Caldwell Care of Cascadia

In the surveyor’s words

From the most serious findings on record at Caldwell Care of Cascadia, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Dec 15, 2022

  Based on policy review, record review, staff interview, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to ensure a resident received CPR. This failure resulted in a serious adverse outcome for Resident #5 when CPR was not provided and placed the health and safety of 19 residents in the facility who had a Full Code status in immediate jeopardy of serious harm, impairment, or death. Findings include: The facility's policy, Cardiopulmonary Resuscitation, updated [DATE], stated residents who requested Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status were to receive basic life support, including initiation of CPR in the event they… […]

• Actual harm, isolatedF600Dec 15, 2022

  Based on policy review, record review, staff interview, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to protect Resident #5's right to be free from neglect when CPR was not provided. This was true for 1 of 5 residents (Resident #5) whose closed records were reviewed. This deficient practice resulted in a serious adverse outcome to Resident #5 when CPR was not provided per her wishes and physician order. Findings include: The facility's policy, Cardiopulmonary Resuscitation, updated [DATE], stated residents who requested Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) status were to receive basic life support, including initiation… […]

• No harm, potential for more than minimal, widespreadF585Mar 6, 2026

  Based on observation, record and policy review, and resident and staff interview, it was determined the facility failed to ensure a grievance process was available for residents. This deficient practice created the potential for psychosocial harm if residents' concerns were not identified and addressed in a timely manner. Findings include:The facility's Grievance Process policy, revised 8/29/25, documented the Grievance program addresses the concerns of residents, family members, and visitors and the facility should make prompt efforts to resolve grievances.On 3/2/26 at 8:30 AM, the SA requested a copy of the facility's grievances from September 2025 through March 2026.The facility provided grievances from January 2026 through March 2026. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, review of FDA Food Code, and staff interview, it was determined the facility failed to ensure employees were not wearing jewelry during food preparation and service, and cutting boards were not cleaned properly. These deficiencies had the potential to affect the 59 residents 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:1. The FDA Food Code Section 2-303.11 documented items of jewelry such as rings, bracelets, and watches may collect soil, and the construction of the jewelry may hinder routine cleaning. […]

• No harm, potential for more than minimal, widespreadF727Oct 11, 2024

  Based on review of facility staffing records and staff interview, it was determined the facility failed to ensure an RN was on duty at least 8 consecutive hours per day, 7 days a week. This was true for 1 of 38 days reviewed for RN staffing coverage. The failure created the potential for harm if routine and/or emergency nursing needs went unmet and had the potential to affect all residents living in the facility. Findings include: Licensed Nurse time punches for 9/1/24 to 10/8/24, documented the facility did not have an RN on duty for 8 consecutive hours on 9/1/24. On 10/10/24 at 5:15 PM, the CRN and DON stated on 9/1/24, the RN was covered by an LPN and confirmed there was not an RN for 8 consecutive hours that day.