Deficiency Records for Las Cruces of Cascadia, LLC
Updated as of April 01, 2022
This is not the most recent data for Las Cruces of Cascadia, LLC. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-01-08 | 2021-03-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-01-08 | 2021-03-09 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-01-08 | 2021-03-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-01-08 | 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 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 |
| Keep residents' personal and medical records private and confidential. | Health | 2021-01-08 | 2021-03-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-01-08 | 2021-03-09 | Y |
| 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 | Y |
| 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 other general requirements that are deficient. | 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-05-19 | 2020-07-29 | 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 | 2020-01-30 | 2020-02-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-30 | 2020-02-28 | Y |
| 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 | 2020-01-30 | 2020-02-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-30 | 2020-02-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-01-30 | 2020-02-28 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-25 | 2019-10-18 | Y |
| 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 | 2019-09-25 | 2019-10-18 | 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 | 2019-06-11 | 2019-07-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-11 | 2019-07-18 | 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 | 2019-06-11 | 2019-07-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-11 | 2019-07-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-11 | 2019-07-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-11 | 2019-07-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-11 | 2019-07-18 | 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 | 2019-06-11 | 2019-07-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-11 | 2019-07-18 | 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 | 2019-06-11 | 2019-07-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-11 | 2019-07-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-11 | 2019-07-18 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-11 | 2019-07-18 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-06-05 | 2019-07-18 | N |
