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Deficiency Records for Colfax of Cascadia, LLC
A list of the most recent deficiencies for Colfax of Cascadia, LLC. 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 Colfax of Cascadia, LLC. 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 | 2024-07-22 | 2024-08-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-22 | 2024-08-28 | 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 | 2024-07-22 | 2024-08-28 | 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 | 2024-07-22 | 2024-08-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-22 | 2024-08-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-22 | 2024-08-28 | N |
| Respond appropriately to all alleged violations. | Health | 2024-07-22 | 2024-08-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-07-22 | 2024-08-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-22 | 2024-08-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-22 | 2024-08-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-07-22 | 2024-08-28 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2024-07-22 | 2024-08-28 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-22 | 2024-08-28 | 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 | 2024-07-22 | 2024-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-22 | 2024-08-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-22 | 2024-08-28 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-10 | 2024-08-14 | 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 | 2024-07-10 | 2024-08-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-10 | 2024-08-14 | 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 | 2024-07-10 | 2024-08-14 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-10 | 2024-08-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-06-28 | 2024-08-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-03 | 2024-05-28 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-05-03 | 2024-05-28 | Y |
| 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 | 2024-04-08 | 2024-05-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-08 | 2024-05-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-22 | 2024-02-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-11-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-12 | 2023-11-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-08 | 2023-03-29 | 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 | 2023-03-08 | 2023-03-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-08 | 2023-03-29 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Develop a communication plan. | Fire Safety | 2023-02-13 | 2023-03-17 | 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 | 2023-02-13 | 2023-03-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-13 | 2023-03-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-06 | 2023-02-27 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-30 | 2023-02-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-12 | 2023-01-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-10-28 | 2022-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-12 | 2022-08-25 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-14 | 2022-08-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-15 | 2022-07-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-03 | 2022-06-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-10 | 2022-06-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-28 | 2022-03-04 | Y |
| Report COVID19 data to residents and families. | Health | 2022-01-28 | 2022-03-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-28 | 2022-03-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-03 | 2022-01-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-14 | 2022-01-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-14 | 2022-01-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-14 | 2022-01-06 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-14 | 2022-01-06 | Y |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2021-10-04 | 2021-10-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-04 | 2021-10-27 | Y |
| Provide appropriate foot care. | Health | 2021-10-04 | 2021-10-27 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-05 | 2019-10-14 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2019-08-05 | 2019-10-14 | 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 | 2019-08-05 | 2019-10-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-08-05 | 2019-10-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-05 | 2019-10-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-05 | 2019-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-05 | 2019-10-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-05 | 2019-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-05 | 2019-10-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-05 | 2019-10-14 | 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 | 2019-08-05 | 2019-10-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-05 | 2019-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-05 | 2019-10-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-05 | 2019-10-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-05 | 2019-10-14 | N |
| Use approved construction type or materials. | Fire Safety | 2019-08-06 | 2019-08-17 | 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 | 2019-08-06 | 2019-08-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-08-06 | 2019-08-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-06 | 2019-08-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-06 | 2019-08-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-06 | 2019-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-06 | 2019-08-07 | N |
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