Deficiency Records for Stafholt Health and Rehabilitation of Cascadia
Updated as of October 01, 2020
This is not the most recent data for Stafholt Health and Rehabilitation of Cascadia. For the most recent information, click here.
A list of the most recent deficiencies for Stafholt Health and Rehabilitation 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-25 | 2019-10-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-25 | 2019-10-18 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-09-25 | 2019-10-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-05 | 2019-07-31 | N |
| Be properly staffed | Fire Safety | 2019-06-05 | 2019-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-03 | 2019-07-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-15 | 2019-07-14 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-07 | 2019-07-14 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-06-07 | 2019-07-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-06-07 | 2019-07-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-06-07 | 2019-07-14 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-07 | 2019-07-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-07 | 2019-07-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| 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 | 2019-06-07 | 2019-07-14 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-06-07 | 2019-07-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-07 | 2019-07-14 | N |
| Dispose of garbage and refuse properly. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-06-07 | 2019-07-14 | 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 | 2019-06-07 | 2019-07-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-06-05 | 2019-07-10 | 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 | 2019-06-05 | 2019-07-10 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-05 | 2019-07-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-06-05 | 2019-07-10 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-05 | 2019-07-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-05 | 2019-07-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-05 | 2019-07-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-05 | 2019-07-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-06 | 2019-04-08 | 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 | 2019-02-22 | 2019-04-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-22 | 2019-04-08 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-02-01 | 2019-04-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-02-01 | 2019-04-08 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-12 | 2018-06-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-04-20 | 2018-06-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-04-20 | 2018-06-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-04-20 | 2018-06-04 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-04-20 | 2018-06-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-04-20 | 2018-06-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-20 | 2018-06-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-20 | 2018-06-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-04-20 | 2018-06-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-04-20 | 2018-06-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-20 | 2018-06-04 | 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 | 2018-04-20 | 2018-06-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-20 | 2018-06-04 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-04-20 | 2018-06-04 | 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 | 2018-04-20 | 2018-06-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-20 | 2018-06-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-04-20 | 2018-06-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-20 | 2018-06-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-20 | 2018-06-04 | 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 | 2018-04-20 | 2018-06-04 | Y |
| 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 | 2018-04-20 | 2018-06-04 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-04-12 | 2018-05-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-04-12 | 2018-05-16 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-04-12 | 2018-05-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-04-12 | 2018-04-16 | 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 | 2017-03-13 | 2017-05-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-03-13 | 2017-05-25 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-03-13 | 2017-05-25 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-13 | 2017-05-25 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-03-13 | 2017-05-25 | 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 | 2017-03-13 | 2017-05-25 | N |
| Develop policies and procedures for influenza and pneumococcal immunizations. | Health | 2017-03-13 | 2017-05-25 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-03-13 | 2017-05-25 | 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 | 2017-03-08 | 2017-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-03-08 | 2017-04-19 | 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 | 2017-03-08 | 2017-04-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-03-08 | 2017-04-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2017-03-08 | 2017-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-08 | 2017-04-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2017-03-08 | 2017-04-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-03-08 | 2017-04-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-03-08 | 2017-04-19 | N |
