Cascades at Riverwalk

Inspectors wroteBased on interview and record review, it was determined that the facility did not inform each resident periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. Specifically, for 2 out of 3 sampled residents, 2 residents did not receive a Skilled Nursing Facility Beneficiary Notice of Non-coverage (SNF ABN) or a Notice of Medicare Non-Coverage (NOMNC) when one was due. Resident identifiers: 60 and 61.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the reach-in refrigerator were not labeled, food in the walk-in refrigerator was not labeled and/or dated, and food in the walk-in freezer was open to air.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 of 39 sampled residents, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not use personal protective equipment (PPE) when administering medications through a peripherally inserted central catheter (PICC) line, staff did not wear PPE when entering resident rooms with contact precautions and PPE was not worn in enhanced barrier precautions (EBP) rooms. Resident identifiers:

Inspectors wroteBased on interview and record review, the facility did not ensure that 1 of 39 sample residents who was continent of bladder on admission receives services and assistance to maintain continence. Specifically, one resident who was continent upon admission later became incontinent and was not on a toileting program. Resident identifier: 24.

Inspectors wroteBased on interview and record review the facility did not provide routine and emergency drugs and biologicals to 1 of 39 sample residents. Specifically, one resident did not have 6 medications available for administration on multiple occasions. Resident identifier: 5.

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 of 39 sample residents' drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Specifically, a resident received a medication used to treat hypotension outside of prescribed parameters. Resident identifier: 5.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure that the resident environment remained as free of accidents hazards as was possible. Specifically, a resident who was in the shower did not have access to a call light. Resident identifier: 3 In response to the incident involving Resident 3, the facility identified the quality deficiency and developed a corrective action plan. At the time of the complaint survey, it was determined that the facility had implemented corrective measures and met the requirements of F689. Due to the facility ' s corrective measures, the noncompliance was determined to be past noncompliance. The facility ' s corrective action plan, which was developed and implemented by April 9, 2025, included the following measures: a. Removing Certified Nursing Assistant (CNA) 1 from the facility staff. b. [...]

Inspectors wroteBased on interview and record review, it was determined, for 1 of 43 sampled residents, that the facility did not ensure that a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections. Specifically, the facility bladder scanner was broken and a resident required bladder scans prior to being straight catheterized (cathed) to remove urine. The resident was transferred to the hospital and diagnosed with a urinary tract infection (UTI) and sepsis. Resident identifier: 77.

Inspectors wroteBased on observation and interview, it was determined that the facility did not ensure a clean and comfortable homelike environment. Specifically, walls with large white patches and not painted, privacy curtain dirty, wheelchair armrests are cracked and have duct tape on them, melted piece of carpet floor, and threshold missing and replaced with duct tape. Resident identifiers:

Inspectors wroteBased on observation, interview and record review it was determined, for 14 of 43 sampled resident, that the facility did not provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, a test tray was bland and resident council minutes revealed complaints of food quality. Resident identifiers: 7, 12, 22, 25, 29, 30, 50, 56, 62, 72, 77, 82, 85 and 365.

Inspectors wroteBased on observation, interview, and record review it was determined, for 2 out of 43 sampled residents, that the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, a resident was observed to have medications on the bedside table in a medication cup and another resident was not evaluated to determine if they were safe to self administer medications. Resident identifiers: 9 and 47.

Inspectors wroteBased on interview and record review it was determined, for 3 out of 43 sampled residents, that the facility did not ensure all alleged violations of abuse, neglect, exploitation or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. Specifically, the facility did not report a allegations of abuse within 2 hours of the allegation. Resident identifiers: 12, 20 and 157.

Inspectors wroteBased on interview and record review, it was determined for 1 or 43 sampled residents that the facility did not ensure the comprehensive care plan included the services needed to achieve the highest practicable physical, mental and psychosocial well-being. Specifically, a resident with pressure ulcers did not have a care plan that addressed the specific pressure ulcers. Resident identifier: 71.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 43 sampled residents, the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents who were unable to carry out the activities of daily living. Specifically, a resident was not showered twice weekly according to his preferences. Resident identifier: 77.

Inspectors wroteBased on interview and record review, the facility did not ensure for 1 of 43 sampled residents, that residents did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and the residents with pressure ulcers received necessary treatment and services. Specifically, a resident developed pressure ulcers during his stay and did not receive timely skin checks or wound treatments. Resident identifier: 71.

Inspectors wroteBased on observation, interview, and record review, it was determined that for 1 of 43 sampled residents, the facility did not ensure a resident receiving enteral feeding received appropriate care and services to prevent complications of enteral feeding. Specifically a resident's feeding tube bag had not been changed for 3 days. Resident identifier: 98 Findings Included: Resident 98 was admitted to the facility 7/12/23 with the following diagnosis that included dysphagia, aphasia, type 2 diabetes mellitus, hemiplegia, hemiparesis, and vascular dementia. On 10/2/23 at 2:12 PM, an observation was made of resident 98's feeding tube setup. A 1000 milliliter (ml) feeding bag was observed with the date of 9/29/23 and time of 1:54 PM. Resident 98's medical record was reviewed on 10/3/23. A physician enteral feed order with a start date of 9/11/23 documented one time a day for enteral care: [...]

Inspectors wroteBased on interview and record the review it was determined, for 1 of 43 sampled residents, that the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident with documented pain had received pain medication recommendations from the pain clinic that were not implemented. Resident identifier: 160.

Inspectors wroteBased on interview and record review it was determined, for 1 of 43 sampled residents, that the facility did not ensure that residents who received psychotropic drugs were not given these drugs unless the medication was to treat a specific condition as diagnosed and documented in the clinical record. Specifically, the facility continued to administer psychotropic medications after the recommendation to discontinued the psychotropic medications. Resident identifier 96.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 43 sampled residents, the facility did not provide each resident with food that accommodated resident allergies, intolerance's and preferences. Specifically, a resident with lactose intolerance was not provided food and a supplement that was lactose free. Resident identifier: 22.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, there were soiled areas in the kitchen and the vents above the food preparation area had dust on them.

Inspectors wroteBased on interview and record review it was determined that the facility did not provide, for 1 of 43 sampled residents, specialized rehabilitative services such as physical therapy and occupational therapy that were required in the resident's comprehensive plan of care. Specifically, a resident was not provided specialized rehabilitation services after returning from the hospital with a physician's orders to be evaluated and treated. Resident identifier: 77.

Inspectors wroteBased on observation, interview, and record review, it was determined, that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 1 out of 43 sampled residents, a resident's urinal containing urine was stored on the bedside table next to and on the resident's food tray. Resident identifier: 92.

Inspectors wroteBased on observations and interviews, it was determined the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. If a qualified dietitian or other clinically qualified nutrition professional was not employed full-time, the facility must designate a person to serve as the director of food and nutrition services who was a certified dietary manager. Specifically, the Dietary Manager (DM) for this facility had not yet completed certification to become a certified dietary manager.

Inspectors wroteBased on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility provided a data analysis that was not dated and incomplete of information regarding who completed the assessment and what actions were being taken to ensure necessary resources to care for its residents.

Inspectors wroteBased on observations, interviews and record reviews it was determined, for 3 of 38 sample residents, that the facility did not ensure residents who were unable to carry out Activities of Daily Living (ADLs), received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, who were dependent on staff for ADL care, showers or bathes were not provided or offered per the assigned bathing schedule. Resident identifiers: 7, 44 and 46.

Inspectors wroteBased on observation, interview and record review it was determined, for 8 of 38 residents, that the facility did not provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment. Specifically, residents complained to the survey staff and in resident council meetings about the staffing level, residents were not receiving regularly scheduled showers, and resident call lights were not being answered in a timely manner. Resident identifiers: 15, 19, 22, 24, 44, 46, 53 and 71.

Inspectors wroteBased on interview and record review it was determined that for 6 of 38 sample residents, the facility did not ensure that the drug regimen of the residents were reviewed at least once a month by a licensed pharmacist. Specifically, residents did not have monthly pharmacy reviews completed and recommendations were not implemented in a timely manner. Residents: 6, 62, 65, 21, 28 and 56.

Inspectors wroteBased on interview and record review, it was determined that for 1 of 38 sampled residents, the facility did not ensure that resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, the facility did not administer medications according to parameters ordered by the physician. Resident identifier: 6.

Inspectors wroteBased on observations, interviews, and record review it was determined, for 14 of 38 sample residents, the facility did not ensure each resident received and provided, food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents had complaints regarding the overall palatability of the food, grievances and resident council minutes revealed complaints about the food, and the test tray was not attractive and palatable. Resident identifiers: 7, 9, 15, 18, 21, 23, 24, 40, 44, 46, 49, 55, 63, and 70.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, staff were observed without Personal Protective Equipment (PPE), a vital signs machine was disinfected in the hallway without the appropriate solution, a laundry aide was not observed performing hand hygiene after touching surfaces in resident rooms, staff did not know where visitors should doff PPE and food was transported uncovered through the hallway.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 38 sample residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident was not provided with interpretive services, her call light was not responded to in a manner that promoted quality of life, and she was spoken of by staff in a manner that did not promote dignity. Resident identifier: 19.

Inspectors wroteBased on interview and observation, it was determined that for 1 or 38 sample residents the facility did not provide reasonable accommodation of the needs and preferences. Specifically, a resident had expressed concerns as well as completed a grievance form regarding a certain staff member. The staff member was still working with the resident. Resident identifier: 322.

Inspectors wroteBased on interview and record review it was determined, for 2 of 38 sample residents, that the facility did not ensure that resident's had the right to request, refuse, and /or discontinue treatment and to formulate an advance directive. Specifically, resident's advanced directives were not accurately documented in the medical records. Resident identifiers: 44 and 62.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined, for 2 of 38 sample residents, the facility did not develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. The facility did not ensure the comprehensive care plans described the services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, resident's care plan interventions were not implemented, in regards to the use of hearing devices and the use of interpretive services . Resident identifiers: 7 and 19.

Inspectors wroteBased on interview and record review it was determined, for 1 of 38 sample residents, that the facility did not provide appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living which included bathing. Specifically, a resident complained they were not showered according to their shower schedules. Resident identifiers: 5. Findings Include: Resident 5 was admitted to facility on 9/26/2020 with diagnoses which included Multiple sclerosis, atazia, polyneuopathy and epilepsy. On 10/25/21 at 9:55 AM, an interview was conducted with resident 5. Resident 5 stated the last shower he received was on 10/20/21. Resident 5 stated that he was scheduled to have showers Tuesdays and Saturday in the afternoon. Resident 5 stated that he would like to have showers on these days but that he was only showered 1 time a week. [...]

Inspectors wroteBased on observations, interviews, and record review it was determined, for 1 of 38 sample residents, that the facility did not ensure that residents received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, the facility did not provide a resident with assistance in maintaining hearing ability through coordination in obtaining hearing aides. In addition, the staff continued to document utilization of hearing aides after the resident's hearing aides had been missing. Resident identifier: 7.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that the environment remained as free of accident hazards as was possible. Specifically, a public restroom that residents had access to had elevated water temperatures in the hand washing sink.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 38 sample residents, the facility did not ensure that residents maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrated that this was not possible. Specifically, one resident who had significant weight loss was not provided interventions to prevent further weight loss. Resident identifier: 6. Findings Include: Resident 6 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus type two, diabetic neuropathy, dementia without behavioral disturbance, chronic kidney disease stage three, cognitive communication deficit, reduced mobility, retention of urine and essential hypertension. On 10/25/21 at 1:57 PM, an interview was conducted with a family member of resident 6. [...]

Inspectors wroteBased on observation and interviews, it was determined, for 1 of 38 sample residents, that the facility did not adequately equip each resident with a communication system that was relaying calls directly to staff or a centralized work area. Specifically, a resident's call light was not functioning properly. Resident Identifier 322. Findings Include: On 10/27/21 at approximately 10:30 AM, an interview was conducted with resident 322. Resident 322 stated that occasionally the wait for a call light to be answered had been hours but had since discovered the call light will not work occasionally. Resident 322 stated that in order to get the call light to turn on. Resident 322 stated she pressed the hand held call light multiple times. Resident 322 stated that if that did not work then resident 322 placed the bed in a relined position to press the call light button on the wall until it lit up. [...]