Cove of Cascadia, The

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 25, 2024

  Based on record review and staff interview, it was determined the facility failed to provide adequate supervision and functioning devices to prevent elopement and fall. This was true for 1 of 6 residents (Resident #29) reviewed for accidents and elopement. This deficiency created the potential for physical harm (Resident #29 was harmed) if residents were not supervised or assistive devices not functioning when residents at risk for elopement left the facility. Findings include: Resident #29 was admitted to the facility on [DATE], with multiple diagnoses including fractures of the right hip and pubic bone, prostate and bone cancer, and dementia. A quarterly MDS assessment, dated 8/23/24, documented Resident #29 was severely cognitively impaired. […]

• No harm, potential for more than minimal, patternF684Nov 21, 2025

  Based on record review and staff interview, it was determined the facility failed to follow physician orders of delivering specific medications when residents do not have BM within 72 hours for 4 of 12 residents (#17, #20, #24, and #30) whose records were reviewed for bowel and bladder care. This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order. Findings include: Resident #17 was admitted to the facility initially on 6/22/22 with readmission on [DATE] with multiple diagnoses including post-surgical left above knee amputation and obesity. […]

• No harm, potential for more than minimal, patternF812Oct 25, 2024

  Based on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. Additionally, the facility failed to ensure food was not exposed to cross-contamination while raw food was defrosting over cooked food. These deficiencies had the potential to affect the 69 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: The FDA (Food Drug Administration) Food Code Section ,d+[DATE].11 Preventing Food and Ingredient Contamination/Packaged and Unpackaged Food - Separation, Packaging, and Segregation. […]

• No harm, potential for more than minimal, patternF812Jun 29, 2023

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices for food storage. These failed practices placed the 31 residents who consumed food prepared by the facility at risk for adverse health outcomes, including food-borne illnesses. Findings include: The facility's Food and Supply Storage policy, dated 11/28/17, states food products that are opened and not completely used or prepared at the facility and stored, the product should be labeled with contents and use-by dates. This policy was not followed. […]

• No harm, potential for more than minimal, patternF848Jun 29, 2023

  Based on staff interview and record review, the facility failed to ensure the facility's arbitration agreement (a document that designates a third party to resolve a dispute between others), presented to residents to sign, included the selection of a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) was convenient to both parties and a choice of arbitration services (where the parties can choose an arbiter to use). This was true for 3 of 4 residents (#14, #15, and #183) whose records were reviewed for arbitration agreements. […]