Deficiency Records for Clarkston Health and Rehab of Cascadia
Updated as of March 01, 2024
A list of the most recent deficiencies for Clarkston 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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-25 | 2023-10-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-25 | 2023-10-31 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-25 | 2023-10-16 | Y |
| Provide or obtain dental services for each resident. | Health | 2023-05-09 | 2023-06-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-09 | 2023-06-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-10-28 | 2022-12-09 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-28 | 2022-12-09 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-28 | 2022-12-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-28 | 2022-12-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-28 | 2022-12-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-28 | 2022-12-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-10-28 | 2022-12-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-28 | 2022-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-28 | 2022-12-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-28 | 2022-12-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-28 | 2022-12-09 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Meet the requirements of an integrated health system. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Meet other general requirements. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-25 | 2022-11-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-01 | 2022-09-01 | Y |
| Report COVID19 data to residents and families. | Health | 2022-08-01 | 2022-09-01 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-08-01 | 2022-09-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-15 | 2022-04-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-15 | 2022-04-22 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-15 | 2022-04-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-15 | 2021-08-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-16 | 2021-07-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-17 | 2021-04-09 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-25 | 2019-07-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-21 | 2019-07-29 | 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 | 2019-06-21 | 2019-07-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-21 | 2019-07-29 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-21 | 2019-07-29 | 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 | 2019-06-21 | 2019-07-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-21 | 2019-07-29 | 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 | 2019-06-21 | 2019-07-29 | 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 | 2019-06-21 | 2019-07-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-06-21 | 2019-07-29 | 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 | 2019-06-21 | 2019-07-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-06-21 | 2019-07-29 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-06-21 | 2019-07-29 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2019-06-21 | 2019-07-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-06-21 | 2019-07-29 | 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 | 2018-04-19 | 2018-06-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-19 | 2018-06-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-04-19 | 2018-06-15 | 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 | 2018-04-19 | 2018-06-15 | N |
| Provide activities to meet all resident's needs. | Health | 2018-04-19 | 2018-06-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-04-19 | 2018-06-15 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-19 | 2018-06-15 | 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 | 2018-04-19 | 2018-06-15 | 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 | 2018-04-19 | 2018-06-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-04-19 | 2018-06-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-18 | 2018-06-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-04-18 | 2018-06-05 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-04-18 | 2018-06-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-18 | 2018-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-04-18 | 2018-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-18 | 2018-06-05 | N |
