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Deficiency Records for North Cascades Health and Rehabilitation Center
A list of the most recent deficiencies for North Cascades Health and Rehabilitation 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 North Cascades Health and Rehabilitation 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? |
|---|---|---|---|---|
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-08-12 | 2024-09-03 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-07-18 | 2024-08-15 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-06-20 | 2024-07-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-20 | 2024-07-25 | 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 | 2024-06-20 | 2024-07-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-17 | 2024-05-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-04-17 | 2024-05-06 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-04 | 2024-04-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-08 | 2024-04-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-08 | 2024-04-18 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-03-08 | 2024-04-18 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-08 | 2024-04-18 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-03-08 | 2024-04-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-08 | 2024-04-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-08 | 2024-04-18 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-08 | 2024-04-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-08 | 2024-04-18 | 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 | 2024-03-08 | 2024-04-18 | 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 | 2024-03-08 | 2024-04-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-03-08 | 2024-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-08 | 2024-04-18 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-03-08 | 2024-04-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-08 | 2024-04-18 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2024-03-08 | 2024-04-18 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-08 | 2024-04-18 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-04 | 2024-04-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Develop a communication plan. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2024-03-04 | 2024-04-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-21 | 2024-01-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-21 | 2024-01-19 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-12-21 | 2024-01-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-21 | 2024-01-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-21 | 2024-01-19 | 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 | 2023-12-21 | 2024-01-19 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-21 | 2024-01-19 | Y |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-12-21 | 2024-01-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-21 | 2024-01-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-13 | 2023-12-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-13 | 2023-12-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-30 | 2023-12-07 | 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 | 2023-10-30 | 2023-12-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-30 | 2023-12-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-19 | 2023-10-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-19 | 2023-10-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-09 | 2023-07-26 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-09 | 2023-07-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-09 | 2023-07-26 | 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 | 2023-06-09 | 2023-07-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-09 | 2023-07-26 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-06-09 | 2023-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-09 | 2023-07-26 | 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 | 2023-06-09 | 2023-07-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-09 | 2023-07-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-09 | 2023-07-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-09 | 2023-07-26 | 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 | 2023-06-09 | 2023-07-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-09 | 2023-07-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-06-09 | 2023-07-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-09 | 2023-07-26 | N |
| Post nurse staffing information every day. | Health | 2023-06-09 | 2023-07-26 | 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 | 2023-06-09 | 2023-07-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-06-09 | 2023-07-26 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-06-09 | 2023-07-26 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-06-09 | 2023-07-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-09 | 2023-07-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Establish methods for sharing information. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-06 | 2023-07-06 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-06-06 | 2023-06-16 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-04 | 2023-05-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-22 | 2023-05-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-22 | 2023-05-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-22 | 2023-05-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-22 | 2023-05-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-13 | 2023-01-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-24 | 2022-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-24 | 2022-09-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-13 | 2022-01-07 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-22 | 2021-11-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-22 | 2021-11-15 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-06-23 | 2021-08-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-23 | 2021-08-05 | 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 | 2021-06-23 | 2021-08-05 | 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 | 2021-06-23 | 2021-08-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-23 | 2021-08-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-23 | 2021-08-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-23 | 2021-08-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-23 | 2021-08-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-23 | 2021-08-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-23 | 2021-08-05 | 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 | 2021-06-23 | 2021-08-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-06-23 | 2021-08-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-23 | 2021-08-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-23 | 2021-08-05 | 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 | 2021-06-23 | 2021-08-05 | 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 | 2021-06-23 | 2021-08-05 | N |
| Provide or obtain dental services for each resident. | Health | 2021-06-23 | 2021-08-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-23 | 2021-08-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-23 | 2021-08-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-23 | 2021-08-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-10 | 2021-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-10 | 2021-06-11 | N |
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