Teton Healthcare of Cascadia

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 20, 2024

  Based on observation, policy review, record review, staff interview, and review of the facility's investigation report, it was determined the facility failed to ensure proper storage and use of Hoyer lift equipment to prevent resident falls or injury. This was true for 1 of 1 resident (Resident #233) whose record was reviewed for falls. This resulted in harm to Resident #233 when proper use of a Hoyer lift was not provided. Findings include: The facility Space and Equipment policy revision date 12/4/19, documented under Procedure 6. Resident care equipment is stored after use in an area out of egress while maintaining availability. Licensed nursing and plant operations will validate proper storage and availability of resident care equipment when not in use. […]

• Actual harm, isolatedF726Dec 20, 2024

  Based on observation, review of policy, record review, and interviews, it was determined the facility failed to ensure a) Certified Nursing Assistants (CNAs) were trained and had documented competencies to operate the facility Hoyer lifts and b) Licensed nurses had appropriate competencies and skills sets to provide respiratory related services to residents. This was true for all nursing staff employed by the facility. This had the potential for adverse effects and harm to residents who are transferred with Hoyer lifts or had an order for respiratory therapy. […]

• No harm, potential for more than minimal, widespreadF812Dec 20, 2024

  Based on observation and staff interview, it was determined the facility failed to ensure a) the kitchen equipment and environment was maintained and clean, and b) food was served in a safe and sanitary manner. These deficiencies placed all residents who consumed food prepared by the facility at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section ,d+[DATE].12 Cleaning, Frequency and Restrictions, documented cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. […]

• No harm, potential for more than minimal, patternF584Dec 20, 2024

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all 74 residents who resided in the facility whose equipment and environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified and b) residents were injured due to unsafe areas in the facility. Findings include: The facility's Resident's Environment policy, revision date 11/28/19, documented: - The facility would provide a safe, clean, comfortable, and homelike environment. […]

• No harm, potential for more than minimal, patternF641Dec 20, 2024

  Based on record review and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) had correct assessment information. This was true for 3 of 5 residents (#27, #41, and #52) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments. Findings include: The Resident Assessment Instrument (RAI), revised 10/1/2024, documents if a PASRR (Preadmission Screening and Resident Review) Level II determines a resident has a serious mental illness then section A1500 of the MDS should be marked yes. 1. […]