Silverton Health and Rehabilitation of Cascadia

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Aug 6, 2021

  Based on observation, resident and staff interview, and review of resident records, facility policies, nursing schedules, and manufacturers' instructions, it was determined the facility failed to ensure infection control measures were consistently implemented when: - There was no designated staff working only with COVID-19 positive residents. - The physical barrier separating the COVID-19 positive unit from other units was not kept closed as required. - A COVID-19 negative resident was placed in the facility's COVID-19 positive unit. - Clinical staff failed to perform hand hygiene between glove changes. - PPE was improperly doffed and donned by clinical staff. - Residents were not offered hand hygiene before meals. - The facility used a cleaning agent that was not EPA-registered. […]

• Actual harm, isolatedF760Oct 4, 2023

  Based on policy review, record review, and staff interview, it was determined the facility failed to ensure residents were free of significant medication errors. This was true for 1 of 7 residents (Resident #8) whose medications were reviewed. This failure created harm to Resident #8 when she received an incorrect administration of medication requiring hospitalization . Findings include: The facility's Medication Errors policy, dated 8/1/23, documented a medication error was the preparation, or administration of drugs or biologicals that were not in accordance with the following: - Prescriber's order - Manufacture's specifications - Accepted professional standards and principles that apply to professionals providing services. […]

• Actual harm, isolatedF584Aug 6, 2021

  Based on observation, record review, and staff interview, it was determined the facility failed to ensure residents were provided with a safe and sanitary environment. This was true for 1 of 12 residents (Resident #3) whose environment was observed. Resident #3, who was unable to express herself, experienced psychosocial harm when she was consistently exposed to a strong odor of urine in her room due to her roommate's lack of compliance with personal hygiene. Findings include: * Resident #3 was admitted to the facility on [DATE], with multiple diagnoses which included Alzheimer's disease. […]

• No harm, potential for more than minimal, widespreadF804Jan 9, 2026

  Based on observation, record review, and resident and staff interview, it was determined the facility failed to provide food which was palatable and within resident's preferred temperature. This was true for all residents eating meals prepared by the facility. This deficient practice created the potential for decreased quality of life, incomplete meal intake due to dissatisfaction with meals. Findings include:On 1/5/26 at 11:35 AM, Resident #6 stated that her cold salads were served warm as it was placed on the hot food plate under the plate cover. She stated she preferred her salads cold, and she did not know why salads were not served with the cold beverages.On 1/6/26 at 12:31 PM, Resident #22 refused her lunch tray. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation, staff interview, and the FDA Food Code, it was determined the facility failed to provide a clean and sanitary environment when staff were observed without appropriate beard guard facial covers while in food preparation areas. This deficient practice created the potential for harm by placing residents at risk for potential foodborne illness, physical food contaminants, and adverse health outcomes. Findings include:The FDA Food Code Section 2-402.11 Effectiveness, documented, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. […]