Creekside Health and Rehabilitation of Cascadia

Based on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed. This placed residents at risk for living in an uncomfortable and un-homelike environment. Findings include: Resident 38 was admitted to the facility in 2023 with a diagnosis of quadriplegia.On 5/19/26 at 10:11 AM, Resident 38 stated the carpets were stained in several spots and needed to be replaced.On 5/21/26 at 10:12 AM, observation of all facility halls revealed multiple areas of stained and discolored carpeting throughout resident hallways. Large dark stains were observed on the carpeted walking surfaces. Multiple light-colored bleach stains were observed adjacent to resident room doorways. The carpets appeared worn, dingy and discolored, resulting in an unclean appearance.On 5/21/26 at 10:12 AM, Staff 7 (Maintenance Director) observed the 400, 600, and 700 halls confirmed the carpets were stained in multiple areas, large dark stains were observed in the carpet, and multiple light colored bleach stains were observed adjacent to resident rooms.…

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 store medications properly for 1 of 3 medication refrigerators. This placed residents at risk for receiving ineffective medication. Findings include:The CDC requires medication refrigerators to always maintain a temperature between 36 and 46 degrees Fahrenheit (F).On 5/21/26 at 1:37 PM, Staff 2 (DNS/CNO) provided the temperature log for the facility's narcotic refrigerator for the last 30 days. The temperatures were as follows:-4/21/26 at 7:00 AM 25.16 degrees F-4/21/26 at 7:00 PM 28.04 degrees F-4/22/26 at 7:00 AM 30.2 degrees F-4/22/26 at 7:00 PM 28.58 degrees F-4/23/26 at 7:00 AM 28.4 degrees F-4/23/26 at 7:00 PM 27.68 degrees F-4/24/26 at 7:00 AM 25.88 degrees F-4/24/26 at 7:00 PM 27.5 degrees F-4/25/26 at 7:00 AM 25.34 degrees F-4/25/26 at 7:00 PM 27.5 degrees F-4/26/26 at 7:00 AM 24.08 degrees F-4/26/26 at 7:00 PM 29.48 degrees F-4/27/26 at 7:00 AM 25.16 degrees F-4/27/26 at 7:00 PM 27.86 degrees F-4/28/26 at 7:00…

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 interview and record review it was determined the facility failed to provide timely lab services for 2 of 5 sampled residents (#s 6 and 11) reviewed for unnecessary medications. This placed residents at risk for delayed treatment. Findings include: Resident 6 was admitted to the facility on [DATE] with a diagnosis of acute pyelonephritis (severe kidney infection). Resident 6's 4/2026 BIMS Assessment indicated a score of 15 (cognitively intact). A review of the resident's clinical record revealed on 3/6/26 Resident 6 reported burning with urination for a couple of days to Staff 12 (NP). Staff 12 ordered a UA for Resident 6. Additional notes revealed the specimen was sent to the lab 3/6/26. No documentation was located in the clinical record of the lab results for the 3/6/26 urine sample. On 5/21/26 at 10:30 AM, Staff 4 (IP) stated the facility was notified by the lab on 3/10/26 the resident's name was not identifiable on the specimen. The clinical record revealed a new order was obtained for a UA 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 interview and record review, it was determined the facility failed to ensure a resident was treated with dignity and respect for 1 of 4 sampled residents (#16) reviewed for abuse. This placed residents at risk for lack of dignity and respect. Findings include: Resident 16 was admitted to the facility in 3/2025, with diagnoses including anxiety. An admission MDS dated [DATE] indicated Resident 16 was cognitively intact. The Baseline Care Plan dated 3/28/25, indicated Resident 16 used anti-anxiety medications, with interventions including she/he could become overwhelmed. Staff could assist with one-on-one support. Resident 16 required moderate assistance of one staff member for stand pivot transfers and toileting. A 3/29/25 facility investigation was initiated after two residents complained about Staff 5 (Former CNA). Multiple grievances against Staff 5 led to him being placed on administrative leave. Resident 16 filed a grievance on 3/29/25, which detailed an incident on 3/28/25 during the evening or…

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 follow physician orders for 1 of 5 residents(#50)reviewed for unnecessary medications. This placed residents at risk for adverse side effects to medications. Findings include: Resident 50 was admitted to the facility in 11/2024 with diagnoses including congestive heart failure. A 12/20/24 physician order for Enestro (a heart and blood pressure medication) indicated to hold the medication if Resident 50's systolic blood pressure(SBP)was less than 120. A review of the 1/2025 MAR revealed on 1/2/25 the PM dose of Enestro was given with a SBP of 118 and on 1/4/25 the PM dose of Enestro was given with a SBP of 110. A review of the 2/2025 MAR revealed on 2/1/25 the PM dose of Enestro was given with a SBP of 104. On 2/14/25 at 11:58 AM Staff 2(DNS)acknowledged Resident 50 received Enestro on 1/2/25, 1/4/25, and 2/1/25 when the medication should have been held per orders. On 2/14/25 at 2:19 PM Staff 10(LPN)stated he gave Enestro on 2/1/25 when it should have been held based on the blood pressure parameter order.…

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 provide assistive devices for 1 of 5 sampled residents (#313) reviewed for nutrition. This placed residents at risk for unmet needs. Findings include: Resident 313 was admitted to the facility in 1/2025 with diagnoses including anxiety. A 1/23/25 Nutrition Evaluation indicated Resident 313 had difficulty grasping a fork related to hand tremors and the RD recommended adaptive ware (flatware in foam tubes to make it easier to grip) for all meals. A 1/23/24 order indicated Resident 313 was to have adaptive flatware for all meals. On 2/10/25 at 12:52 PM Resident 313 was observed eating in the dining room, no adaptive ware was observed. On 2/11/25 at 1:38 PM Resident 313's tray was observed without adaptive ware. On 2/12/25 at 12:25 PM Resident 313's tray was observed without adaptive ware. On 2/12/25 at 12:25 PM Staff 18 (Dietary Aide) stated adaptive ware are added to the trays during the tray line in the kitchen based on what the tray tickets indicated. On 2/13/25 at 2:52 PM Staff 13 (RD)…

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 update resident care plans for 2 of 2 sampled residents (#s 6 and 36) reviewed for accidents. This placed residents at risk for lack of ADL care needs and safety. Findings include: 1. Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness. Review of Resident 36's Care Plan initiated 9/29/23, revealed the resident had an ADL self-care performance deficit related to blindness, decreased mobility and wounds. The resident required one or two-person extensive assist with toileting, substantial/maximum assistance for repositioning, personal hygiene and dressing. The resident was encouraged to use her/his pressure sensitive call device to ring for assistance. The admission MDS, dated [DATE], revealed Resident 36 had a BIMS score of 11 which indicated the resident had moderate cognitive impairment. Random observations from 10/16/23 through 10/18/23 revealed Resident…

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 implement care planned interventions related to fall safety for 1 of 2 sampled residents (#36) reviewed for accidents. This placed residents at risk for injury. Findings include: Resident 36 was admitted to the facility in 9/2023 with diagnoses including multiple pressure ulcers and legal blindness. A review of an incident report, dated 10/1/23, indicated Resident 36 had an unwitnessed fall and was found next to her/his bed on 10/1/23. The resident indicated she/he attempted to reposition herself/himself in bed, slid off the bed and onto the floor. The resident was assessed and not injured from the fall. Review of Resident 36's Care Plan, initiated 9/29/23, revealed the resident was at risk for falls related to visual impairment and impaired functional mobility. A revision on 10/6/23 revealed the resident had a non-injury fall out of bed on 10/1/23 and interventions included a fall mat at bedside, bed in a low position 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 ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#18) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea. Findings include: Resident 18 was admitted to the facility in 2023 with diagnoses including diabetes. Resident 18's current physician orders indicated the resident had an order for MiraLAX (a laxative) once daily for constipation. The medication was to be held for loose stools. Bowel elimination records from 9/20/23 through 10/17/23 revealed Resident 18 had loose stools or diarrhea documented on the following dates: - 9/20/23, 9/28/23, 9/29/23, 10/4/23, 10/6/23, 10/13/23, and 10/17/23. Resident 18's MARs from 9/20/23 through 10/17/23 indicated the scheduled MiraLAX was not held for the loose stools. On 10/18/23 at 2:20 PM Staff 5 (LPN) stated Resident 18's MiraLAX should have been held on the days the resident had loose stools. On 10/19/23 at 12:09 PM Staff 2 (DNS) verified Resident 18 was administered MiraLAX…

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.