Avamere Rehabilitation of Cascade Park

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and orderly discharge for 1 of 1 residents (Resident 1) reviewed for admission, transfer, and discharge. This failure placed residents at risk of lack of stable housing and disruption of continuity of care.

Inspectors wroteBased on record review and interview, the facility failed to ensure a safe and appropriate discharge for 1 of 3 former residents (Resident 1) reviewed for discharge. As a result of this failure, Resident 1 experienced harm when she was discharged without necessary supports, which led to complications from an existing stage 4 sacral wound requiring hospitalization for symptom management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for 2 of 4 sampled residents (Resident 75 & 112) reviewed for physical restraints. This failure placed residents at risk of injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for 3 of 14 sampled residents (Resident 75, 19, & 71) reviewed for physical restraints, behavior-emotional, dementia care, and unnecessary medications. This failure placed residents at risk for risk of injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received restorative aid (RA) services for 1 of 3 residents (Resident 8) reviewed for activities of daily living. These failures placed residents at risk for further decline and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement physician orders and/or care plans for 1 of 5 residents (Resident 71) reviewed for weights and 1 of 4 residents (Resident 112) reviewed for physical restraints. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor for adverse side effects for antianxiety medication (fast-acting prescription medication used primarily for its calming and sedative effects) for 1 of 5 residents (Resident 19) reviewed for unnecessary medication. This failure placed residents at risk for experiencing side effects and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to use personal protective equipment (PPE, gloves, gown and/or mask) on 1 of 1 resident (Resident 11) reviewed for transmission-based precautions (infection control measures). This failure placed residents at risk of infection transmission and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing hours were accurately posted and/or updated daily for 31 of 31 days reviewed for nurse staff postings. This failure placed residents, resident representatives, and visitors at risk of not being fully informed of the current staffing levels and census information. Findings Included. Record review of the Daily Staffing Hours postings, prior to being edited, from 10/18/2025 to 11/17/2025 were not provided for review. Review of the Daily Staffing Hours postings provided by the facility, from 10/18/2025 to 11/17/2025, showed changes for every day to columns titled Actual Number of staff, and/or Actual Total Hours daily. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate blood sugar monitoring was provided for the administration of oral diabetic medications for 1 of 4 sampled residents [1] reviewed for unnecessary medications. This failure placed residents at risk for not receiving needed medication adjustments and a decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure ulcers were thoroughly assessed, consistently monitored, and skin care and treatment were provided timely to promote healing of an existing pressure ulcer and prevent development of a new pressure ulcer for 1 of 6 sample residents (51) reviewed for pressure ulcers. Resident 51 experienced harm when an existing pressure ulcer on the coccyx worsened and a new pressure ulcer developed to the right buttock and upper thigh area that became infected and required hospital treatment. This failure placed residents at risk for deterioration in skin conditions, discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an assessment, consent and/or physician order was obtained for beds being against the wall and bed rails for 4 of 5 sampled residents (5, 31, 61, & 189) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a manner that promoted residents' dignity related to urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) care for 2 of 2 sampled residents (Residents 11 & 39) reviewed for urinary catheter. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or their representatives were offered the opportunity to participate in care conferences for 1 of 6 sampled residents (53) reviewed for right to participate in planning care. This failure placed residents at risk of a diminished quality of life when not allowed to be involved in their long-term care needs.

Inspectors wroteBased on interview and record review, the facility failed to provide and/or have procedures in place to assist with completing advance directives (AD), and obtaining and maintaining Durable Power of Attorney (DPOA) documentation for 1 of 6 sampled residents (53) reviewed for ADs. This failure place residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a timely response and/or resolution to resident concerns about lost items was completed for 2 of 7 sampled residents (50 & 286) reviewed for grievances. This failure placed residents at risk for not having their concerns addressed, increased frustration and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Bed-Hold notice to the resident or resident's representative at the time of transfer to the hospital for 2 of 6 sampled residents (36 & 31) reviewed for notices of bed holds. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan was developed and implemented for focused areas of care for 1 of 2 sampled residents (61) reviewed for care plans related to skin conditions. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure necessary care and services were provided for positioning in a wheelchair for 1 of 1 sampled resident (#21) reviewed for quality of care related to positioning. This failure placed residents at risk for unmet care needs, discomfort, a diminished quality of life and being unable to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control and prevention practices were implemented for hand hygiene during a clean technique dressing change and during care of catheter bags for 2 of 8 sampled residents (Residents 51 & 11) reviewed for infection prevention and control. This failure placed residents at risk for wound infection, health complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative nursing services to prevent potential avoidable reduction of range of motion (ROM) and mobility for 7 of 10 sampled residents (1, 2, 3, 4, 5, 6 & 7) reviewed for ROM/mobility services. This failure placed residents at risk for increased contractures and decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure cold food items, served to resident, were held at the proper cold holding temperature; and failed to maintain and document refrigerator temperatures for 3 of 3 unit refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness and a diminished quality of life.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure a care conference was held within 72 hours of admission and on a regular basis for 4 of 4 sampled residents (Residents (R) 40, R333, R55, and R71) reviewed for care conferences. This failure placed residents at risk of being uninformed regarding their care and services.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were provided notices of their resident rights, both orally and written, annually for five of five sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the resident council. This had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on interview and observation, the facility failed to ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the resident council were provided information and contact information for the State Long-Term Care Ombudsman program. This had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the Resident Council meeting were familiar with their right to read the facility's survey results and knew where the results of the surveys were located. This had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the Resident Council meeting were provided the opportunity to choose their preferred meal. This had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed ensure 5 of 5 sampled residents (Resident (R) 49, R16, R28, R286, and R1) interviewed in the Resident Council meeting were aware of their right to ask for and receive snacks between meals and at bedtime. This had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on interview, record review, and review of the facility's arbitration agreement, the facility failed to inform residents and/or their resident representative that signed arbitration agreements remained in effect for all care and services rendered at the facility even if such care and services were rendered following a discharge and readmission to the facility for 3 of 4 sampled residents and/or their resident representative (Resident (R) 24, R287, and R50) reviewed for arbitration agreements.

Inspectors wrote2) Review of R48's admission Record, located in the Profile tab of the electronic medical record (EMR), revealed R48 was admitted to the facility on [DATE] with diagnoses including fractures of the bones in his lower legs, end-stage renal disease, and was dependent on dialysis. Review of R48's admission Minimum Data Set (MDS) assessment, located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 07/27/2023, showed R48 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, which indicated R48 was cognitively intact. Review of a Hospital DNR (Do Not Resuscitate) form, located in the Miscellaneous tab of the EMR, showed while in the hospital, R48 had a DNR order in place. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative describing the reason for transfer for 3 of 5 sampled residents (17, 26 & 25) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 1 of 5 sampled residents (26) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital.