Brookfield Health and Rehab of Cascadia

In the surveyor’s words

From the most serious findings on record at Brookfield Health and Rehab of Cascadia, in the surveyor’s own words.

• Actual harm, isolatedF760Jun 9, 2025

  Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (Resident 1) reviewed for medication errors when another resident's medication(s) were left unattended and then taken by/ingested by the wrong resident. Resident 1 experienced harm when they became unresponsive and required intensive care level hospitalization and mechanical ventilation. This failure placed all residents at risk for medical complications. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including liver cirrhosis (scarred liver with impaired functioning) and stage 3 kidney disease (impaired functioning of the kidney(s). […]

• Actual harm, isolatedF689Aug 6, 2024

  Based on interview and record review, the facility failed to ensure residents were free from avoidable accidents during resident bed mobility assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm when the resident was found to have a fractured femur (thighbone) after a fall that required medical intervention when facility staff did not use two-person assistance with bed mobility as indicated as necessary by the comprehensive care plan. This failure placed residents at risk for injury and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including asthma, diabetes mellitus type 2, hypertension, and chronic heart failure. […]

• Actual harm, isolatedF686Mar 7, 2024

  Based on interview and record review, the facility failed to assess and provide preventative equipment interventions to prevent further pressure injury development and deterioration for 1 of 6 sampled residents (Resident 1) reviewed for pressure injuries. This caused harm to Resident 1 when the resident admitted with one Stage 3 (full thickness tissue loss, subcutaneous fat may be visible) and two Stage 2 (a partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed) pressure injuries to the buttocks and the resident was not assessed for an air mattress (the professional standard of practice for redistribution of pressure for pressure ulcer/injury treatment and prevention) or bed mobility bars, developed three new unstageable (base of wound is covered by a… […]

• Actual harm, isolatedF770Mar 7, 2024

  Based on interviews and record review, the facility failed to ensure timely laboratory services were provided for 1 of 6 sampled residents (1) reviewed for laboratory services. This caused harm to Resident 1 when STAT (immediate) lab tests were not completed timely (three days after the STAT order) and the resident required a hospital evaluation for high lab values. This failure placed residents at risk for delay in treatment, decline in medical conditions and a diminished quality of life. Findings included . […]

• Actual harm, isolatedF600Jan 8, 2024

  Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 5 sampled residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when the facility failed to take timely action once allegations of potential staff to resident abuse were first identified and suspected by staff in order to protect the resident from the potential of further abuse. This failure placed residents at risk for abuse and a diminished quality of life. Findings included . The [NAME] State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, defines sexual abuse to include any sexual contact between a staff person of a facility and a vulnerable adult living in that facility whether or not it is consensual. […]