Wellspring Health & Rehabilitation of Cascadia

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Jul 26, 2024

  Based on observation, resident interview, staff interview, and record review, it was determined the facility failed to: 1. a. protect residents who had tested negative for COVID-19 and had a roommate who tested positive for COVID-19 from continuing to be exposed by their cohort and, b. ensure infection control measures were implemented and executed in accordance with professional standards of practice for hand hygiene and use of personal protective equipment (PPE) to prevent the spread of COVID-19. These failures placed the 84 residents currently residing in the facility in immediate jeopardy of serious illness, harm, impairment, or death due to the increased risk of contracting COVID-19. 2. provide COVID-19 vaccinations to every resident who requested vaccination. […]

• Actual harm, isolatedF693Jul 26, 2024

  Based on record review and staff interview, it was determined the facility failed to ensure a person who received nutrition through an enteral tube received the appropriate treatment to prevent complications. This was true for 1 of 2 residents (Resident #85) whose records were reviewed for the use of enteral feeding tubes. This failure harmed Resident #85 and placed other residents who used enteral feeding tubes at risk for feeding tube complications. Findings include: Resident #85 was admitted to the facility on [DATE] with multiple diagnoses including acute respiratory failure with hypoxia (low blood oxygen levels), a tracheostomy (a surgically created opening through the neck into the windpipe to allow air to fill the lungs), she was dependent on the use of a ventilator to breathe (a… […]

• No harm, potential for more than minimal, patternF812Jul 26, 2024

  Based on observation, record review, and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained in a sanitary manner. These deficiencies had the potential to affect 69 of 80 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses. Findings include: The FDA Food Code Section 6-501.12 Cleaning, Frequency and Restrictions. 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, patternF908Jul 26, 2024

  Based on review of the glucometer calibration documentation, policy review and staff interview, it was determined facility failed to ensure glucometers were calibrated to maintain accuracy, ensure reliability, and ensure correct results for 2 of 4 halls (100 Hall and 200 Hall) whose glucometer were reviewed. This deficient practice had the potential for a higher risk for improper blood sugar monitoring of residents who required blood glucose monitoring. Findings include: The facility's Blood Glucose -EvenCare Glucose Monitoring, revised 3/4/24 documented directed staff to calibrate the glucometer nightly or per manufacturer's guidelines. […]

• No harm, potential for more than minimal, isolatedF761Sep 18, 2025

  Based on observations, interviews, and policy review, the facility failed to ensure medications were labeled with open and discard dates, individual insulin syringes were labeled with the resident's name, expired medications were disposed of and not made available, and unknown pill left in pill cup on the medication cart for two of two medication carts (200 hall and 300/500 hall) reviewed. This had the potential to cause medication errors, adverse medication reactions, and residents to receive suboptimal therapeutic actions of medications. […]