Deficiency Records for Salmon Creek Post Acute and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Salmon Creek Post Acute and Rehabilitation. 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 maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Develop a communication plan. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-05 | 2024-02-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-08 | 2024-01-11 | 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 | 2023-12-08 | 2024-01-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-08 | 2024-01-11 | 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 | 2023-12-08 | 2024-01-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-08 | 2024-01-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-12-08 | 2024-01-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-08 | 2024-01-11 | N |
| Post nurse staffing information every day. | Health | 2023-12-08 | 2024-01-11 | 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 | 2023-12-08 | 2024-01-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-08 | 2024-01-11 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish methods for sharing information. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-05 | 2024-01-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-20 | 2023-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-19 | 2023-08-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-21 | 2023-05-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-23 | 2023-03-06 | 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 | 2023-01-23 | 2023-03-06 | 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 | 2023-01-23 | 2023-03-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-01-23 | 2023-03-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-23 | 2023-03-06 | 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 | 2023-01-23 | 2023-03-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-01-23 | 2023-03-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-23 | 2023-03-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-23 | 2023-03-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-23 | 2023-03-06 | N |
| Post nurse staffing information every day. | Health | 2023-01-23 | 2023-03-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-23 | 2023-03-06 | 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 | 2023-01-23 | 2023-03-06 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-26 | 2023-02-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-26 | 2023-02-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-09-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-12 | 2021-06-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-05-12 | 2021-06-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-12 | 2021-06-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-12 | 2021-06-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-05-12 | 2021-06-24 | 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 | 2021-05-12 | 2021-06-24 | N |
| Post nurse staffing information every day. | Health | 2021-05-12 | 2021-06-24 | 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 | 2021-05-12 | 2021-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-12 | 2021-06-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-12 | 2021-06-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-12 | 2021-06-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-12 | 2021-06-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-12 | 2021-06-15 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-05-12 | 2021-06-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-31 | 2021-04-27 | Y |
