Cashmere Post Acute

Inspectors wroteBased on interview and record review the facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate required to perform laboratory tests within the facility. This failure placed residents at risk for substandard care, delayed diagnosis and incorrect medical treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure 3 of 5 residents (Residents 81, 2, and 77) were reviewed for gradual dose reduction (GDRs- the slow, step-by-step process of decreasing a residents medication overtime), or provide a clinical rationale for its contraindication as required for the use of psychotropic medication (drugs that alter brain function used to treat mental health conditions) reviewed for unnecessary medications. This failure placed residents who used psychotropic medications at risk for adverse side effects (ASEs) which could negatively impact their overall health and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and implementation of care plan interventions to prevent resident-to-resident altercations for 3 of 3 residents (Residents 48, 38, and 3) reviewed for accidents. This failure placed the residents at risk for potential verbal and physical abuse, serious pain, injury, and emotional distress. Additionally, the facility failed to ensure 1 of 3 residents (Resident 77), who utilized a transfer pole, had a process in place to ensure appropriate placement of equipment for safety and to mitigate the risk of entrapment. This failure placed Resident 77 at risk for injuries if improperly placed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 1 of 1 kitchen areas (dishwasher room) and 3 of 4 utility rooms (West clean and soiled utility rooms, and the South clean utility room) reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their environment.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received dignified care and services by ensuring delivered care from their preference of female caregivers for 1 of 3 residents (Resident 79) reviewed for resident rights. This failure placed the resident at risk for compromised dignity, diminished self-worth, decreased self-esteem, and feelings of embarrassment.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 4 residents (Resident 100) reviewed for urinary (the body's processes, organs, or functions related to the productions, storage, and discharge or urine) catheter, were fully informed of their care. This failure placed the resident at risk of poor understanding in their health care decisions and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents 48 and 38) reviewed for resident-to-resident altercations with Resident 3. This failure placed the residents at risk for continued abuse, injury, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse prevention policy in the areas of identification, investigation, protection, and reporting for 2 of 3 residents (Residents 48 and 38) reviewed for altercations with Resident 3. This failure placed the residents at risk for continued unidentified abuse, fear, and dissatisfaction with their living situation.

Inspectors wroteBased on interview and record review, the facility failed to ensure an incident of abuse was reported to the State Agency as required for 1 of 3 residents (Resident 48) reviewed for an altercation with Resident 3. This failure placed the residents at risk for additional/continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an incident of abuse for 1 of 3 residents (Resident 48) reviewed for an altercation with Resident 3. This failure placed the residents at risk for further unidentified and/or further abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of transfer to the hospital for 1 of 3 residents (Resident 10) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed prior to admission for 1 of 5 residents (Resident 81 ) and updated when new SMIs were identified. and had the required Level II (a comprehensive evaluation by the appropriate state-designated authority) referral if residents had a positive Level I (a pre-screening evaluation for identifying SMI/ID/DD) PASARR for 1 of 5 residents (Resident 3) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings Included . [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fluids were readily available and provided to 1 of 3 residents (Resident 88) and to identify and monitor skin bruising for 1 of 4 residents (Resident 79) reviewed for quality of care. This failure placed the residents at risk for excessive thirst, dehydration, further skin injury and serious adverse health conditions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding a resident history of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening or traumatic event) for 1 of 5 residents (Resident 81) reviewed for trauma-informed care .This failure placed the resident at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were destroyed in 1 of 1 medication room and failed to ensure refrigerated medications were stored at proper temperatures in 1 of 1 medication refrigerator. These failures placed residents at risk of receiving medications that could cause unintended outcomes due to improper storage and compromised efficacy. Findings Included. Review of the facility's undated policy titled, Medication Storage, showed to ensure all medications would be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. During an observation on 04/01/2026 at 9:37 AM, the facility medication room showed the following expired supplies and medications were identified: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a designated Infection Preventionist (IP) who worked at least part-time at the facility and was responsible for the facility's Infection Control and Prevention Program (IPCP), including implementation of infection prevention measures to prevent the spread of communicable diseases. These failures placed the residents at risk for transmission of infectious disease and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan, within 48 hours of admission, that documented resident-specific goals and treatment plans for 3 of 4 residents (Residents 48, 196, and 9) reviewed for baseline care plan. Failure to develop a baseline care plan placed the residents at risk of not receiving continuity of care and resident centered care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) store Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) and dry goods that did not have the proper labels and dates for food safety tracking for 1 of 1 kitchen reviewed, 2) adequately disinfected food preparation areas to prevent cross contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's right to choose important aspects of their life, including frequency of showers and meal preferences for 2 of 3 residents (Residents 87 and 22) reviewed for choices. This failure disallowed Resident 87 the opportunity to increase their weekly showers and Resident 22 the right to dietary preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain confidentiality of medical conditions through posting of signs in a Resident's room for 1 of 7 residents (Resident 84) reviewed for resident's rights. Posting a sign that identified a medical condition, prevented protection of residents' right to privacy of a medical condition.

Inspectors wroteBased on observation and interview, the facility failed to ensure a sanitary and homelike environment for 1 of 1 shower room reviewed for environment. This failure placed residents at risk for not having a comfortable and homelike experience during showers.

Inspectors wroteBased on interview and record review, the facility failed to issue a written notice of bed hold (holding or reserving a resident's bed while the resident was absent from the facility) at the time of hospital transfer for 2 of 4 residents (Residents 27 and 58), reviewed for hospitalization. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed and monetary charges associated with the bed hold while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] assessment accurately reflected residents' mental health conditions for 3 of 6 residents (Resident 51, 55, and 84) reviewed for unnecessary medications. Additionally, the facility failed to ensure a PASARR was completed prior to admission for 1 of 6 residents (Resident 9) reviewed for PASARR screening on admissions. These failures placed residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive Care Plans (CPs) for one of seven residents (Resident 27) whose CPs were reviewed. The failure to develop and/or implement comprehensive CP interventions left residents at risk for unmet care needs and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a process of monitoring daily fluid intake for residents with a physician's order for daily fluid restriction for 1 of 2 residents (Resident 196) reviewed for quality of care. Additionally, the facility failed to identify and provide needed care and services for 1 of 2 residents (Resident 4) reviewed for positioning. These failures placed the residents at risk for health complications and poor clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an effective pain management program for 1 of 3 residents (Resident 51) reviewed for pain management. This failed practice placed the residents at risk for unmanaged pain and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Two medication errors were identified for 2 of 10 residents (Residents 345 and 8) observed during 26 medication administration opportunities that resulted in an error rate of 7.69%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from use for 2 of 4 medication carts (South and North) and 1 of 4 medication carts (East), and 1 of 2 wound carts were secured when unsupervised. Additionally, the facility failed to follow Centers for Disease Control (CDC) guidance for temperature monitoring of vaccines in 1 of 1 medication storage refrigerator located in the medication storage room. These failures placed the residents at risk for receiving expired medication and/or experiencing compromised or ineffective medications and vaccines and access to potentially harmful medications and negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Infection Control and Prevention Program (IPCP) including implementation of infection prevention measures to mitigate the spread of infection in the areas of hand hygiene for 1 of 1 staff (Staff Q) during dining service, cleaning of equipment for 8 of 8 staff (Staff W, Y, S, V, T, U, AA, and BB) during transfers with a mechanical lift, wound care for 1 of 1 staff (Staff C) while performing a dressing change, enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) for 7 of 7 staff (Staff EE, L, CC, FF, GG, HH, and N) during high contact resident care, transmission-based precautions (additional infection control precautions used in healthcare to prevent the spread of disease) for 2 of 2 staff (Staff U, and AA) while [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 4 of 5 days of the survey period. This failed practice prevented residents, family members and visitors from knowing the facility's actual number of available nursing staff.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an incident involving a missing resident for 1 of 3 residents (Resident 1) reviewed for elopement (when a resident leaves the premises or a safe area without authorization or appropriate supervision). The failure to complete a thorough investigation placed the resident at risk for re-elopement and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received substance use disorder (SUD, a medical condition that is defined by the inability to control the use of a particular substance or substances despite harmful consequences) assessments and interventions for 3 of 3 residents (Residents 1, 2, and 3) reviewed for elopement (when a resident leaves the premises without authorization or necessary supervision to do so). Additionally, the facility failed to timely implement all aspects of their elopement process when Resident 1 eloped from the facility twice. These failed practices placed residents at risk for unidentified risk factors and preventable accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 1) and/or their representative was informed of an increase in their monthly financial responsibility before charging the debit card on file. This deficient practice placed residents at risk of financial hardship and potential loss of other benefits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable accident by ensuring the plan of care regarding transfers was followed for 1 of 3 residents (Resident 1) reviewed for accidents. The failure to safely transfer Resident 1 using two-person assist resulted in an assisted fall and Resident 1 experienced harm when they sustained a facial laceration (a skin wound usually caused by a sharp object or blunt trauma) requiring evaluation and intervention by the local emergency room (ER).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 5 nursing assistants registered (P, Q, R, S and T) met competency requirements defined under State Law, for license and certification. This failure placed residents at risk to receive care from an unlicensed staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for 4 of 5 residents (Residents 22, 35, 24, and 188) reviewed for unnecessary psychotropic medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, Resident Representative (RR), or payee were notified when their personal funds account reached a balance that was below $200 of the Social Security Income (SSI, a monthly Social Security benefit for people with low incomes, limited resources and who are blind, disabled or 65 or older) resource limit of $2000, for 1 of 5 residents (Resident 24) reviewed for personal funds. This failed practice placed the resident at risk of losing their Medicaid (a federal system of health insurance for those requiring financial assistance) or SSI eligibility.

Inspectors wroteBased on interview and record review, the facility failed to implement a process to assist residents and/or their representatives in the development and periodic review of Advanced Directives (AD) for 2 of 3 residents (Resident 60 and 19) reviewed for AD. This deficient practice denied the residents and/or their representatives the opportunity to make their choices known, regarding end-of-life care.

Inspectors wroteBased on interview and record review, the facility failed to provide a required liability notice for 1 of 3 residents (Resident 77) reviewed for liability notices, who was discharged from the facility and had skilled benefit days remaining. This failure placed the resident at risk for not fully understanding their Medicare benefits.

Inspectors wroteBased on interview, and record review, the facility failed to implement a system for notifying residents of the grievance process or how to report a grievance (verbally, in writing or anonymously) for 16 of 16 residents (Residents 5, 243, 15, 18, 19, 37, 38, 45, 47, 60, 65, 66, 81, 82, 239 and 241) reviewed during resident council. Additionally, the facility failed to consistently follow up on missing items and concerns voiced during resident council meetings. This failure placed residents at an increased risk for unresolved concerns, their right to express their concerns and unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to comprehensively assess and monitor the need for a physical restraint (any physical, mechanical device or equipment that limits a resident's freedom of movement) when applying foam wedges under the resident's bed linen which prevented the resident from getting out of bed, for 1 of 1 resident (Resident 42) reviewed for physical restraints. This failure placed the resident at risk for the inhibition of free movement and/or activity and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to the state agency for 1 of 6 residents (Resident 55) reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential for ongoing abuse and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a thorough or complete investigation following allegations of rape and/or abuse for 1 of 6 residents (Residents 55) reviewed for abuse. This failure placed the resident at risk for unidentified abuse, unmet care needs, and the potential continued exposure to abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP) to address anticoagulant (a high-risk, blood thinning medication) use for 1 of 6 residents (Resident 26) reviewed for activities of daily living. This failure placed the resident at risk for unrecognized adverse side effects (ASE) and unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that 2 of 2 residents (Resident 27 and 55) reviewed for constipation were assessed daily for frequency of bowel movements, and signs and symptoms of impaction or obstruction, in accordance with professional standards of practice. Additionally, the facility failed to develop an integrated comprehensive care plan for 1 of 1 resident (Resident 246) reviewed for Hospice. These failures placed residents at risk for medical complications and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 1 resident (Resident 54), reviewed for urinary catheter care. This placed the resident at risk of developing medical complications, secondary to an infection in the bladder.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were adequately monitored and/or administered within the physician ordered parameters (instructions to ensure medications are properly given and may prevent unwanted effects) for 2 of 7 residents (Residents 22 and 29) reviewed for unnecessary medications. These failures placed residents at an increased risk for adverse side effects, unintended medical complications, and unmet care needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled, dated, or discarded in accordance with currently accepted professional standards for 1 of 1 medication room and 2 of 4 medication carts (West and East carts). This deficient practice placed residents at risk of receiving compromised or inaccurate medications and had the potential for misappropriation of residents' property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices for 4 of 4 residents (Resident 246, 189, 190 and 54 ) were implemented related to hand hygiene and glove changes between dirty and clean tasks (after touching the resident and/or the resident's environment and during wound care dressing changes). These failures placed the residents at an increased risk for exposure to cross-contamination (harmful spread of diseases) and transmission of infectious diseases.