Orchards of Cascadia, The

In the surveyor’s words

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

• Immediate jeopardy, isolatedF698Nov 14, 2025

  Based on policy review, record review, the facility's Incident and Accident (I&A) Report, and staff interview it was determined the facility failed to ensure a resident receiving dialysis services were provided appropriate monitoring, emergency response, and staff intervention consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. This was true for 1 of 3 residents (Resident #103) reviewed for hemodialysis. […]

• Actual harm, isolatedF689Jun 6, 2024

  Based on policy review, record review, facility Incident Report review, staff interview, and resident and resident representative interview, it was determined the facility failed to ensure adequate supervision and intervention was provided during a resident's transfer to prevent falls. This was true for 1 of 3 residents (Resident #44) reviewed for falls. This resulted in harm to Resident #44 who sustained a hematoma on the right side of her face, eye, and jaw, and chest pain. Findings include: Resident #44 was admitted on [DATE] and readmitted on [DATE], with multiple diagnoses including abnormalities of gait and mobility, and contracture (rigidity of muscle or tendons resulting in a fixed deformity of a joint) of muscle to her right upper arm. […]

• Actual harm, isolatedF684Sep 12, 2022

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for 2 of 7 residents (#3 and #5) whose records were reviewed for quality of care. Specifically: - Resident #3 experienced harm when she developed a [CONDITION(S)] to her left third toe. - Resident #5 was at risk for undetected neurological changes when his neurological assessments were not completed after unwitnessed falls. Findings include: 1. […]

• No harm, potential for more than minimal, patternF565Dec 1, 2025

  Based on interview, record review, and facility policy review, the facility failed to investigate resident grievances in a timely manner for four of four resident (Resident (R) 70, R15, R57, and R59) reviewed for resident council and eight of eight residents (R48, R8, R61, R77, R82, R4, R27, and R14) reviewed for repeated grievances of noise at night and concerns about customer service of 31 sample residents. This deficient practice had the potential to allow grievances to not be responded to in a timely manner for 93 residents.Findings include:Review of the facility's policy titled, Grievance Process, with a revision date of 08/29/25, revealed: Policy: Residents and their families have the right to file a complaint without fear of reprisal. […]

• No harm, potential for more than minimal, isolatedF628Aug 5, 2026

  Based on policy review, record review, and staff interviews, it was determined the facility failed to ensure transfers or discharges were documented in the resident's medical record and failed to provide required written notice of transfer or discharge to the resident or resident representative. This was true for 2 of 3 residents (Residents #2 and #3) whose records were reviewed for discharge processes. The lack of documentation and required notice created the potential for misinformation, poor continuity of care, and uncertainty regarding the resident's rights and discharge planning. […]