Deficiency Records for Creekside Health and Rehab of Cascadia
Updated as of March 01, 2024
A list of the most recent deficiencies for Creekside Health and Rehab 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 the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-20 | 2023-11-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-11-28 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-20 | 2023-11-28 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-26 | 2023-11-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-26 | 2023-11-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-26 | 2023-11-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-26 | 2023-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-26 | 2023-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-26 | 2023-11-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-26 | 2023-11-28 | 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 | 2022-09-09 | 2023-01-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-08 | 2022-10-29 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-09-08 | 2022-10-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-09-09 | 2022-10-24 | 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 | 2022-09-09 | 2022-10-24 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-09 | 2022-10-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-09 | 2022-10-24 | N |
| Post nurse staffing information every day. | Health | 2022-09-09 | 2022-10-24 | 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 | 2022-09-09 | 2022-10-24 | N |
| Provide or obtain dental services for each resident. | Health | 2022-09-09 | 2022-10-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-09 | 2022-10-24 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-09-08 | 2022-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-30 | 2022-05-05 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-30 | 2022-05-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-04-26 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-03-30 | 2022-04-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-30 | 2022-04-26 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-01-07 | 2022-04-06 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-01-07 | 2022-04-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-07 | 2022-02-26 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-07 | 2022-02-26 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-07 | 2022-02-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-07 | 2022-02-26 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-07 | 2022-02-26 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-07 | 2022-02-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-25 | 2021-07-14 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-25 | 2021-07-14 | 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 | 2018-08-03 | 2018-09-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-03 | 2018-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-03 | 2018-09-22 | 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 | 2018-08-03 | 2018-09-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-03 | 2018-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-03 | 2018-09-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-03 | 2018-09-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-03 | 2018-09-22 | N |
| Post nurse staffing information every day. | Health | 2018-08-03 | 2018-09-22 | N |
| Ensure that a resident does not develop patterns of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless unavoidable. | Health | 2018-08-03 | 2018-09-22 | 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 | 2018-08-03 | 2018-09-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-03 | 2018-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-03 | 2018-09-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-03 | 2018-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-03 | 2018-09-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-03 | 2018-09-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-08-02 | 2018-09-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-02 | 2018-09-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-08-02 | 2018-09-22 | N |
