Deficiency Records for Shuksan Healthcare Center
Updated as of August 01, 2018
This is not the most recent data for Shuksan Healthcare Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2018-03-27 | 2018-06-18 | 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 |
| 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 |
| 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 |
| 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 ne | 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 |
| 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 | Y |
| 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 | Y |
| 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 |
| 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 |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-02-21 | 2017-04-20 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-02-21 | 2017-04-20 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-02-21 | 2017-04-20 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-02-21 | 2017-04-20 | N |
| Provide housekeeping and maintenance services. | Health | 2017-02-21 | 2017-04-20 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-02-21 | 2017-04-20 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-02-21 | 2017-04-20 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-02-21 | 2017-04-20 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-02-21 | 2017-04-20 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-02-21 | 2017-04-20 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-02-21 | 2017-04-20 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-02-21 | 2017-04-20 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-02-21 | 2017-04-20 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-02-21 | 2017-04-20 | N |
| 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. | Health | 2017-02-21 | 2017-04-20 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-02-21 | 2017-04-20 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-02-21 | 2017-04-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-02-21 | 2017-04-20 | N |
| Use approved construction type or materials. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-02-09 | 2017-02-17 | 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 | 2017-02-09 | 2017-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-02-09 | 2017-02-17 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2016-06-03 | 2016-07-12 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-06-03 | 2016-07-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-06-03 | 2016-07-12 | Y |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2016-04-04 | 2016-07-12 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2016-04-04 | 2016-07-12 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-04-04 | 2016-07-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2016-04-04 | 2016-07-12 | N |
| Provide housekeeping and maintenance services. | Health | 2016-04-04 | 2016-07-12 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-04-04 | 2016-07-12 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-04-04 | 2016-07-12 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2016-04-04 | 2016-07-12 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-04-04 | 2016-07-12 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-04-04 | 2016-07-12 | N |
| Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. | Health | 2016-04-04 | 2016-07-12 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-04-04 | 2016-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-04-04 | 2016-07-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-04-04 | 2016-07-12 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2016-04-04 | 2016-07-12 | N |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2016-04-04 | 2016-07-12 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-04-04 | 2016-07-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-04-04 | 2016-07-12 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-04-04 | 2016-07-12 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-04-04 | 2016-07-12 | N |
| Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. | Health | 2016-04-04 | 2016-07-12 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-04-04 | 2016-07-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-04-04 | 2016-07-12 | N |
| Approved construction type or materials. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Properly maintained smoke detectors. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Exits that are free from obstructions and can be used at all times. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-03-31 | 2016-05-13 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-02-21 | Not Fixed | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-02-21 | Not Fixed | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-02-21 | Not Fixed | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-02-21 | Not Fixed | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-21 | Not Fixed | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility | Health | 2017-02-21 | Not Fixed | N |
