Deficiency Records for Alderwood Park Health and Rehab of Cascadia
Updated as of March 01, 2024
A list of the most recent deficiencies for Alderwood Park 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-21 | 2023-09-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-21 | 2023-09-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-31 | 2023-09-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-31 | 2023-09-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-31 | 2023-09-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-24 | 2023-05-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-24 | 2023-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-24 | 2023-05-23 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-04-24 | 2023-05-23 | Y |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2023-04-24 | 2023-05-23 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-04-24 | 2023-05-23 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-24 | 2023-05-23 | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-04-24 | 2023-05-23 | 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 | 2022-12-09 | 2023-01-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-12-09 | 2023-01-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-09 | 2023-01-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-17 | 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 | 2022-12-09 | 2023-01-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-09 | 2023-01-17 | N |
| Post nurse staffing information every day. | Health | 2022-12-09 | 2023-01-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-12-09 | 2023-01-17 | N |
| Provide or obtain dental services for each resident. | Health | 2022-12-09 | 2023-01-17 | 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 | 2022-12-09 | 2023-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-09 | 2023-01-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Develop a communication plan. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-12-06 | 2023-01-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-14 | 2022-10-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-29 | 2022-08-23 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-29 | 2022-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-18 | 2022-03-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-18 | 2021-11-10 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-05 | 2021-09-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-05 | 2021-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-09-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-05 | 2021-09-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-23 | 2019-10-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-23 | 2019-10-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-08-23 | 2019-10-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-23 | 2019-10-01 | 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 | 2019-08-23 | 2019-10-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-23 | 2019-10-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-23 | 2019-10-01 | 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 | 2019-08-23 | 2019-10-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-23 | 2019-10-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-23 | 2019-10-01 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-08-23 | 2019-10-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-23 | 2019-10-01 | 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 | 2019-08-23 | 2019-10-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-23 | 2019-10-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-23 | 2019-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-08-23 | 2019-10-01 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-08-23 | 2019-10-01 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-08-23 | 2019-10-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-23 | 2019-10-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-23 | 2019-10-01 | 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 | 2019-08-23 | 2019-10-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-08-23 | 2019-10-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-23 | 2019-10-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-08-23 | 2019-10-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-23 | 2019-10-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-23 | 2019-10-01 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-08-23 | 2019-10-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-19 | 2019-09-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-06-14 | 2018-07-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-06-14 | 2018-07-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-06-14 | 2018-07-25 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-06-14 | 2018-07-25 | N |
| Respond appropriately to all alleged violations. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-14 | 2018-07-25 | 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 | 2018-06-14 | 2018-07-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-06-14 | 2018-07-25 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-06-14 | 2018-07-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-06-14 | 2018-07-25 | 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 | 2018-06-14 | 2018-07-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide activities to meet all resident's needs. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-14 | 2018-07-25 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-06-14 | 2018-07-25 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-06-14 | 2018-07-25 | 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 | 2018-06-14 | 2018-07-25 | N |
| Provide or obtain dental services for each resident. | Health | 2018-06-14 | 2018-07-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-06-14 | 2018-07-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-14 | 2018-07-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-06-06 | 2018-06-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-06-06 | 2018-06-29 | N |
