Cascade Senior Care Center

In the surveyor’s words

From the most serious findings on record at Cascade Senior Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF839Mar 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure eight residents (Resident #14, #15, #23, #27, #31, #36, #39, and #47) received skilled nursing services including medication administration and assessments by a licensed nurse, resulting in Immediate Jeopardy when an unlicensed staff member administered medications, performed assessments, and falsified medical records to reflect the skilled nursing services were performed by a Registered Nurse (RN). Findings include: Review of the facility staff list revealed Staff Member J was a Nurse Grad. In an interview on 03/15/23 at 1:43 PM, Staff Member J self reported she was the facility's scheduler and wound nurse. Staff Member J identified herself as a Registered Nurse. […]

• Immediate jeopardy, widespreadF880Mar 21, 2023

  Based on observation, interview, and record review the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of COVID-19 resulting in Immediate Jeopardy when the facility failed to ensure that facility staff fully utilized Personal Protective Equipment (PPE) for residents with COVID-19 infection. This deficient practice resulted in 27 residents testing positive for COVID-19 including Resident #1, #9, #22, #24, #25, #26, #27, #28, #35, #36, and #53, the hospitalization of Resident #22, Resident #24, and Resident #28, the death of Resident #9 and Resident #53, and the likelihood for further cross contamination of COVID-19 to other residents and staff, thereby putting all 50 residents at risk for… […]

• Immediate jeopardy, patternF600Apr 22, 2022

  This citation pertains to Intake: MI 247, MI 816 Based on observation, interview, and record review, the facility failed to monitor, supervise, and provide an environment free from abuse and protect five residents (R9, R26, R32, R40 and R43) of eight residents reviewed for abuse resulting in Immediate Jeopardy when the facility failed to prevent continued resident to resident abuse. Findings include: Review of the facility's CMS-672 Resident Census and Conditions of Residents dated 4/12/22 revealed the facility's census was 54, of which 36 required assistance of one or two staff for bathing, 54 required assistance of one or two staff for dressing, 48 required assistance of one or two staff for transferring, 51 required assistance of one or two staff for toilet use, and 24 required… […]

• Actual harm, isolatedF684Jun 4, 2025

  Based on interview and record review, the facility failed to assess and monitor respiratory status for one (R51) of one reviewed, resulting in R51 being discovered unresponsive and pronounced deceased . Findings include: A Progress Note for [DATE] at 11:58 PM reflected R51 arrived to the facility, from the hospital, via ambulance, at 11:10 PM. The ambulance company reported R51 was hypoxic (low oxygen level), with an oxygen saturation level in the 70's. The note further reflected the ambulance company applied a non-rebreather mask (delivers high concentrations of oxygen) and gave instructions to begin BiPAP (Bilevel Positive Airway Pressure/machine that helps breathing) upon arrival to the facility. BiPAP was initiated with four liters of oxygen per minute. […]

• Actual harm, isolatedF600Mar 20, 2023

  This citation pertains to Intake MI00134570 and MI00134606 Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse by staff for one resident (R101) of three reviewed for abuse, resulting in R101 left acute displaced proximal 5th phalanx fracture (pinky finger) and soft tissue swelling. Findings include: Complaints and Facility Reported Incident(FRI) were filed with the State Agency and alleged that R101 sustained an injury of unknown origin (fracture to the left hand) and alleged the resident was abused by employee/certified nursing assistant (CNA) N. […]