Cascades of St. Anne

Inspectors wroteBased on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the proper qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain food safety and services in accordance with professional standards by:1. Not having food items labeled, dated and/or covered for 1 of 1 Kitchen Refrigerator, 2. Not discarding cups of prune juice after their best-by-dates stored in the Steel Kitchen Rack,3. Not monitoring the dishwashing machine temperature,4. Not monitoring the sanitizing solution for the Three-compartment sink,5. Not maintaining the sanitizing solution within the recommended ppm (parts per million - a unit of measurement for concentration) for 1 of 2 sanitizing buckets,6. Not properly disinfecting the food thermometer for 1 of 1 staff (Staff M),7. Not maintaining milk temperature at 41 degrees Fahrenheit at serving time, 8. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents' environment were maintained for 4 of 15 resident rooms (Rooms 159, 161, 170 & 162) and 1 of 1 therapy gym, reviewed for environment. The failure to ensure resident rooms and therapy gym were maintained, air vents were cleaned, baseboard heater cover were in good repair, and lower door frame and walls were repaired, placed the residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 6 of 16 residents (Residents 7, 38, 36, 2, 3 & 19), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure resident assessments were completed accurately on the MDS regarding documentation date of gradual dose reduction (GRD-tapering of medication dosage), immunization status and use of anticoagulants (medications used to prevent blood clots) placed the residents at risk for unidentified and/or unmet care needs, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the facility name and the actual hours worked by registered and licensed nursing staff directly responsible for resident care per shift for 6 of 6 days (01/13/2026, 01/14/2026, 01/15/2026, 01/16/2026, 01/20/2026 & 01/21/2026), reviewed for sufficient and competent nurse staffing. The failure to post a complete and accurate nurse staffing form daily prevented the residents, resident representatives, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was less than five percent (%). The failure to properly administer 3 of 28 medications for 4 of 5 residents (Residents 35, 10, 12 & 31), observed during medication administration resulted in a medication error rate of 10.7%. This failure placed the residents at risk for not receiving the correct form, dose, and/or receiving less than the intended therapeutic effects of physician ordered medications and possible adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. In addition, the facility failed to ensure Transmission Based Precautions (TBP-specialized infection control measures used to prevent the spread of specific infections) were followed by 3 of 5 staff (Staff J, O & V), reviewed for infection control. The failure to change the face mask after exiting a TBP room, use of eye protection (face shield or goggles) before entering a TBP room and perform hand hygiene, placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was evaluated, assessed, and care planned for self-administration of medications for 1 of 1 resident (Resident 23), reviewed for self-administration of medications. This failure placed the residents at risk for medication errors, adverse reactions, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide information regarding advance directive (a written instruction, such as a living will or Durable Power of Attorney for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) for 1 of 3 residents (Resident 3), reviewed for advance directives. This failure placed the resident at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice.

Inspectors wroteBased on interview and record review, the facility failed to ensure report of an incident was thoroughly investigated for 1 of 2 residents (Resident 8), reviewed for accidents. The failure to investigate a fall incident placed the resident at risk for unidentified neglect or mistreatment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide bed hold and/or transfer notices to the residents and/or their representatives in writing for 2 of 2 residents (Residents 25 & 32), reviewed for hospitalization. These failures placed the residents at risk of not having an opportunity to make an informed decision about their transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a care plan for 3 of 15 residents (Residents 2, 15 & 36), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for pressure ulcer (bed sore), anticoagulant (blood thinner), diuretics (water pills-medications that make kidneys produce more urine) and dementia (memory loss) placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care conference or care plan meeting was conducted for 1 of 1 resident (Resident 3), reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 1 of 1 resident (Resident 6), reviewed for Activities of Daily Living (ADL). The failure to provide bath/shower for a resident who was dependent on staff for assistance placed the resident at risk for poor hygiene, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the Oxygen Storage Room door electronic keypad lock was functioning for 1 of 1 oxygen storage room, reviewed for accident hazards. This failure placed residents at risk of accidents, injuries and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a tube feeding [TF - a method of delivering liquid nutrients, fluids, and medication directly into the stomach or small intestine through a flexible tube]) was administered in accordance with physician's orders and professional standards of practice for 1 of 1 resident (Resident 2), reviewed for TF. The failure to follow the physician's orders on the amount of formula to administer, document the amount of formula and water flush administered, and label, with date, and time TF formula bottle and water flush bag placed the resident at risk for unmet nutrition need, adverse health outcomes, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store the Continuous Positive Airway Pressure (CPAP - a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask when not in use and have a proper physician order in place for 1 of 3 residents (Resident 19), reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store biologicals (diverse group of medicines made from natural sources) in accordance with Centers for Disease Control and Prevention (CDC) guidelines and accepted professional standards for 1 of 1 medication refrigerator (Medication Room Refrigerator), reviewed for medication storage. In addition, the facility failed to properly store drugs for 1 of 1 resident (Resident 23). These failures placed the residents at risk for receiving compromised and ineffective medications/biological and medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ sufficient staff that were adequately trained to properly perform kitchen sanitization practices (sanitizing buckets) and safely carry out functions of meal preparation (use of food thermometer) for 2 of 4 dietary staff (Staff L & Staff M), reviewed for food safety. These failures placed the residents at risk for food-borne illnesses (caused by ingestion of contaminated food or beverages) and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia [a lung infection]) were up to date and offered to 2 of 5 residents (Residents 2 & 36), reviewed for pneumococcal immunizations. This failure placed the residents at risk for acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal disease.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation about COVID-19 (a viral illness that causes fever, difficulty breathing or possibly death) vaccination status for 1 of 1 staff (Staff H), reviewed for COVID-19 immunizations. This failure placed staff and residents at risk of exposure to illness from COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to follow the care plan for 1 of 1 resident (Resident 1), reviewed for accident hazards. The failure to follow two-person assistance when providing toileting care and repositioning placed the resident at risk for further falls, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate non-pharmacological interventions for pain management prior to the administration of pain medication for 1 of 2 residents (Resident 1), reviewed for pain management. In addition, the facility failed to adequately monitor adverse side effects of pain medication for Resident 1. These failures placed the resident at risk for unnecessary medications, incomplete pain control and unrecognized adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of antipsychotic (medication used to treat mental disorders) for 1 of 2 residents (Resident 1), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, unrecognized adverse side effects, and related complications. Review of the admission Minimum Data Set (a required assessment) dated 02/14/2025 showed Resident 1 was admitted to the facility on [DATE] with diagnosis that included a delirium (a sudden change in a person's mental state, often characterized by confusion, disorientation, and difficulty thinking clearly). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed use of Personal Protection Equipment (PPE - use of gown, gloves, respirator/N95 mask and face shield/goggles) in accordance with the Centers for Disease Control guidelines when caring for residents with known COVID-19 (highly contagious respiratory disease) infection for 1 of 2 residents (Resident 2), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for COVID-19 infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary supervision for 1 of 1 resident (Resident 1), reviewed for elopement. The failure to provide the necessary supervision for Resident 1 resulted in an elopement and placed the resident at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure survey results were posted in a place readily accessible to residents and residents' legal representatives. This failure prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of correction.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 5 of 16 residents (Residents 9, 17, 3, 31 & 4), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding use of antibiotic (medication to inhibit growth of bacteria), use of insulin (medication/hormone that regulates blood sugar levels) injections, use of anticoagulant (medication to prevent blood clot), use of intrathecal pump (administration of medication through an injection into the spinal canal), use of diuretic (medication to increase urination), and tube feeding (a medical device used to provide nutrients through a tube directly into the stomach) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen tubing/supplies and nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 4 of 4 residents (Residents 9, 22, 32 & 28), reviewed for respiratory care. This failure placed the residents at risk for unmet care needs, respiratory infections, and related complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure the daily nurse staffing form was placed in a prominent place accessible to residents, residents' representatives and visitors. This failure placed the residents, their representatives and visitors at risk of not being fully informed of the current staffing levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs or biologicals (diverse group of medicines made from natural sources) for 1 of 1 Medication Storage Room and 1 of 2 medication carts (South Medication Cart), reviewed for medication storage and labeling. In addition, the facility failed to ensure the Medication Storage Room was free of expired medical supplies and tube feeding (TF-the delivery of nutrients through a tube directly into the stomach to provide nutrition) formulas. These failures placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to periodically test the sanitizing solution/agent used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for food service safety for 1 of 1 kitchen and failed to consistently monitor and document refrigerator temperatures for 1 of 5 refrigerators (Snack Refrigerator), reviewed for food services. In addition, the facility failed to properly label, date, and/or discard nutritional supplements in the Food Refrigerator in the Medication Storage Room. These failures placed the residents at risk for food borne illness [caused by the ingestion of contaminated food or beverages] and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a comprehensive water management program that assessed, measured, and/or monitored potential risk for exposure to Legionnaire's disease (or Legionella - a potentially dangerous bacteria that grows in water, which could cause a serious lung infection) or other waterborne pathogens (a bacterium, virus, or other microorganisms that can cause a disease). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of houseflies for 3 of 3 residents (Residents 29, 93 & 5), for 1 of 1 dining room, and for 1 of 1 kitchen, reviewed for dining and kitchen. This failure placed the residents at risk for infection, maggot infestation (small, worm like bugs that hatch from fly eggs), and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike dining experience was provided for 1 of 8 residents (Resident 94), reviewed for dignity/privacy during dining. This failure placed the resident at risk for dignity issues and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of abuse and/or neglect were thoroughly investigated for 2 of 4 residents (Resident 3 & 31), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 1 of 2 residents (Resident 28), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered for 1 of 2 residents (Resident 28), reviewed for hospitalization. This failure placed the resident or their representative at risk for lack of knowledge regarding the right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) Level I was completed for 1 of 6 residents (Resident 17), reviewed for unnecessary medications. This failure placed the resident at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for 2 of 16 residents (Residents 31 & 17), reviewed for comprehensive care plan. The failure to develop care plans for diuretic (reduce swelling/fluid buildup in the body) medications placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADL) assistance were consistently provided for 2 of 3 residents (Residents 34 & 26), reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with showers/bathing placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure diabetic [diabetes - a disease that occurs when blood sugar level is too high] nail care was provided for 1 of 6 residents (Resident 34), reviewed for quality of care. In addition, the facility failed to ensure residents on diuretic (that helps with edema [swelling] to reduce fluid buildup in the body) and/or anticoagulant medications (that stops blood from clotting too easily to help stop life-threatening conditions) were monitored for adverse side effects for 2 of 6 residents (Residents 31 & 32), reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring of antibiotic (medication to treat infection) side effects and use of antibiotic use had an appropriate diagnosis for 1 of 5 residents (Resident 22), reviewed for unnecessary medications. This failure placed the resident at risk for receiving unnecessary medication and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consistently maintain an established Antibiotic (medications to treat infection) Stewardship Program to promote the appropriate use of antibiotics for 1 of 3 residents (Resident 26), and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs/ symptoms used to determine whether to treat an infection with antibiotic resistance). These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure pneumococcal vaccine (used to prevent pneumonia [a lung infection]) and the COVID-19 vaccine (used to prevent an infectious disease caused by coronavirus) were provided for 1 of 5 residents (Resident 9), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from pneumococcal and/or COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct routine maintenance to ensure side rails were safe to use for 3 of 4 Residents (Residents 32, 5 & 25), reviewed for accident hazards. This failure placed the residents at risk for injury and/or entrapment.

Inspectors wroteBased on interview and record review, the facility failed to timely report an allegation of abuse to the State Agency and failed to initiate timely investigation for 1 of 3 residents (Resident 1), reviewed for abuse reporting. These failures placed the residents at risk for abuse, unmet care needs, and a diminished quality of life. Findings Included . Review of the Abuse/Neglect Prevention Program Policy, dated April 2021, showed residents have the right to be free from abuse/neglect, this includes but is not limited to freedom from physical abuse. (8) Identify and investigate allegations of abuse. (9) Report any allegations within time frames required by the Federal Government. (10) Protect residents from further harm during investigations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed use of Personal Protection Equipment (PPE - use of gown, gloves, respirator/N95 and face shield/goggles) in accordance with the Centers for Disease Control guidelines when caring for residents with known COVID-19 (highly contagious respiratory disease) infection for 1 of 2 residents (Resident 1), reviewed for infection control. This failure placed the residents, staff, and visitors at risk for COVID-19 infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide timely treatment of pressure injuries/pressure ulcers (wounds that occur due to prolonged pressure on the skin) for 1 of 3 residents (Resident 1), reviewed for pressure ulcers. The failure to provide timely treatments for pressure ulcers placed the resident at risk of further decrease in skin integrity, wound infection, and related complications. Findings Included . Review of the admission Minimum Data Set assessment (MDS - an assessment tool) dated 04/08/2024, showed Resident 1 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (weakness or inability to move one side of the body) after a stroke. The MDS also showed Resident 1 required assistance with mobility and was at risk for pressure ulcers. Review of the admission screen form dated 04/02/2024, showed Resident 1 had redness to toes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge process were implemented for 3 of 3 residents (Residents 1, 2 & 3), reviewed for discharge planning. The failure to ensure residents who discharged against medical advice (AMA) were provided risks and benefits prior to leaving the facility placed the residents at increased risk for hospital readmission, injury, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for weight loss and dehydration (lack of necessary fluid intake) were free from neglect when services to provide needed nutrition and hydration were not consistently provided. There was a lack of assessment, follow-up when food and fluid intake was significantly low, and involvement of healthcare professionals to address the low intake. This failure caused harm to Resident 1 who had a significant and unplanned weight loss, dehydration, decline in nutritional status and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional service including assessments and interventions to address significant weight loss and lack of intake for 2 of 3 residents (Residents 1 and 2), reviewed for nutrition/hydration. These failures placed Resident 2 at risk for unmet nutritional needs and caused harm to Resident 1 who had a significant and unplanned weight loss, dehydration (lack of necessary fluid intake), decline in nutritional status, and related complications.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative when there was a change in medications for 1 of 3 residents (Resident 1), reviewed for notification of change. This failure prevented the resident's representative of not having information to make informed decisions or be involved in the resident's health care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inspect food items for quality upon receipt and ensure their proper storage. In addition, the facility failed to keep track of when to discard perishable foods, and failed to ensure foods stored in the freezers and refrigerators were covered, labeled, and dated. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene practices were followed during medication administrations for 3 of 7 residents (Residents 4, 11, & 27) observed for infection control. Additionally, the facility failed to have a water management program that assessed, measured, and/or monitored the growth of Legionella (a water-borne bacteria that can cause pneumonia [a lung infection]) or other waterborne pathogens (an organism that can cause disease). These failures placed the residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label and store drugs and/or biologicals for 1 of 1 medication storage room, and 1 of 2 medication carts (Southwest Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised, incorrect, and/or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective resident centered discharge plan was in place for 1 of 12 residents (Resident 24), reviewed for discharge planning. The failure to initiate a discharge plan consistent with the resident's needs and/or the resident representative's expressed discharge goals, placed the resident at risk for unmet care needs, decreased self-worth, and a diminished quality of life.