Twin Falls Transitional Care of Cascadia

In the surveyor’s words

From the most serious findings on record at Twin Falls Transitional Care of Cascadia, in the surveyor’s own words.

• Actual harm, isolatedF684Nov 5, 2021

  Based on policy review, record review, I&A report review, fall investigation summary report review, and resident and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 4 of 5 residents (#1, #3, #5, and #7) reviewed for quality of care. Specifically: * Resident #5 was harmed when he had an unwitnessed fall resulting in pain and an undetected and untreated pelvic fracture and pelvic dislocation. * Resident #1 and #7 were at risk for worsening conditions or adverse reactions when their medications were administered late. * Resident #1 and #3 were at risk for worsening conditions when they did not receive their medications as ordered. […]

• Actual harm, isolatedF686Nov 5, 2021

  Based on record review, policy review, and staff interview, it was determined the facility failed to ensure residents received appropriate care to prevent and treat pressure ulcers. This was true for 3 of 8 residents (Resident #3, #4, and #7) reviewed for wounds. This deficient practice resulted in harm to Resident #3 when his Stage 4 pressure ulcer worsened after a surgical procedure, and Resident #3, #4 and #7, when they developed avoidable pressure ulcers. Findings include: The National Pressure Injury Advisory Panel website, accessed on 11/9/21, defined pressure ulcer staging as follows: Stage 1- Intact skin with a localized area of non-blanchable (skin that does not turn white when pressed with a finger) [CONDITION(S)] (red discoloration of the skin resulting from injury), which may… […]

• No harm, potential for more than minimal, widespreadF812Jul 5, 2024

  Based on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure proper procedures for cooling leftovers were followed; maintain proper holding food temperatures; and equipment, floors, and dishware were cleaned and/or maintained. This placed all 52 residents residing in the facility who received meals from the kitchen at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The facility's policy titled, Use of Leftovers, dated 2021, documented leftovers must be cooled to 70 degrees F (Fahrenheit) within 2 hours and then to 41 degrees F within another 4 hours. […]

• No harm, potential for more than minimal, patternF812Jul 22, 2026

  Based on observation, interview, policy review, and review of the 2022 FDA Food Code, the facility failed to appropriately store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses. Findings include:The facility's Food and Storage Policy dated 11/21/17, documented under Labeling and Rotation, Opened or repackaged food must be labeled with use-by date.The FDA Food Code Section 3-501.17 Ready-to-Eat, TCS (time/temperature control for safety) food, date marking, states marking the date or day the original container is opened in a food establishment, with… […]

• No harm, potential for more than minimal, patternF880Jul 22, 2026

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection. Findings include:The facility's Inhalant (Nebulizer) Medication Administration policy revision date 9/16/25, documented equipment must be cleaned and maintained according to infection control protocols. […]