Village Manor of Cascadia

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 12, 2025

  Based on interview and record review, it was determined the facility failed to implement care plan interventions to prevent a fall for 1 of 3 sampled residents (#1) reviewed for accidents. As a result, Resident 1 sustained multiple pelvic fractures. Findings include:Resident 1 was admitted to the facility in 2025, with diagnoses including dementia. Resident 1's 7/25/25 Care Plan revealed Resident 1 was a fall risk because of a prior fall and was a one-person max assist for dressing. Resident 1 was care planned for supervision and touch assistance for bathing, used a shower bench or bathtub, and was to wear non-skid footwear when up. A 7/28/25 FRI indicated Staff 5 (Housekeeping) and Staff 6 (Housekeeping) reported Resident 1 had a fall in the shower room. […]

• Actual harm, isolatedF689Aug 10, 2021

  Based on interview and record review it was determined the facility failed to follow the care plan to prevent falls for 1 of 3 sampled residents (#4) reviewed for accidents. Resident 4 sustained a spinal fracture as a result of a fall. This placed residents at risk for injury. Findings include: Resident 4 admitted to the facility in 2016 with diagnoses including Alzheimer's disease. A 3/18/21 Physical Restraint/Device Record of Informed Consent revealed Resident 4 was to have a floor pressure mat alarm and seat belt alarm in place for fall preventions. […]

• No harm, potential for more than minimal, widespreadF880Jun 11, 2021

  Based on observations, interviews and record review it was determined the facility failed to maintain appropriate infection control practices to prevent the spread of the COVID-19 virus and other infectious diseases for 2 of 2 halls, 1 of 1 breakrooms and 1 of 1 PPE storage areas reviewed for infection control. This placed residents at increased risk for infections. Findings include: 1. The Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last revised 2/23/21, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing personal protective equipment (PPE) which included gloves. […]

• No harm, potential for more than minimal, patternF578Jan 17, 2024

  Based on interview and record review it was determined the facility failed to determine if residents had or wished to formulate an advance directive upon admission to the facility for 3 of 3 sampled residents (#s 9, 18 and 56) reviewed for advance directives. This placed residents at risk for not having their health care wishes honored. Findings include: 1. Resident 9 was readmitted to the facility in 6/2023 with a diagnosis of suicidal ideations. A review of Resident 9's clinical record revealed no evidence the resident had an advance directive or wished to formulate an advance directive upon admission to the facility. […]

• No harm, potential for more than minimal, patternF847Jan 17, 2024

  Based on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents (#s 42, 55 and 58) reviewed for binding arbitration agreement. This placed residents at risk of being uninformed regarding their legal rights. Findings include: The facility's undated Admission Agreement included the following: The Resident and/or Legal Representative understands that his Arbitration Agreement may be rescinded by giving written notice to the Facility within 10 days of its execution, this Arbitration of its execution. If not rescinded within 10 days of its execution, this Arbitration Agreement shall remain in effect for all claims arising out of the Resident's stay at the Facility. […]