Deficiency Records for Avamere Rehabilitation of Cascade Park
Updated as of March 01, 2024
A list of the most recent deficiencies for Avamere Rehabilitation of Cascade Park. 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 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 | 2023-10-10 | 2023-11-17 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-09-22 | 2023-11-03 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-09-22 | 2023-11-03 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-09-22 | 2023-11-03 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-09-22 | 2023-11-03 | 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 | 2023-09-22 | 2023-11-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-22 | 2023-11-03 | 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 | 2023-09-22 | 2023-11-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-22 | 2023-11-03 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-09-22 | 2023-11-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-11-03 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-09-22 | 2023-11-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Establish methods for sharing information. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-19 | 2023-10-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-09-19 | 2023-10-23 | 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 | 2023-05-24 | 2023-06-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-10 | 2022-12-22 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-10 | 2022-12-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-11-10 | 2022-12-22 | 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 | 2022-11-10 | 2022-12-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-10 | 2022-12-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-22 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-11-10 | 2022-12-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2022-12-22 | 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 | 2022-11-10 | 2022-12-22 | 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 | 2022-11-10 | 2022-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-09 | 2022-12-12 | N |
| Develop a communication plan. | Fire Safety | 2022-11-09 | 2022-11-18 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-09 | 2020-03-31 | 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 | 2020-03-09 | 2020-03-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-03-09 | 2020-03-31 | 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 | 2020-03-09 | 2020-03-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-09 | 2020-03-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-09 | 2020-03-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-09 | 2020-03-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-03-09 | 2020-03-31 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-03-09 | 2020-03-31 | N |
| Post nurse staffing information every day. | Health | 2020-03-09 | 2020-03-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-09 | 2020-03-31 | 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 | 2020-03-09 | 2020-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-09 | 2020-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-09 | 2020-03-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-09 | 2020-03-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-03 | 2020-03-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-03 | 2020-03-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-03 | 2020-03-03 | N |
