A list of the most recent deficiencies for Vancouver Specialty and Rehab Care. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-13 | 2023-10-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-06 | 2023-06-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-05-10 | 2023-05-31 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-04 | 2023-05-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-06 | 2023-05-04 | 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 | 2023-04-06 | 2023-05-04 | 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 | 2023-04-06 | 2023-05-04 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-04-06 | 2023-05-04 | 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 | 2023-04-06 | 2023-05-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-06 | 2023-05-04 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-06 | 2023-05-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-06 | 2023-05-04 | N |
| Post nurse staffing information every day. | Health | 2023-04-06 | 2023-05-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-06 | 2023-05-04 | 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 | 2023-04-06 | 2023-05-04 | 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 | 2023-04-06 | 2023-05-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-05-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-04 | 2023-05-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-14 | 2023-01-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-19 | 2022-09-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-26 | 2022-06-10 | Y |
| 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 | 2022-04-29 | 2022-06-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-29 | 2022-06-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-29 | 2022-06-10 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-29 | 2022-06-10 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-02-03 | 2022-03-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-03 | 2022-03-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-02-03 | 2022-03-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-18 | 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 | 2022-02-03 | 2022-03-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-03 | 2022-03-18 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-02-03 | 2022-03-18 | N |
| Provide appropriate foot care. | Health | 2022-02-03 | 2022-03-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-03 | 2022-03-18 | N |
| 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 | 2022-02-03 | 2022-03-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-03 | 2022-03-18 | 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 | 2022-02-03 | 2022-03-18 | 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 | 2022-02-03 | 2022-03-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-02-03 | 2022-03-18 | N |
| Post nurse staffing information every day. | Health | 2022-02-03 | 2022-03-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-03 | 2022-03-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-03 | 2022-03-18 | 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 | 2022-02-03 | 2022-03-18 | 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 | 2022-02-03 | 2022-03-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-02-03 | 2022-03-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-01 | 2022-02-11 | 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 | 2021-12-15 | 2022-01-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-07 | 2021-11-15 | Y |
| 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 | 2021-10-07 | 2021-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-07 | 2021-11-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-22 | 2021-08-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-22 | 2021-08-30 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-22 | 2021-08-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-22 | 2021-08-30 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-07 | 2021-08-13 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-07-07 | 2021-08-13 | Y |
| 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 | 2021-07-07 | 2021-08-13 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-05-10 | 2019-07-27 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-05-10 | 2019-07-27 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2019-05-10 | 2019-07-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-05-10 | 2019-07-27 | 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 | 2019-05-10 | 2019-07-27 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-05-10 | 2019-07-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-10 | 2019-07-27 | 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 | 2019-05-10 | 2019-07-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-10 | 2019-07-27 | 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 | 2019-05-10 | 2019-07-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-10 | 2019-07-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-05-10 | 2019-07-27 | N |
| Meet other general requirements. | Fire Safety | 2019-05-08 | 2019-07-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-08 | 2019-06-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-05-08 | 2019-05-29 | N |
