A list of the most recent deficiencies for Shuksan Healthcare Center. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-13 | 2024-01-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-13 | 2024-01-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-13 | 2023-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-13 | 2023-08-25 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-21 | 2023-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-21 | 2023-07-28 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | 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 | 2023-02-17 | 2023-03-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-17 | 2023-03-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-17 | 2023-03-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-17 | 2023-03-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Develop a communication plan. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Meet other general requirements. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-02-14 | 2023-03-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-14 | 2023-03-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-14 | 2023-03-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-14 | 2023-03-02 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-14 | 2023-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-14 | 2023-03-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-19 | 2023-01-20 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-12-19 | 2023-01-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-10-13 | 2022-12-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-12-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-29 | 2022-09-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-29 | 2022-09-10 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-07-29 | 2022-09-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-29 | 2022-08-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-29 | 2022-08-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-29 | 2022-08-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-08-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-01 | 2021-12-16 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-12-01 | 2021-12-16 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-12-01 | 2021-12-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-02 | 2021-11-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-28 | 2021-06-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-28 | 2021-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-22 | 2021-05-14 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-19 | 2019-08-20 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-06-27 | 2019-08-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-27 | 2019-08-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-27 | 2019-08-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-06-27 | 2019-08-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-06-27 | 2019-08-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Post nurse staffing information every day. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-06-27 | 2019-08-06 | 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 | 2019-06-27 | 2019-08-06 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-06-27 | 2019-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-27 | 2019-08-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-06-27 | 2019-08-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-27 | 2019-08-06 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Develop a communication plan. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish methods for sharing information. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-19 | 2019-07-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-03-27 | 2018-06-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-30 | 2018-05-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-03-30 | 2018-05-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-03-30 | 2018-05-15 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-03-30 | 2018-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-03-30 | 2018-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-30 | 2018-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-30 | 2018-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-30 | 2018-05-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-03-30 | 2018-05-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-03-30 | 2018-05-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-03-30 | 2018-05-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-03-30 | 2018-05-15 | N |
| Keep all essential equipment working safely. | Health | 2018-03-30 | 2018-05-15 | 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 | 2018-03-30 | 2018-05-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-03-30 | 2018-05-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-03-30 | 2018-05-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-03-30 | 2018-05-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-03-30 | 2018-05-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-03-30 | 2018-05-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-03-30 | 2018-05-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-03-27 | 2018-04-30 | N |
