Cascades Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Cascades Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 6, 2024

  Based on interviews, record reviews and observations, the facility failed to protect the residents' right to be free from neglect when it failed to provide the required structures and processes to maintain and secure the exit doors to meet the needs of residents, for 1 of 1 sampled resident (Resident #1). The deficient practice allowed Resident #1 to leave the facility through an unlocked exit door on 09/12/24 between 4:00 AM and 5:00 AM. Resident #1 wheeled himself in his wheelchair to the facility's loading dock, where he fell and was seriously injured. Resident #1 was transferred to the hospital. There were eighty-nine residents in the facility at the time of the survey. […]

• Immediate jeopardy, isolatedF689Dec 6, 2024

  Based on interviews, record review and observations, the facility failed to provide supervision and a secure environment to prevent 1 of 1 sampled resident (Resident #1), from exiting the safety of the facility and subsequently experiencing a fall with serious injuries. The deficient practice occurred on 9/12/24 between 4:00 AM and 5:00 AM. While in his wheelchair, Resident #1, exited out an unlocked exit door at the end of the 400-Hallway, on the north side of the facility. Resident #1 then wheeled himself down a concrete walkway to the loading dock where there was a set of three steps. Resident #1 fell down the steps with his wheelchair where he suffered serious injuries to his cervical (neck) spine (vertebrae). […]

• No harm, potential for more than minimal, widespreadF812Dec 14, 2025

  Based on observations, interviews and record reviews, the facility failed to maintain a sanitary environment in the kitchen as evidenced by closure by the county health department, due to uncleanliness and pest control issues. The findings included: 1). During an inspection by the Department of Health, on 12/11/25, the following were noted: *One live roach was observed in the multi-function oven.*Two egg cases were observed in the multi-function oven. 2). During a second inspection by the Department of Health, on 12/12/25, the following were noted: *Seven live roaches were observed in a floor stand mixer.*Two live roaches were observed in a Cambro unit.*Two live roaches were observed behind the reach in cooler next to the exit door of the kitchen. […]

• No harm, potential for more than minimal, widespreadF924Mar 17, 2023

  Based on observation, interviews, and records review, the facility failed to ensure that the residents had access to handrails in 4 of 5 units of the facility (Garden, Poinciana, Cobblestone, & Gulfstream). The findings included: Observations conducted on 03/12/23 to 03/14/23 from 9:00 AM to 12:20 PM revealed that all handrails at the facility were removed. The facility was undergoing renovation. Further inquiries revealed that out of five units at the facility, four were residents occupied, and none of the four units had handrails affixed or secured on the walls. During an interview with the Administrator on 03/14/23 at 3:28 PM, he informed that the repairs had started on February 14, 2023. […]

• No harm, potential for more than minimal, patternF584Jun 6, 2024

  Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for: 2 of 4 Residential Units (Gulfstream & Garden), public/staff rest rooms (2), soiled utility rooms ( 4 of 4 ), main dining room, and skilled therapy room. The findings included: 1) During the initial resident screenings conducted by the surveyors on 06/3-4/24, and the Environment Tour Conducted on 06/06/24 at 10 AM with the Maintenance Supervisor, the following were noted: * Gardens Unit: room [ROOM NUMBER]: Electrical box loose and falling out of the wall behind the resident's bed, 2 of 6 dresser drawers not closing properly, and wall mounted lamp broken and falling from wall. […]