Cascades Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain a sanitary environment in the kitchen as evidenced by closure by the county health department, due to uncleanliness and pest control issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and follow appropriate interventions for resident at risk for elopement for 1 of 1 resident reviewed for elopement, with the potential to affect 5 residents at risk for elopement (Resident #85).

Inspectors wroteBased on interviews, record reviews and observations, the facility failed to protect the residents' right to be free from neglect when it failed to provide the required structures and processes to maintain and secure the exit doors to meet the needs of residents, for 1 of 1 sampled resident (Resident #1). The deficient practice allowed Resident #1 to leave the facility through an unlocked exit door on 09/12/24 between 4:00 AM and 5:00 AM. Resident #1 wheeled himself in his wheelchair to the facility's loading dock, where he fell and was seriously injured. Resident #1 was transferred to the hospital. There were eighty-nine residents in the facility at the time of the survey. The facility's administrator was notified of Immediate Jeopardy and was given the Immediate Jeopardy Templates on 12/05/24 at 6:22 PM. The Immediate Jeopardy was removed at the time of the facility exit on 12/06/24. [...]

Inspectors wroteBased on interviews, record review and observations, the facility failed to provide supervision and a secure environment to prevent 1 of 1 sampled resident (Resident #1), from exiting the safety of the facility and subsequently experiencing a fall with serious injuries. The deficient practice occurred on 9/12/24 between 4:00 AM and 5:00 AM. While in his wheelchair, Resident #1, exited out an unlocked exit door at the end of the 400-Hallway, on the north side of the facility. Resident #1 then wheeled himself down a concrete walkway to the loading dock where there was a set of three steps. Resident #1 fell down the steps with his wheelchair where he suffered serious injuries to his cervical (neck) spine (vertebrae). Resident #1 was transferred to the hospital via ambulance. There were eighty-nine residents in the facility at the time of the survey. [...]

Inspectors wroteBased on interview, record review, and observation the facility failed to provide appropriate Perineal Care to prevent Urinary Tract Infections (UTIs) for 1 of 1 resident observed for Perineal care (Resident #2).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for: 2 of 4 Residential Units (Gulfstream & Garden), public/staff rest rooms (2), soiled utility rooms ( 4 of 4 ), main dining room, and skilled therapy room.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and interview, the facility failed to a sanitary soiled utility room [ROOM NUMBER] of 4, and failed to have a designated clean area area in the laundry room.

Inspectors wroteBased on interview and record review, the facility failed to appropriately respond to allegations of sexual assault in 1 of 1 sampled resident for sexual assault (Resident #33).

Inspectors wroteBased on observation, interview, and record review, the facility failed to discontinue a Peripherally Inserted Central Catheter (PICC) line in a timely manner for 1 of 1 resident reviewed for PICC line (Resident #67).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide adaptive equipment as ordered to 2 of 2 residents reviewed for assistive devices, Residents #5 and 15.

Inspectors wroteBased on observation, interviews, and records review, the facility failed to ensure that the residents had access to handrails in 4 of 5 units of the facility (Garden, Poinciana, Cobblestone, & Gulfstream).

Inspectors wroteBased on review of policy and procedure, observation and interview, it was determined that the facility staff failed to: 1) ensure that privacy was maintained for a resident during toileting for 1 of 1 sampled residents observed, Resident #58; and 2) ensure that it addressed a resident in a respectful manner for 1 of 1 sampled resident observed, Resident #41.

Inspectors wroteBased on record review and interview, it was noted that 1 of 3 sampled residents (Resident #299) did not receive a notification of Medicare non-coverage (NOMNC) 48 hours prior to termination of skilled rehabilitation services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to perform adequate fingernail care for 1 of 1 resident's reviewed for fingernail care (Resident #27).

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide a leg band for an indwelling urinary catheter (Resident #52, Resident #55, Resident #202, and Resident #205).

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to provide Trauma Informed Care for 1 of 1 sampled residents, Resident #41.

Inspectors wroteBased on review of policy and procedure, observation and interview, it was determined that the facility failed to ensure that it secured and locked up four (4) over-the-counter (OTC) medications for the sampled residents observed, Resident #58, Resident #34, Resident #347 and Resident #28. The facility failed to discard a loose, ¼ sized portion of a pill in 1 of 5 Medication Carts, in the Gulfstream Locked Alzheimer's/Dementia Unit. And, failed to promptly discard an expired OTC stock dry mouth moisturizing medication in 1 of 4 Medication rooms, in the Gardens Unit.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were offered proper hand hygiene during meal times on 4 of 4 units observed during meal times and the facility failed to follow proper infection control during peri and wound care for 1 of 1 resident's observed for wound care (Resident #27).

Inspectors wroteBased on observations, interviews, and records review, it was determined that the facility failed to ensure the normal functioning of the Call Light System in 1 of 4 units (The Garden), to prevent confusion between the system dysfunctional status (emitting continuous beep) and alerts coming from Residents' activated call lights.