Snohomish Health and Rehabilitation of Cascadia

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 1, 2026

  Based on observation, interview and record review the facility failed to ensure residents who engaged in smoking had adequate supervision to protect residents and/or staff from potential fire hazards for 2 of 3 residents (Resident 51 and 32) reviewed for smoking. This failure placed all residents at serious risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy (IJ).The failed practice resulted in an IJ on 04/26/2026 when the facility failed to ensure the residents' environment was safe from burns and fire. The IJ was removed on 04/28/2026 after the facility provided a safe receptacle for properly disposing of cigarette butts, reassessed and educated staff and residents of the facility's no smoking policy and confiscated residents smoking paraphernalia. […]

• Actual harm, patternF686May 1, 2024

  Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, follow written policy and procedures, develop, and implement timely interventions necessary to prevent the development of avoidable pressure ulcers (PUs)for 4 of 6 sampled residents (Resident 1, 2, 3 and 4), reviewed for PUs. These failures caused harm to Resident 1 who admitted to the facility with a Stage 2 PU which deteriorated into an unstageable PU with osteomyelitis (bone infection), debridement (removal of dead [necrotic] or infected skin tissue to try to help wound heal), and a hospital treatment. […]

• Actual harm, isolatedF689May 1, 2024

  Based on observation, interview, and record review, the facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents/falls for 1 of 1 sample resident (Resident 7) reviewed for falls and accident hazards. Resident 7 experienced harm when they fell out of bed and sustained a left hip fracture (broken bone), pain, and required hospitalization . These failures placed residents at risk for potential falls, injuries, and a decreased quality of life. Findings included . Review of the facility's policy titled, Fall Response & Management, revised on 05/17/2021, showed for a fall with injury, staff should avoid moving the resident their status is fully evaluated to prevent further injury if an injury occurred as a result of the fall. […]

• Actual harm, isolatedF697Feb 9, 2024

  Based on observation, interview, and record review, the facility failed to consistently recognize and respond to complaints of pain and failed to consistently implement wound care recommendations related to pain management in accordance with professional standards for 1 of 3 sampled residents (Resident 55) reviewed for pain management. Resident 55 experienced harm when nursing staff failed to recognize and respond to complaints of pain and failed to implement wound care recommendations related to pain management. This failed practice placed residents at risk for unmanaged pain and a diminished quality of life. Findings included . Resident 55 admitted to the facility 06/30/2023 with diagnoses which included diabetes, history of bleeding in the brain, and throat cancer. […]

• Actual harm, isolatedF600Dec 12, 2023

  Based on interview, and record review the facility failed to protect a cognitively impaired resident from unwanted touch for 1 of 1 resident (Resident 2) reviewed for sexual abuse. Resident 2 experienced psychosocial harm, based on a reasonable person concept, when they received a non-consensual sexual touch from Resident 1, who had been identified in the past of inappropriate behaviors and sexually suggestive statements with female staff and a history of wandering into Resident 2's room on multiple occasions. The facility failed to identify an incident of sexual abuse, report it timely to the state agency, and potentially placed cognitively impaired residents at risk for unwanted sexual touch and psychosocial harm. […]