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Deficiency Records for Shuksan Healthcare Center

A list of the most recent deficiencies for Shuksan Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Shuksan Healthcare Center. 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?
Install an approved automatic sprinkler system. Fire Safety 2024-05-13 2024-08-30 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-05-13 2024-08-30 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2024-05-13 2024-08-30 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2024-05-13 2024-08-30 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2024-05-13 2024-08-30 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-05-16 2024-07-22 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 2024-05-16 2024-07-22 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2024-05-16 2024-07-22 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2024-05-16 2024-07-22 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-05-16 2024-07-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-05-16 2024-07-22 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-05-16 2024-07-22 N
Observe each nurse aide's job performance and give regular training. Health 2024-05-16 2024-07-22 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 2024-05-16 2024-07-22 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 2024-05-16 2024-07-22 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-05-16 2024-07-22 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-05-16 2024-07-22 N
Provide and implement an infection prevention and control program. Health 2024-05-16 2024-07-22 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 2024-05-16 2024-07-22 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2024-05-13 2024-07-22 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-05-13 2024-07-22 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2024-05-13 2024-06-15 N
Establish policies and procedures including evacuation. Fire Safety 2024-05-13 2024-06-15 N
Provide emergency officials' contact information. Fire Safety 2024-05-13 2024-06-15 N
Establish emergency prep training and testing. Fire Safety 2024-05-13 2024-06-15 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 2024-05-13 2024-06-15 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-05-13 2024-06-15 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 2024-05-13 2024-06-15 N
Provide properly protected cooking facilities. Fire Safety 2024-05-13 2024-06-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-05-13 2024-06-15 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-05-13 2024-06-15 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-05-13 2024-06-15 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2024-05-13 2024-06-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-05-13 2024-06-15 N
Have restrictions on the use of portable space heaters. Fire Safety 2024-05-13 2024-06-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-05-13 2024-06-15 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-05-13 2024-06-15 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2024-05-13 2024-06-15 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-03-14 2024-04-17 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2024-03-14 2024-04-17 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2024-03-06 2024-04-17 Y
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 2024-03-06 2024-04-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-12-13 2024-01-13 Y
Provide and implement an infection prevention and control program. Health 2023-12-13 2024-01-13 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-07-13 2023-08-25 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-07-13 2023-08-25 Y
Respond appropriately to all alleged violations. Health 2023-06-21 2023-07-28 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-21 2023-07-28 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2023-02-17 2023-03-28 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 2023-02-17 2023-03-28 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 2023-02-17 2023-03-28 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-02-17 2023-03-28 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 2023-02-17 2023-03-28 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 2023-02-17 2023-03-28 N
Ensure medication error rates are not 5 percent or greater. Health 2023-02-17 2023-03-28 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-02-17 2023-03-28 N
Provide and implement an infection prevention and control program. Health 2023-02-17 2023-03-28 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-02-14 2023-03-20 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-02-14 2023-03-20 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2023-02-14 2023-03-20 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-02-14 2023-03-20 N
Develop a communication plan. Fire Safety 2023-02-14 2023-03-20 N
List the names and contact information of those in the facility. Fire Safety 2023-02-14 2023-03-20 N
Provide emergency officials' contact information. Fire Safety 2023-02-14 2023-03-20 N
Establish staff and initial training requirements. Fire Safety 2023-02-14 2023-03-20 N
Conduct testing and exercise requirements. Fire Safety 2023-02-14 2023-03-20 N
Meet other general requirements. Fire Safety 2023-02-14 2023-03-20 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-02-14 2023-03-20 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-02-14 2023-03-20 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-02-14 2023-03-20 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-02-14 2023-03-20 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-02-14 2023-03-20 N
Have restrictions on the use of portable space heaters. Fire Safety 2023-02-14 2023-03-20 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-02-14 2023-03-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-02-14 2023-03-20 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2023-02-14 2023-03-20 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2023-02-14 2023-03-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-02-14 2023-03-13 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-02-14 2023-03-13 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-02-14 2023-03-02 N
Provide properly protected cooking facilities. Fire Safety 2023-02-14 2023-03-02 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-02-14 2023-03-01 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-12-19 2023-01-20 Y
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2022-12-19 2023-01-20 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-10-13 2022-12-12 Y
Respond appropriately to all alleged violations. Health 2022-10-13 2022-12-12 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-07-29 2022-09-10 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-07-29 2022-09-10 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 2022-07-29 2022-09-10 Y
Provide and implement an infection prevention and control program. Health 2022-07-29 2022-08-29 Y
Respond appropriately to all alleged violations. Health 2022-06-29 2022-08-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-29 2022-08-05 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-06-29 2022-08-05 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-12-01 2021-12-16 Y
Dispose of garbage and refuse properly. Health 2021-12-01 2021-12-16 Y
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 2021-12-01 2021-12-14 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2021-11-02 2021-11-16 Y
Conduct testing and exercise requirements. Fire Safety 2019-06-19 2019-08-20 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2019-06-27 2019-08-06 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2019-06-27 2019-08-06 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2019-06-27 2019-08-06 N
Ensure each resident receives an accurate assessment. Health 2019-06-27 2019-08-06 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2019-06-27 2019-08-06 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2019-06-27 2019-08-06 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2019-06-27 2019-08-06 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-06-27 2019-08-06 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-06-27 2019-08-06 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-06-27 2019-08-06 N
Provide enough food/fluids to maintain a resident's health. Health 2019-06-27 2019-08-06 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Post nurse staffing information every day. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Ensure medication error rates are not 5 percent or greater. Health 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 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 2019-06-27 2019-08-06 N
Provide and implement an infection prevention and control program. Health 2019-06-27 2019-08-06 N
Implement a program that monitors antibiotic use. Health 2019-06-27 2019-08-06 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2019-06-27 2019-08-06 N
Establish an Emergency Preparedness Program (EP). Fire Safety 2019-06-19 2019-07-24 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2019-06-19 2019-07-24 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2019-06-19 2019-07-24 N
Address patient/client population and determine types of services needed. Fire Safety 2019-06-19 2019-07-24 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2019-06-19 2019-07-24 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2019-06-19 2019-07-24 N
Address subsistence needs for staff and patients. Fire Safety 2019-06-19 2019-07-24 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2019-06-19 2019-07-24 N
Establish policies and procedures including evacuation. Fire Safety 2019-06-19 2019-07-24 N
Establish policies and procedures for sheltering. Fire Safety 2019-06-19 2019-07-24 N
Establish policies and procedures for medical documentation. Fire Safety 2019-06-19 2019-07-24 N
Establish policies and procedures for volunteers. Fire Safety 2019-06-19 2019-07-24 N
Create arrangements with other facilities to receive patients. Fire Safety 2019-06-19 2019-07-24 N
Establish roles under a Waiver declared by secretary. Fire Safety 2019-06-19 2019-07-24 N
Develop a communication plan. Fire Safety 2019-06-19 2019-07-24 N
List the names and contact information of those in the facility. Fire Safety 2019-06-19 2019-07-24 N
Provide emergency officials' contact information. Fire Safety 2019-06-19 2019-07-24 N
Provide primary/alternate means for communication. Fire Safety 2019-06-19 2019-07-24 N
Establish methods for sharing information. Fire Safety 2019-06-19 2019-07-24 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2019-06-19 2019-07-24 N
Provide family notifications of emergency plan. Fire Safety 2019-06-19 2019-07-24 N
Establish emergency prep training and testing. Fire Safety 2019-06-19 2019-07-24 N
Establish staff and initial training requirements. Fire Safety 2019-06-19 2019-07-24 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2019-06-19 2019-07-24 N

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