Aspen Park of Cascadia

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were assessed to determine if they were safe to self-administer medications. This was true for 1 of 2 residents (Resident #1) reviewed for self-administration of medication. This failure created the potential for adverse outcomes if Resident #1 was to self-administer oral medications inappropriately. Findings include: The facility's Self-Administration of Medication policy, implemented 11/28/17, stated the facility's Interdisciplinary Team should at a minimum consider the following: - The medication appropriate and safe for self-administration - The resident's physical capacity to swallow and to open medication bottles - The resident's cognitive status - The resident's capability to follow directions - The resident's ability to understand what refusal of medication is - The resident's ability to ensure that medication is stored safely and securely. Resident #1 was readmitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 14 residents (Resident #39) whose records were reviewed. This failed practice created the potential for an adverse outcome if the resident's wishes were not followed. Findings include: The State Operation Manual, Appendix PP, defined an Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. Physician Orders for Life-Sustaining Treatment (or POLST) paradigm form is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the patient's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents Minimum Data Set assessment included correct information. This was true for 1 of 14 residents (Resident #4) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not monitored due to inaccurate assessments. Findings include: The RAI Manual, revised 10/1/24, documented section A1500, PASRR (Preadmission Screening and Resident Review), was to be coded yes when a PASRR Level II screening determined a resident had a serious mental illness and/or intellectual disability, or related condition. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including major depressive disorder, generalized anxiety disorder, and legal blindness. Resident #4's medical record included documentation of a PASRR Level I screening, dated 7/6/23 that identified she had mental illness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure services provided met the professional standards. This was true for 3 of 14 residents (#19, 27, and 44) whose physician orders were reviewed. This failure created the potential for residents to suffer harm from adverse effects during medication administration. Findings include: 1. Resident #19 was admitted to the facility on [DATE] with multiple diagnoses including spastic quadriplegic cerebral palsy (paralysis of all four limbs with muscle stiffness due to brain damage or abnormal development), and constipation. Resident #19 used a percutaneous endoscopic gastrostomy tube (a PEG-tube is a feeding tube surgically placed directly into the stomach through the abdominal wall) for medication, nutrition, and hydration. Resident #19's medical record documented a physicians dietary order, dated 11/9/20, directing she was not to take any medication, nutrition, or hydration by mouth. Resident #19's medical record documented the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview it was determined the facility failed to ensure professional standards of practice were followed for 1 of 14 residents (Resident #33) reviewed for bowel management. This failure created the potential for adverse outcomes when Resident #33's physician orders were not followed for bowel management. Findings include: Resident #33 was readmitted to the facility on [DATE], with multiple diagnoses including intellectual disorder, developmental disorders of speech, and anxiety. Resident #33's record documented the following physician orders, dated 5/25/24: - Milk of Magnesia suspension 1200 mg / 15 ml, give 30 ml by mouth as needed for constipation - No bowel movement for 2 days. - Dulcolax Suppository 10 mg, insert 1 suppository rectally as needed for constipation. If no results in 4 hours see Fleet enema order. - Fleet Enema 7-19 gm/118 ml, Give 1 unit as needed for constipation. Resident #33's care plan, revised on 6/25/24, directed care staff to document bowel movements…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined the facility failed to ensure appropriate dementia care planning was implemented. This was true for 1 of 14 resident (Resident #7) whose record was reviewed for care planning. This failure placed Resident #7 at risk for her needs to go undetected when her care plan did not include services to maintain her highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #7 was admitted to the facility on [DATE] with multiple diagnoses including conversion disorder with seizures (a psychological condition where physical symptoms are caused by psychological trauma, rather than an underlying physical or medical condition), muscle weakness, and osteoporosis. On 10/8/24, Resident #7's medical record documented a new diagnosis of severe dementia with agitation. On 4/30/25 at 5:39 PM, the DON stated she was unsure why Resident #7 did not have services for her diagnosis of dementia on her care plan.

Based on observation and staff interview it was determined the facility failed to ensure infection control practices were implemented during medication observation. This had the potential to affect all residents in the facility when LPN #1 dropped an oral tablet and picked it up with her ungloved hand. Findings include: On 4/30/25 at 7:24 AM, during medication administration, LPN #1 was observed dropping a pill onto the top of the medication cart and picked it up with her ungloved hand, placed it in a medication cup, and administered it to the resident. On 4/30/25 at 7:27 AM, LPN #1 stated it was an infection control concern because it touched the top of the cart, but she did not feel an infection control concern was identified when she touched the pill with her ungloved hand.

Based on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 40 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: FDA Food Code Section 3-305.11(A) documented food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. FDA Food Code Section 4-602.13 documented nonfood-contact surfaces of equipment shall be cleaned at frequency necessary to preclude accumulation of soil residues. FDA Food Code Section 6-501.14(A) documented cleaning ventilation systems intake and exhaust air ducts shall be cleaned so they are not a source of contamination by dust, dirt, and other materials. On 4/16/24 at 9:46 AM, the following observations were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, it was determined the facility failed to ensure information was provided to the receiving hospital for emergent situations for 1 of 2 residents (Resident #17) reviewed for transfers. This deficient practice had the potential to cause harm if the resident was not treated in a timely manner due to lack of information. Findings include: Resident #17 was readmitted to the facility on [DATE], with multiple diagnoses including pneumonia. A discharge MDS assessment, dated 1/3/19, documented Resident #17 was discharged to an acute care hospital. A Nursing Progress Note, dated 1/3/19 at 1:10 PM, documented Resident #17 had a change of condition, Emergency Medical Services was notified, and Resident #17 was transported to the hospital via emergency transport. Resident #17's record did not include documentation his physician was notified and ordered the transfer to the hospital and information regarding Resident #17's status was conveyed to the hospital. On 1/31/19 at 11:06 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, policy review, and record review, it was determined the facility failed to ensure a second bed-hold notice was provided to a resident or their representative upon transfer to the hospital. This was true for 1 of 2 residents (Resident #17) who were reviewed for transfers. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time and may cause psychosocial distress if not informed they may be charged to reserve their bed/room. Findings include: The facility's Bed-Hold readmission Policy, dated 11/28/17, documented the facility issued two notices related to bed-holds, as follows: * The first notice was provided in the admission packet. * The second notice was provided to the resident at the time of transfer, or in cases of emergency transfer, within 24 hours of the transfer. * The notice provided information to the resident that explained the duration of the bed-hold.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, policy review, and record review, it was determined the facility failed to ensure professional standards of practice were followed for 3 of 15 residents (#27, #32, and #46) reviewed for standards of practice. Resident #27 BG levels were high and the physician was not notified timely and her insulin orders were not correctly transcribed to the MAR. Resident #32's hyperglycemia (high BG level) care plan was not followed and action taken in response to Resident #46's hyperglycemia were not documented. These failed practices had the potential to adversely affect or harm residents whose care and services were not delivered according to accepted standards of clinical practice. Findings include: The facility's Hyperglycemia and Diabetic Coma policy and procedure, dated 10/31/17, documented, It is important to treat hyperglycemia as soon as it is detected. If not treated, a condition called ketoacidosis (diabetic coma) could occur . If the resident's blood glucose is over 240 mg/dl and is not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.