Deficiency Records for Stafholt Health and Rehabilitation of Cascadia
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-26 | 2024-02-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-06 | 2023-10-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-28 | 2023-08-23 | Y |
| 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 | 2023-04-25 | 2023-05-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-25 | 2023-05-17 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-04-25 | 2023-05-17 | Y |
| 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 | 2022-11-04 | 2023-01-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-04 | 2023-01-03 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-11-04 | 2023-01-03 | 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 | 2022-11-04 | 2023-01-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-11-04 | 2023-01-03 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-04 | 2023-01-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-04 | 2023-01-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-04 | 2023-01-03 | 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 | 2022-11-04 | 2023-01-03 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-11-04 | 2023-01-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-04 | 2023-01-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-04 | 2023-01-03 | 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 | 2022-11-04 | 2023-01-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-04 | 2023-01-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-04 | 2023-01-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-11-04 | 2023-01-03 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-04 | 2023-01-03 | N |
| Post nurse staffing information every day. | Health | 2022-11-04 | 2023-01-03 | 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 | 2022-11-04 | 2023-01-03 | 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 | 2022-11-04 | 2023-01-03 | N |
| Dispose of garbage and refuse properly. | Health | 2022-11-04 | 2023-01-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-04 | 2023-01-03 | 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 | 2022-11-04 | 2023-01-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-11-04 | 2023-01-03 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-11-04 | 2023-01-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-04 | 2023-01-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-04 | 2022-12-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-31 | 2022-12-05 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-31 | 2022-11-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-10-31 | 2022-11-22 | N |
| Develop a communication plan. | Fire Safety | 2022-10-31 | 2022-11-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-31 | 2022-11-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-31 | 2022-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-15 | 2022-10-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-02 | 2022-09-07 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-08-02 | 2022-09-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-09-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-03 | 2022-05-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-08 | 2022-04-15 | 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 | 2022-03-08 | 2022-04-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-08 | 2022-04-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-01 | 2021-12-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-01 | 2021-12-30 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-11-01 | 2021-12-30 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-11-01 | 2021-12-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-01 | 2021-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-01 | 2021-12-30 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-11-01 | 2021-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-01 | 2021-12-30 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-17 | 2021-04-19 | 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 | 2021-03-17 | 2021-04-19 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-03-17 | 2021-04-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-03-17 | 2021-04-19 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-05 | 2019-07-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-05 | 2019-07-31 | N |
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | 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 |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-04-12 | 2018-06-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-04-12 | 2018-06-08 | 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 |
| 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 | 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 |
| 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 | 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 |
| 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 |
| 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 |
