Stafholt Health and Rehabilitation of Cascadia

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 10, 2025

  Based on interview and record review the facility failed to prevent psychosocial and physical abuse of 1 of 3 residents (Resident 1) reviewed for abuse and neglect. Resident 1, who had a well-known history of sexual trauma, experienced psychosocial and physical harm when during an episode of constipation, a Nursing Assistant Certified (NAC) proceeded to break up and remove the resident's impacted feces without their consent and outside their scope of practice even after the resident told the NAC to stop. […]

• Actual harm, isolatedF692Feb 9, 2024

  Based on observation, interview, and record review the facility failed to offer assistance and supervision with meals, consistently offer an alternative meal when residents at less than 50% of their meal and evaluate the effectiveness of weight loss interventions to determine if additional interventions were needed for 2 of 3 residents (Resident 46 and 31) reviewed for nutritional needs. These failures caused harm to Resident 46 when they experienced a severe weight loss of 9.1% in less than three months and placed other residents at risk for additional weight loss and a decline in their nutritional status. Findings included . […]

• Actual harm, isolatedF686May 3, 2022

  Based on observation, interview, and record review, the facility had a systemic failure to provide accurate comprehensive assessments, monitors, treatments, and the development and implementation of timely interventions to minimize the risk, the development, or the deterioration of a pressure injury for one of three residents (1) reviewed for pressure injury/ulcers. These failures caused harm for Resident 1 who developed an in-house acquired Stage III pressure injury to their right ankle and placed other residents at risk for harm and unmet care needs. […]

• Actual harm, isolatedF689Nov 1, 2021

  Based on observation, interview and record review the facility failed to ensure two of two residents (1 and 2) received adequate supervision related to Resident 1's impulse control and a history of sexually acting out, and Resident 2's cognitive impairment. This failed practice resulted in harm to Resident 2 and placed other residents at a potential risk of harm, pertaining to Resident 1 having unsupervised access. Findings included . Review of the facility's policy for one-to-one supervision showed the facility did not have a policy to address the needs of facility residents who require one to one supervision. […]

• Actual harm, isolatedF740Nov 1, 2021

  Based on interview, and record review, the facility failed to implement behavioral health interventions for one of one resident (1) reviewed for behavioral health. The failure to implement individualized approaches for Resident 1, resulted in harm to Resident 1 related to displacement from their home and placed other residents at risk of physical and psychological harm, and diminished emotional quality of life related to being displaced from their home. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the care plan problem showed that the resident displayed inappropriate behaviors related to a previous TBI, recent stroke and impulse control impairment evidence by inappropriate hand gestures and attempted to… […]