Eagle Rock Health and Rehabilitation of Cascadia

In the surveyor’s words

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

• Actual harm, isolatedF760Aug 14, 2024

  Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 4 residents (#1 and #3) reviewed for medication errors. This deficient practice created harm for one resident (Resident #1) who was hospitalized , and the potential for harm for one resident (Resident #3), due to receiving the wrong medications. Findings include: The facility's Medication Errors policy and procedure, release date 11/28/2017, documented a medication error as the administration of drugs or biologicals which is not in accordance with prescribers' orders, manufacturers specifications, and accepted professional standards. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2025

  Based on observation, record review, and staff interview, it was determined the facility failed to maintain kitchen sanitation and food storage at least 6 inches above the floor. These deficiencies had the potential to affect the 53 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food and food services equipment. Findings include: 1. The Food and Drug Administration (FDA) Food Code Section 3-305.11, documented: (A) Food should be protected from contamination and stored in a clean, dry location where it was not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. […]

• No harm, potential for more than minimal, patternF628Apr 2, 2026

  Based on policy review, record review, and staff interviews it was determined the facility failed to ensure pertinent health information was provided to the receiving health facility for 5 of 9 residents (Resident #1, #3, #7, #11, and #28) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer. Findings include:Resident #1 was initially admitted to the facility on [DATE], and readmitted on [DATE], with multiple diagnoses including Progressive Supranuclear Ophthalmoplegia (Steele-Richardson-Olszewski syndrome) (a rare brain disorder causing progressive damage to balance, eye movement, and mobility) and pulmonary embolism (a blockage in a lung… […]

• No harm, potential for more than minimal, patternF655Apr 2, 2026

  Based on interview, policy review, and staff interview, it was determined the facility failed to complete a baseline care plan for 2 of 2 residents (#4 and #70). This failure created the potential for harm when staff were not provided direction of care for resident. The facility also failed to provide a resident's baseline care plan to the resident or his/her representative for 5 of 7 residents (#7, #9, #11, #21, and #28) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan. Findings include:The facility's Baseline Care Plans policy, revised 9/3/25, documented the facility will initiate a baseline care plan for each resident within 48 hours of admission. […]

• No harm, potential for more than minimal, patternF761Apr 2, 2026

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and were secure and inaccessible to unauthorized staff and residents; this was true for 2 of 2 medication carts inspected and 1 of 1 treatment carts observed. This failure created the potential for residents to receive expired medications with decreased efficacy, the potential for adverse effects if residents self-administered medications inappropriately, and the potential for residents to obtain prescribed wound care supplies used for other residents and presented the risk for cross-contamination of wound care products stored in the treatment cart. […]