Royal Plaza Health and Rehabilitation of Cascadia

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 24, 2021

  Based on record review, Incident and Accident (I&A) report review, resident, family, and staff interview, it was determined the facility failed to ensure residents received the level of supervision necessary to prevent residents with diminished cognitive ability from elopement from the facility and to prevent falls. This was true for 2 of 6 residents (#6 and #12) reviewed for supervision and accidents. The facility's failure to implement and maintain supervision measures to prevent elopement placed Resident #12 in immediate jeopardy of serious harm, impairment, or death. […]

• Immediate jeopardy, isolatedF740Jul 24, 2021

  Based on policy review, record review, staff interview, and resident interview, it was determined the facility failed to ensure a resident was provided with behavioral health care services to maintain her highest practicable physical, mental, and psychosocial well-being consistent with her needs. This was true for 1 of 4 residents (Resident #12) reviewed for behavioral health. The health and safety of all residents residing in the facility were placed in immediate jeopardy when a) Resident #12 was at risk of suicide and ongoing elopement due to inadequate behavioral health services and b) the other 43 residents residing in the facility were at risk of experiencing isolation and compromised physical and psychosocial well-being related to a lack of preventing, relieving, and/or accommodating… […]

• Actual harm, patternF725Jul 24, 2021

  Based on observation, record review, Facility Assessment review, policy review, review of the Facility Assessment, review of I&A Reports, review of staffing schedules, and interviews with residents, family, and staff, it was determined the facility failed to ensure there were sufficient numbers of competent staff to meet supervision, ADL needs, medication administration, and answer call lights in a timely manner for residents. This was true for 16 of 22 residents (#2, #3, #6, #12, #20, #21, #25, #27, #29, #32, #35, #37, #38, #39, #141, and #630) reviewed for staffing concerns. […]

• Actual harm, isolatedF677Jul 24, 2021

  Based on record review, resident representative interview, and resident and staff interview, it was determined the facility failed to ensure residents were provided with bathing and oral care consistent with their needs. This was true for 6 of 12 residents (#3, #12, #20, #32, #37, and #39) reviewed for ADLs. This failure caused psychosocial harm to Resident #39 when she experienced embarrassment her showers were not given and created the potential for other residents to experience embarrassment, isolation, decreased sense of self-worth, skin impairment, and compromised physical and psychosocial well-being. Findings include: 1. Residents did not receive showers and/or baths following their care plan. Examples include: a. […]

• Actual harm, isolatedF686Jul 24, 2021

  Based on record review and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent and treat pressure ulcers. This was true for 2 of 4 residents (#37 and #630) reviewed for wounds. This deficient practice resulted in harm to Resident #37 and Resident #630 when they developed avoidable pressure ulcers in the facility. Findings include: The National Pressure Injury Advisory Panel website, accessed on 7/28/21, defined pressure ulcer staging as follows: Stage 1- Intact skin with a localized area of non-blanchable [CONDITION(S)] (red discoloration of skin as a result of injury) which may appear differently in darkly pigmented skin. […]