A list of the most recent deficiencies for Cascade Manor. 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 that residents are fully informed and understand their health status, care and treatments. | Health | 2022-12-20 | 2023-02-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-20 | 2023-02-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-20 | 2023-02-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-20 | 2023-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-02-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-12-15 | 2023-02-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-15 | 2023-02-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-15 | 2023-02-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-15 | 2023-02-08 | 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 | 2022-12-20 | 2023-01-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-08 | 2021-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-03-08 | 2021-03-26 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-31 | 2018-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-31 | 2018-09-21 | 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 | 2018-08-02 | 2018-09-12 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-02 | 2018-09-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-02 | 2018-09-12 | 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 | 2018-08-02 | 2018-09-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-02 | 2018-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-02 | 2018-09-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-08-02 | 2018-09-12 | 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 | 2018-08-02 | 2018-09-12 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2018-08-02 | 2018-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-02 | 2018-09-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-05-23 | 2017-07-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-05-23 | 2017-06-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-05-23 | 2017-06-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-05-23 | 2017-06-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-05-23 | 2017-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-05-23 | 2017-06-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-05-23 | 2017-06-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-05-23 | 2017-06-12 | N |
