Shaw Mountain of Cascadia

In the surveyor’s words

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

• Actual harm, isolatedF604Feb 9, 2024

  Based on observation, record review, and staff interview, it was determined the facility failed to ensure a lap tray was used to treat a medical symptom and not used as a physical restraint for 1 of 1 resident (Resident #78) who was observed for use of restraints. This resulted in harm to Resident #78 was left in a wheelchair with a lap tray for long periods which resulted in skin impairment and psychosocial distress. Findings include: Resident #78 was admitted to the facility on [DATE], with multiple diagnoses including schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior), anxiety disorder, and malnutrition. […]

• Actual harm, isolatedF600Mar 12, 2021

  Based on record review, policy review, Reportable Incident review, staff time card review, and staff interview, it was determined the facility failed to ensure residents were free from verbal and mental abuse. This was true for 1 of 1 resident (Resident #3) reviewed for abuse. This failure resulted in Resident #3 being abused by a staff and the staff continuing to care for Resident #3, placing Resident #3 at risk if continued abuse and the other residents in the facility at risk of abuse. Findings include: The facility's policy for Preventing Abuse, released on 10/1/17 and revised on 7/13/18, documented the following: * The facility had processes in place to assist with preventing abuse. * Residents, visitors, and staff were observed to identify inappropriate behaviors. […]

• Actual harm, isolatedF689Jan 28, 2021

  Based on staff interview, review of facility policies, record review, and review of Incident & Accident (I&A) reports, the facility failed to ensure sufficient supervision of residents to prevent falls. This was true for 1 of 4 residents (Resident #9) reviewed for falls. This resulted in harm to Resident #9 when he had multiple falls and bruised and fractured his little finger. Findings include: The facility's Fall Prevention Program policy, revised 11/28/20, directed staff to identify residents who were at risk for falls and develop individual and practical care strategies based on assessed needs, implement the falls management program, provide ongoing assessment, monitoring, and evaluation of the effectiveness of fall management and to complete a root cause analysis to determine the… […]

• No harm, potential for more than minimal, widespreadF880Mar 7, 2025

  Based on observation, review of the State Operations Manual, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained when 1) staff was assisting residents with meals and 2) medication administration, and 3) unsanitary conditions in the laundry room. This failure had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include: The State Operations Manual, Appendix PP, updated 8/8/24, documented failure to change gloves and wash hands between tasks, such as medical treatments or contact with residents .can contribute to cross-contamination. […]

• No harm, potential for more than minimal, widespreadF727Feb 9, 2024

  Based on facility record review, review of the Payroll-Based Journal Staffing Data Report, and staff interview, it was determined that the facility failed to have an RN on duty for at least eight consecutive hours daily. This was true for 4 of the 31 days reviewed for RN coverage. This created the potential for harm if routine and/or emergency nursing services went unmet and had the potential to affect all residents residing at the facility. Findings include: The Payroll-Based Journal Staffing Data Report for Quarter 1, 2023, documented the facility had no RN coverage on Sunday 12/4/22, Saturday 12/17/22, Sunday 12/18/22, and Monday 12/26/22. […]