Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
AVAMERE REHABILITATION OF CASCADE PARK
VANCOUVER, WA · 88 certified beds · Last Life Safety survey August 9, 2024
CMS Certification Number 505389 · first certified September 1991
Ownership
Operated by AVAMERE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WA
44 citations — more than 76% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 16 citations; the earlier surveys in the window averaged 14. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (July 2025 to October 2025), and past the point by which nine in ten WA facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
20 of the 44 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 44 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 44 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 10, 2022 | 11 |
| September 22, 2023 | 17 |
| August 9, 2024 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-08-09 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 3 | 2024-08-09 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-08-09 |
| E-0035 | Provide family notifications of emergency plan. | 2 | 2024-08-09 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-08-09 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2024-08-09 |
| E-0015 | Address subsistence needs for staff and patients. | 2 | 2024-08-09 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2024-08-09 |
What the citations cover
- Emergency Preparedness Deficiencies 20
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Services Deficiencies 4
- Other 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 20 |
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 9, 2024 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (October 14, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (September 11, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (September 11, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (October 2, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 11, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 11, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 11, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 15, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 11, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 13, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 11, 2024) |
September 22, 2023 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 23, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (October 23, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 23, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 23, 2023) |
November 10, 2022 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 12, 2022) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (December 12, 2022) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (December 12, 2022) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (November 18, 2022) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (December 12, 2022) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (December 12, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (December 12, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 12, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 12, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (December 12, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 12, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.