Cascade Manor

Based on interview and record review it was determined the facility failed to notify the provider of abnormal vitals for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for adverse side effects to a low pulse. Findings include:Resident 2 was admitted to the facility in 3/2026 with diagnoses including heart failure and arterial fibrillation (an irregular heartbeat).A review of Resident 2's orders revealed a 3/7/26 order for amiodarone (a medication used to treat irregular heartbeat) 200 mg daily.A review of Resident 2's vital record revealed the following pulses:-3/7/26 59 beats per minute (BPM)-3/8/26 56 BPM-3/9/26 44 BPM and 55 BPM-3/10/26 47 BPM-3/11/26 59 BPM and 51 BPM-3/12/26 52 BPM-3/13/26 39 BPM-4/1/26 44 BPM-4/7/26 40 BPMA review of Resident 2's medical record revealed no evidence the provider was notified of the low pulses.On 4/14/26 Resident 2 had a pulse of 42 beats per minute and a blood pressure reading at 108/47, and an order was received to decrease the dose of amiodarone from 200 mg to 100 mg.On 4/22/26 at 2:28 PM…

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.

Based on interview and record review it was determined the facility failed to ensure residents did not receive unnecessary medications for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for adverse side effects to receiving medications unnecessarily. Findings include:Resident 2 was admitted to the facility in 3/2026 with diagnoses including heart failure and arterial fibrillation (an irregular heartbeat).A review of orders revealed a 3/8/26 order for spironolactone (a medication that helps remove excess water and salt from the body) hold if the systolic blood pressure (SBP, the top number in a blood pressure reading) was less than 100.A 3/27/26 progress note indicated Resident 2's provider recommended checking Resident 2's orthostatic blood pressure (checking the blood pressure after changing positions).A review of Resident 2's medical record revealed no evidence of orthostatic blood pressures being completed.A review of Resident 2's blood pressures revealed Resident 2 received spironolactone when her/his blood pressure was 98/58 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.

Based on interview and record review it was determined the facility failed to track infection organisms for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for antibiotic resistance. Finding include: Resident 2 was admitted to the facility in 3/2026 with diagnoses including a urinary tract infection (UTI) and heart failure.A 3/19/26 progress note indicated Resident 2 had three UTIs this year.A 3/27/26 progress note indicated Resident 2 had frequent UTIs.A 4/3/26 progress note indicated Resident 2 had increased confusion, frequent urination, and pelvic pain. An order for a urinary analysis with culture and sensitivity was received, and Resident 2 was started on antibiotics.A 4/5/26 urinary culture indicated skin flora (harmless bacteria on the skin).A 4/8/26 progress note indicated Resident 2's provider was requesting the final urinary culture and sensitivity.A 4/9/26 progress note indicated Resident 2's provider was requesting the final urinary culture and sensitivity.A review of Resident 2's medical record revealed no evidence of…

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.

Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate beard restraints during meal preparation and failed to ensure food was stored appropriately and discarded in a timely manner for 1 of 1 facility kitchen reviewed for sanitation and food storage. This placed residents at risk for unsanitary foods and food-borne illness. Findings include: 1. Review of the US FDA Food Code 2022 revealed: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food. On 3/25/25 at 12:20 PM a concurrent interview with Staff 5 (Dietary Manager) and observation of the meal preparation occurred. Staff 7 (Cook) had facial hair and was observed preparing food without a beard restraint in place. Staff 5 stated the dietary staff only were required to wear a beard restraint if the beard was long and unkempt. On 3/26/25 at 1:00 PM Staff 5 stated she reviewed the food code and…

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.

Based on interview and record review it was determined the facility failed to care plan for hospice care for 1 of 1 sampled resident (#3) reviewed for hospice care. This placed residents at risk for unmet end of life needs. Findings include: Resident 3 was admitted to the facility in 1/2023 with diagnoses including cardiac heart failure. A review of the medical record revealed Resident 3 was admitted to hospice on 1/24/23. A review of the care plan revealed no evidence Resident 3 was care planned for hospice care. On 3/25/25 at 3:17 PM Staff RCM (RNCM) stated Resident 3 was admitted to hospice on 1/24/25. Staff RCM stated when a resident was placed on hospice the resident should be care planned for hospice care. Staff RCM acknowledged Resident 3 had no care plan for hospice care.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure care planned interventions to reduce the risk of injury from falls were in place for 1 of 1 sampled resident (#2) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 2 admitted to the facility in 2021 with diagnoses including Cauda Equina Syndrome (neurological condition). Resident 2's 12/1/24 care plan directed staff to encourage her/him to use her/his call light for assistance, to keep the call light in reach and keep the bed in the low position. A 12/22/24 progress note revealed Staff 4 (LPN) documented on 12/21/24 at 10:55 PM Resident 2 was heard yelling and staff found her/him on the fall mat, on the ground, next to her/his bed. Resident 2 told staff, I was looking for my call light and fell out of bed. Staff 4 inspected Resident 2's room and the call light was connected to the wall, but was not in reach of the resident. Resident 2's 12/30/24 fall investigation summary revealed Staff…

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.

Based on observation, interview and record review it was determined the facility failed to ensure proper handwashing practices were in place and food was prepared and stored to meet food safety standards for 1 of 1 kitchen. This placed residents at risk for foodborne illness. Findings include: An undated Anytime Menu for breakfast indicated eggs were available poached, soft boiled, fried or scrambled for residents. An undated handwritten meal service count provided on 2/22/24 at 6:00 PM by Staff 7 (Certified Dietary Manager) indicated undercooked eggs were served 49 times to residents during the last 35 days. On 2/19/24 at 12:25 PM no pasteurized (partial sterilization involving heat) eggs were observed in the kitchen. On 2/19/24 at 12:38 PM two 20-quart containers that were approximately 18 inches deep of warm soup were observed on the counter in the kitchen. The soup containers were uncovered with a plastic container of ice partially immersed into the contents to promote cooling. Staff 10 (Cook) stated the facility had no practice to verify the temperatures of foods that cooled to…

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 observation, interview, and record review it was determined the facility failed to maintain water temperatures for 3 of 3 resident rooms (#s 20, 21, and 31) reviewed for accident hazards. This placed residents at risk for injury. Findings include: Industry standards and best practices endorse water temperatures not to exceed 120 degrees F. On 2/19/24 at 3:40 PM, 2/19/24 at 3:50 PM and 2/20/24 at 8:30 AM the hot water was assessed in resident rooms [ROOM NUMBER]. On 2/20/24 at 8:31 AM the surveyor checked the temperature of the water in the visitation room and the thermometer indicated the water was 122 degrees F. On 2/21/24 at 8:11 AM Staff 13 (Maintenance Supervisor) used a thermometer to measure the water temperature in resident room [ROOM NUMBER]. The thermometer indicated the water was 135 degrees F. On 2/21/24 at 8:12 AM Staff 13 used a thermometer to measure the water temperature in resident room [ROOM NUMBER]. The thermometer indicated the water was 135 degrees F. Both residents in resident room…

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.

Based on interview and record review it was determined the facility failed to ensure the facility was staffed to include the services of a RN at least eight consecutive hours per day seven days per week for 13 of 36 days reviewed. This placed residents at risk for lack of comprehensive assessments. Findings include: Review of the Direct Care Staff Daily Reports identified on the payroll based journal report, first quarter 2023, for no RN and from 1/19/24 through 2/18/24 revealed there were no RNs scheduled during a 24 hour period on 2/4/23 (Saturday), 2/5/23 (Sunday), 2/18/23 (Saturday), 2/19/23 (Sunday), 3/4/23 (Saturday), 3/5/23 (Sunday), 1/21/24 (Sunday), 1/26/24 (Friday), 2/3/24 (Saturday), 2/9/24 (Friday), 2/13/24 (Tuesday), 2/17/24 (Saturday), and 2/18/24 (Sunday). On 2/20/24 at 1:57 PM Staff 1 (Administrator) acknowledged there were multiple days the facility did not have a RN scheduled to provide direct care and the facility did not have a waiver. Staff 1 stated the DNS or the RNCM was usually available during the week and available by phone if needed on the weekend. A…

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.

Based on interview and record review it was determined the facility failed to implement a physician's plan for therapy for 1 of 1 sampled resident (#9) reviewed for rehabilitation and therapy. This placed residents at risk for lack of therapy interventions. Findings include: Resident 9 admitted to the facility in 2023 with diagnoses including chronic heart disease and depression. A 12/22/23 revised care plan indicated Resident 9 had a problem with shortness of breath and coughing due to suspected aspiration (food or liquid in a person's airway) pneumonia. A 12/22/23 physician progress note indicated during rounds on 12/6/23 Resident 9 was observed to cough after eating and now required antibiotics for pneumonia. A 1/3/24 Encounter Nursing Home Visit revealed a previous speech consult was not completed as anticipated, Staff 15 (Nurse Practioner) spoke to a nurse and Resident 9 was to receive a bedside swallow evaluation. On 1/4/24 the plan was signed and acknowledged by three staff including Staff 3 (LPN). A 1/17/24 Encounter Nursing Home Visit revealed a swallow evaluation was…

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.

Based on interview and record review it was determined the facility failed to systematically analyze data and implement plans of action to correct identified deficiencies related to water temperatures for 12 of 12 resident rooms reviewed for accident hazards. Findings include: On 2/21/23 at 8:12 AM Staff 13 (Maintenance Supervisor) stated five rooms a day were monitored for water temperatures. Staff 13 added he believed Staff 14 (Director of Facility Services) reviewed the temperature logs. On 2/21/24 at 9:14 AM Staff 14 stated the custodians performed water temperature monitoring. Staff 14 added she participated in QAPI meetings but was unsure of expectations for reporting data and the water temperatures were not discussed. On 2/22/24 at 5:59 PM Staff 1 (Administrator) was asked about the QAPI process. Staff 1 stated during her first QAPI meeting, she identified QAPI was an area they needed to improve. Refer to F689

Based on interview and record review it was determined the facility failed to address advance directives for 2 of 2 sampled residents (#s 7 and 9) reviewed for advanced directives. This placed residents at risk for healthcare decisions to be in conflict with resident wishes. Findings include: 1. Resident 7 admitted to the facility in 2022 with diagnoses including stroke and chronic obstructive pulmonary disease. A 9/20/22 Skilled Nursing Facility admission Agreement for CCRC (Continuing Care Retirement Community) Residents indicated Resident 7 had an Advance Directive. Resident 7's clinical record revealed no Advance Directive. On 2/22/24 at 4:28 PM Staff 5 (Health Services Coordinator) stated because Resident 7 had a POLST (Physician Orders for Life Sustaining Treatment) in her/his file she did not notify Staff 4 (Social Services Director) to ensure follow-up communication with Resident 7 regarding her/his Advance Directive took place. Staff 5 acknowledged a follow-up conversation with Resident 7 regarding her/his Advance Directive was necessary. 2. Resident 9 readmitted to 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.

Based on interview and record review it was determined the facility failed to provide Notices of Medicare Non-Coverage (NOMNC) for 1 of 2 sampled residents (#115) reviewed for liability and appeal notices. This placed residents at risk for lack of appeal information. Findings include: Resident 115 admitted to the facility in 2023 with diagnoses including cancer and convulsions. a. A NOMNC form indicated the last covered day was 12/22/23. The form was signed by Resident 115 on 12/28/23. On 2/22/24 at 10:21 AM Staff 1 (Administrator) stated she did not know why the notice was signed late. b. A NOMNC form indicated the last covered day was 1/12/24 for Resident 115's readmission. There was no evidence in the clinical record the NOMNC form was presented to Resident 115 prior to the end of Medicare coverage. On 2/22/24 at 10:21 AM Staff 1 (Administrator) stated she could not locate a second NOMNC form for Resident 115.

Based on observation and interview it was determined the facility failed to follow infection control standards for 1 of 1 sampled resident (#3) reviewed for transmission based precautions (TBP). This placed residents at risk for exposure to infections. Findings include: Resident 3 admitted to the facility in 2021 with diagnoses including arthritis and low back problems. The facility indicated Resident 3 was on contact precautions (required the use of gloves and a gown) for a wound infection. There was no signage at the Resident's room or PPE supplies which indicated contact precautions were in place for Resident 3. On 2/19/24 at 4:19 PM Staff 11 (RN) was asked about wound care and TBP. Staff 11 stated wound care usually occurred on day shift but she occasionally had to perform a dressing change if the dressing came off. Staff 11 indicated she only wore gloves for the dressing change. On 2/19/24 at 4:34 AM Staff 6 (RNCM) stated there was no signage posted because the nurses performed wound care and they knew Resident 3 was on contact precautions. On 2/20/24 at 8:18 AM Staff 3 (LPN)…

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.