Avamere Rehabilitation of Cascade Park

In the surveyor’s words

From the most serious findings on record at Avamere Rehabilitation of Cascade Park, in the surveyor’s own words.

• Actual harm, isolatedF686Aug 9, 2024

  Based on observation, interview and record review, the facility failed to ensure pressure ulcers were thoroughly assessed, consistently monitored, and skin care and treatment were provided timely to promote healing of an existing pressure ulcer and prevent development of a new pressure ulcer for 1 of 6 sample residents (51) reviewed for pressure ulcers. Resident 51 experienced harm when an existing pressure ulcer on the coccyx worsened and a new pressure ulcer developed to the right buttock and upper thigh area that became infected and required hospital treatment. This failure placed residents at risk for deterioration in skin conditions, discomfort and a diminished quality of life. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2023

  Based on observation, interviews, and record review, the facility failed to ensure cold food items, served to resident, were held at the proper cold holding temperature; and failed to maintain and document refrigerator temperatures for 3 of 3 unit refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness and a diminished quality of life. Findings included . <Cold Holding Temperatures> On 09/20/2023 at 11:40 AM, Staff D, Dietary Manager, was observed temping cold food item (cole slaw) using a facility thermometer. The cole slaw temped at 47.6 degrees Fahrenheit (F). When asked what the process for food that was not at cold holding temperatures, Staff D said the cole slaw should be at 41 degrees F or below. […]

• No harm, potential for more than minimal, widespreadF880Nov 10, 2022

  Based on observations, interview and record review, the facility failed to ensure washing machine water met the required temperature to kill infectious organisms in soiled laundry by implementing regular hot water temperature checks for three of three washing machines and failed to ensure infection control procedures for Aerosol Generating Procedures (AGP) were implemented per current standards of practice for one of one sampled residents (242) reviewed for infection prevention and control. […]

• No harm, potential for more than minimal, patternF604Aug 9, 2024

  Based on observation, interview and record review, the facility failed to ensure an assessment, consent and/or physician order was obtained for beds being against the wall and bed rails for 4 of 5 sampled residents (5, 31, 61, & 189) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life. Findings included . Record review of the facility's policy entitled, Use of Restraints, revised April 2017, documented, 1. Physical Restraints' are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . 9. […]

• No harm, potential for more than minimal, patternF688Oct 10, 2023

  Based on observation, interview and record review, the facility failed to provide restorative nursing services to prevent potential avoidable reduction of range of motion (ROM) and mobility for 7 of 10 sampled residents (1, 2, 3, 4, 5, 6 & 7) reviewed for ROM/mobility services. This failure placed residents at risk for increased contractures and decreased quality of life. Findings included . 1) Resident 1 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting the left side. A contracture (a condition of shortening and hardening of muscles and tendons often leading to deformity and rigidity of joints), unspecified hand, was added to Resident 1's diagnosis on 01/30/2023. […]