02-21 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 2021-12-21 2022-02-21 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 2021-12-21 2022-02-21 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-12-21 2022-02-21 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-12-21 2022-02-21 N
Provide properly protected cooking facilities. Fire Safety 2021-12-20 2022-02-03 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-12-20 2022-02-03 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2021-12-20 2022-02-03 N
Keep residents' personal and medical records private and confidential. Health 2021-07-21 2021-09-03 Y
Prepare residents for a safe transfer or discharge from the nursing home. Health 2021-07-21 2021-09-03 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-07-21 2021-09-03 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-07-21 2021-09-03 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-07-21 2021-09-03 Y
Provide and implement an infection prevention and control program. Health 2021-07-21 2021-09-03 Y
Keep residents' personal and medical records private and confidential. Health 2021-01-08 2021-03-09 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2021-01-08 2021-03-09 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 2021-01-08 2021-03-09 N
Plan the resident's discharge to meet the resident's goals and needs. Health 2021-01-08 2021-03-09 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-01-08 2021-03-09 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 2021-01-08 2021-03-09 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 2021-01-08 2021-03-09 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 2021-01-08 2021-03-09 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 2021-01-08 2021-03-09 N
Dispose of garbage and refuse properly. Health 2021-01-08 2021-03-09 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2021-01-08 2021-03-09 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2021-01-08 2021-03-09 N
Address patient/client population and determine types of services needed. Fire Safety 2021-01-05 2021-03-09 N
Establish policies and procedures for volunteers. Fire Safety 2021-01-05 2021-03-09 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2021-01-05 2021-03-09 N
Establish emergency prep training and testing. Fire Safety 2021-01-05 2021-03-09 N
Meet other general requirements. Fire Safety 2021-01-05 2021-03-09 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-01-05 2021-03-09 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-01-05 2021-03-09 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2021-01-05 2021-03-09 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-01-05 2021-03-09 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-01-05 2021-03-09 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-01-05 2021-03-09 N
Meet Health Care Facilities Code mechanical requirements. Fire Safety 2021-01-05 2021-03-09 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-01-05 2021-03-09 N