Cherry Ridge of Cascadia

Inspectors wroteBased on record review, review of the SOM, and staff interview, it was determined the facility failed to ensure the designated Culinary Manager met the required professional qualifications for overseeing food and nutrition services. This failure had the potential to impact all residents receiving meals and nutrition services.

Inspectors wroteBased on observation, review of the FDA Food Code, review of the SOM, and staff interviews, it was determined the facility failed to ensure 1) the kitchen cooking hood was kept clean, 2) food items were free from mold, 3) personal staff beverages were stored in a manner to prevent contamination, 4) kitchen staff performed proper hand hygiene, 5) required food and refrigerator temperatures were recorded to ensure safe hot-holding and cold-holding of Time/Temperature Control for Safety (TCS) foods. These failures placed all residents who consumed meals prepared by the facility at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on the facility's Quality Assurance and Performance Improvement (QAPI) Committee policy, the facility's Quality Assurance Performance Improvement Plan, and staff interview, it was determined the facility failed to ensure good faith efforts were made to implement and monitor performance improvement activities related to skin assessments and food sanitation. This failure created the potential to affect all residents who reside in the facility and receive nursing services or consume food provided by the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were informed in advance of the care and treatment to be furnished, including the risks and benefits of treatment. This was true for 1 of 5 residents (Resident #23) whose records were reviewed for informed consent. This failure created the potential for miscommunication and adverse effects when Resident #23 was not informed in advance of the risks and benefits of his ordered medication.

Inspectors wroteBased on observation, resident and staff interviews, it was determined the facility failed to ensure residents' call lights are within their reach. This was true for 1 of 1 resident (Resident #38) reviewed for residents' rights. This deficient practice created the potential for harm if the resident could not call for assistance when needed or experienced an adverse medical event that required attention.

Inspectors wroteBased on the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure a copy of a resident's advance directive was maintained in the medical record. This was true for 1 of 12 residents (Resident #32) whose records were reviewed for advanced directives. The absence of the advance directive created the potential for an adverse outcome if Resident #32 became unable to communicate treatment preferences and those preferences were not available to guide care.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure medications were administered with an appropriate clinical indication. This was true for 1 of 5 residents (Resident #23) reviewed for unnecessary medications. The lack of an appropriate indication created the potential for chemical restraint use and improper medication administration.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to ensure an allegation of misappropriation was reported to the State Agency as required. This was true for 1 of 1 resident (Resident #23) reviewed for misappropriation. This failure created the potential for poor communication and continued misappropriation of resident funds.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to ensure an allegation of misappropriation was investigated as required. This was true for 1 of 1 resident (Resident #23) reviewed for misappropriation. This failure created the potential for continued misappropriation of resident funds.

Inspectors wroteBased on record review, policy review, and staff interviews, it was determined the facility failed to ensure that a written notice of discharge was provided to 1 of 3 residents (Resident #37) whose records were reviewed for discharges and transfers. This failure created the potential for Resident #37 to be without access to discharge information or appeal advocacy resources.

Inspectors wroteBased on record review, resident observation, and staff interviews, it was determined the facility failed to implement a comprehensive, person centered care plan as written. This was true for 1 of 12 residents (Resident #32) whose record was reviewed for care plan implementation. This failure created the potential for Resident #32 to develop pressure injuries and adverse outcomes when his heels were not offloaded as directed by his care plan.

Inspectors wroteBased on observation, policy review, record review, and staff interviews, it was determined the facility failed to ensure resident's medications were administered according to professional standards of practice. This was true for 1 of 1 resident (Resident #30) whose medication was reviewed and true for 1 of 3 residents (Resident #9) whose medication administration was observed. This failed practice created the potential for Resident #30 to receive improper treatment, skin irritation, allergic reaction, or other adverse outcomes and created the potential for Resident #9 to not receive the full dose of their prescribed eye drops.

Inspectors wroteBased on record review, resident observation, and staff interviews, it was determined the facility failed to ensure podiatry treatment orders and care plan interventions were implemented as written. This was true for 1 of 1 resident (Resident #32) reviewed for podiatry services. This failure created the potential for untreated foot conditions, discomfort, and deterioration of skin integrity due to the lack of required podiatry services.

Inspectors wroteBased on record review, resident observation, and staff interview, it was determined the facility failed to ensure proper monitoring was conducted to identify potential catheter associated urinary tract infections. This was true for 1 of 3 residents (Resident #32) reviewed for catheter care. This failure created the potential for undetected signs of infection if Resident #32 was not monitored for appropriate symptoms.

Inspectors wroteBased on observation, resident and staff interviews it was determined the facility failed to ensure an oxygen concentrator was removed from the resident's room after the physician discontinued the resident's oxygen order. This was true for 1 of 1 resident (Resident #12) whose oxygen concentrator was observed. This deficient practice created the potential for harm if the resident attempted to use the oxygen equipment without a valid physician order.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure medications were administered with an appropriate clinical indication. This was true for 1 of 5 residents (Resident #23) reviewed for unnecessary medications. The lack of an appropriate indication created the potential for improper medication administration and use of medication without a clearly defined clinical need.

Inspectors wroteBased on resident interview, staff interview, and record review, it was determined the facility failed to ensure food was served at palatable temperatures as required. This was true for 1 of 1 resident (Resident #31) reviewed for food quality. This failure created the potential for reduced enjoyment of meals and decreased dietary intake when food was not served at acceptable temperatures.

Inspectors wroteBased on record review and staff interviews, it was determined the facility failed to ensure a physician order was clarified regarding its clinical indication and medication dosage. This was true for 2 of 2 residents (#1 and #12) whose records were reviewed. This deficient practice resulted in inaccurate documentation within the resident's medical record.

Inspectors wroteBased on record review, policy review, and interviews it was determined the facility failed to consider caregiver/support person availability, capacity, and capability to perform required care as part of the identification of discharge needs. This was true for 1 of 3 residents (Resident #1) reviewed for the facility's transfer and discharge process. This deficient practice created the potential for harm when Resident #1 was transported to a homeless shelter that was unable to provide the required level of care.

Inspectors wroteBased on record review, CMS SOM Appendix PP, policy review, and staff interview, it was determined the facility failed to ensure resident centered care plans were comprehensively written. This was true for 1 of 3 residents (Resident #1) whose care plans were reviewed in the sample. This deficient practice created the risk of adverse outcomes if residents comprehensive care plans did not reflect the care necessary for each resident.

Inspectors wroteBased on record review, CMS SOM Appendix PP, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect current needs and interventions. This was true for 1 of 3 residents (Resident #1) whose care plans were reviewed in the sample. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure medications available for residents were labeled and dated. This was true for 1 of 2 medication carts inspected. This failure created the potential to receive expired medication with decreased efficacy.

Inspectors wroteBased on observation, record review, resident and staff interview, it was determined the facility failed to provide a pest-free environment and an effective pest control program. This deficient practice created the potential for facility residents (#3, #4, #6, #7, #12, #13, #16, #19, #24, #25, #26, #27, #28, #29, and #39) to experience pest infestation if measures were not taken to eradicate and contain common household pests like flies.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure food was stored appropriately, dated, and not contaminated by ice, and the kitchen was clean and free of pests. These deficiencies had the potential to affect the 31 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on record review, observation, and staff interview, it was determined the facility failed to implement effective infection control practices during medication administration and shower room sanitation. This failure created the potential to affect all residents who reside in the facility due to risk for cross-contamination and adverse outcomes.

Inspectors wroteBased on review of The Long-Term Care Agency reporting portal, facility's incident report, record review and staff interview it was determined the facility failed to conduct a thorough investigation into an allegation of abuse. This was true for 1 of 3 residents (Resident #7) whose record was reviewed for Abuse and Neglect. This failure created the potential for undetected harm due to incomplete investigative procedures.

Inspectors wroteBased on the review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure a residents Minimum Data Set assessment included correct information. This was true for 1 of 3 residents (Resident #6) whose records were reviewed for accuracy of assessments. This deficient practice had the potential for negative consequences if residents were not monitored due to inaccurate assessments.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to refer residents with a diagnosed mental disorder to the appropriate state-designated authority for an evaluation and determination. This was true for 3 of 3 residents (#5, #6, and #8), reviewed for PASRR level I evaluations. This deficient practice had the potential to cause harm if resident's specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on observation, record review and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate with hours posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on facility policy, record review, and staff interview it was determined the facility failed to ensure significant medication errors were prevented. This was true for 3 of 3 residents (#2, #3, and #17) whose records were reviewed for significant medication errors. These findings created the potential for increased pain and adverse outcomes when medication was not administered according to the resident's physician order.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a minimum of 12 hours of in-service education per year for 2 of 3 CNAs (Certified Nursing Assistants; #1 and #2) reviewed for sufficient and competent CNA staffing. This deficient practice placed residents at risk of receiving care from staff who were not adequately trained to meet residents' needs.

Inspectors wroteBased on record review, review of the State Survey Agency's Long-Term Care Reporting Portal, hospital record review, and staff interview, it was determined the facility failed to ensure a resident's care plan was followed to prevent falls. This was true for 1 of 4 residents (Resident #10) whose records were reviewed for falls. This failure harmed Resident #10 when she suffered fractures to her right lower leg after a fall from her bed.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a RN was on-site 8 consecutive hours a day, 7 days a week to provide care and treatment to the residents. This is true for 5 of 21 days reviewed for sufficient staffing. This failure created the potential for harm if routine and /or emergency nursing needs were unmet and had the potential to affect all 33 residents in the facility.

Inspectors wroteBased on policy review and staff interview, it was determined the facility failed to ensure residents were provided with clean equipment to obtain vital signs and perform transfers. This deficient practice created the potential for residents to experience psychosocial harm if unclean equipment was used for their care.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity. This was true for 3 of 7 residents (Resident's #24, #26, and #29) observed during dining in the facility. This deficient practice had the potential for residents to experience embarrassment, and low feelings of self-worth.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure resident records were provided to the hospital upon transfer. This was true for 1 of 2 residents (Resident #16) reviewed for hospital transfers. This deficient practice created the potential for harm if Resident #16 was not treated in a timely manner due to lack of information provided upon transfer.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure medication was administered according to professional standards of practice. This was true for 1 of 5 residents (Resident #31) observed during medication administration. This created the potential for Resident #31 to develop a yeast infection when she did not rinse her mouth with water after taking her medication.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice was followed for 1 of 13 residents (Resident #32) reviewed for standards of practice. Resident #32's care plan was not followed as directed. This deficient practice created a potential for harm to Resident #32 if care and services were not delivered according to her care plan.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents taking antipsychotic medications received an abnormal involuntary movement scale (AIMS) evaluation. This is true for 2 of 5 residents (Resident's #5 and #16) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents receiving antipsychotic medications were not monitored for adverse side effects.