Clearwater Health & Rehabilitation of Cascadia

Inspectors wroteBased on observation, interview, and review of the U.S. Food and Drug Administration 2022 Food Code, it was determined the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This was true for 1 of 2 garbage cans observed in the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wroteBased on observation, review of the FDA Food Code, and staff interviews, it was determined the facility failed to ensure the kitchen equipment, ice machines, and cutting surfaces were maintained, clean, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 36 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 review of the State Operations Manual (SOM), record review, and staff interview, it was determined the facility failed to ensure residents exercised their right to formulate an Advanced Directive. This was true for 1 of 5 residents (Resident #5) whose records were reviewed. This failed practice created the potential for an adverse outcome if the residents' wishes were not followed.

Inspectors wroteBased on observation, policy review, and staff interview it was determined the facility failed to provide a homelike environment when resident's walls were left unrepaired and baseboard heater coils were left exposed. This was true for 1 of 12 residents (Resident #13) whose rooms were observed. This created the potential for psychosocial harm and embarrassment if residents did not have a homelike environment if their walls and baseboard heaters were not repaired and did not have consistent wall paint.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure an allegation of resident abuse was reported to the State Survey Agency Portal within 2 - 24 hours. This was true for 1 of 3 residents (Resident #6) reviewed for abuse and neglect. This failure created the potential for harm if allegations were not acted upon in a timely manner and the resident abuse continued.

Inspectors wroteBased on record review, review of the SOM, and staff interview, it was determined the facility failed to ensure an allegation of abuse was investigated thoroughly for 1 of 3 residents (Resident #6) reviewed for abuse and neglect. This failure created the potential for residents to be subjected to ongoing abuse and risk of physical and psychosocial harm.

Inspectors wroteBased on record review, policy review, and staff interviews, it was determined that the facility failed to provide hospital transfer documents for 2 of 3 residents (#8 and #42) reviewed for hospitalization. This deficient practice created the potential for residents to experience harm if they were not treated in a timely manner due to lack of information.

Inspectors wroteBased on review of the Resident Assessment Instrument (RAI) Manual, record review, and staff interview, it was determined the facility failed to ensure residents' Minimum Data Set (MDS) Assessments included correct assessment information. This was true for 1 of 2 residents (Resident #13) whose MDS records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on review of records, policy review, and staff interview, it was determined that the facility failed to ensure residents received further evaluation after being identified as having major mental illness. This was true for 1 of 2 residents (Resident #8) reviewed for PASRR Level II evaluations. This deficient practice created the potential for harm if residents specialized services for mental health needs were not evaluated by an appropriate state-designated authority.

Inspectors wroteBased on records review, policy review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the target behavior being monitored for residents. This was true for 2 of 5 residents (#4 and #8) whose care plans were reviewed. This deficient practice created the potential for harm should residents receive inappropriate or inadequate care.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with respiratory services consistent with professional standards of practice. This was true for 1 of 2 residents (Resident #15) whose respiratory device was not stored properly. This deficient practice created the potential to cause contamination of respiratory equipment and increase the risk of respiratory infection for residents who require oxygen therapy.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure nursing assistants (NAs) had completed or had enrolled in a state approved training and competency evaluation program within four months of hire. This was true for 1 of 6 NAs (NA #1) whose personnel file was reviewed. This failure had the potential to compromise the quality and safety of care provided to all residents living in the facility.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This was true for 3 of 3 residents (#4, #28, and #35) whose medications were reviewed. This deficient practice created the potential for Resident #4 to develop hypoglycemia when she did not receive her insulin. Resident #28 was at risk of worsening infection when he did not receive two doses of his antibiotic. Resident #35 was at risk of treatment failure when his cholestyramine was administered at the same time as his other medications

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide a minimum of 12 hours of in-service education per year for 1 of 5 CNAs (CNA #2) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained in competencies to meet residents' needs. Findings Include: On 6/25/26, the prior year's in-service training was requested for CNA #2. On 6/25/26 at 4:12 PM, the ACNO stated she was unable to provide documentation of CNA #2's 12-hour annual training.

Inspectors wroteBased on observation, Food Drug Administration (FDA) Food Code, and staff interview, it was determined the facility failed to ensure kitchen equipment was maintained. This deficiency had the potential to affect the 35 residents who consumed food prepared by the facility. This placed residents at risk for potential foodborne illnesses and adverse health outcomes due to contaminated food services equipment.

Inspectors wroteBased on staff interview, record review, and review of the State Survey Agency's Long-Term Care Reporting Portal, it was determined the facility failed to ensure residents were free from misappropriation of a controlled pain medication. This was true for 1 of 1 resident (Resident #44) reviewed for misappropriation of resident property. This failed practice created the potential for all facility residents to experience uncontrolled pain if misappropriation of their controlled pain medications went undetected, or if their controlled pain medication was not administered.

Inspectors wroteBased on 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 12 residents (Resident #29) whose records were reviewed for accuracy. This deficient practice had the potential for negative outcomes if residents were not monitored due to inaccurate assessments.

Inspectors wroteBased on record review, and staff interview, it was determined the facility failed to ensure residents were offered non-pharmacological interventions while receiving opioid pain medication. This was true for 1 of 5 residents (Resident #7) reviewed for unnecessary medication. This failure created the potential for residents to experience adverse outcomes such as increased pain due to lack of offering non-pharmacological interventions.

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

Inspectors wroteBased on record review, resident interview, and staff interview, it was determined the facility failed to ensure residents received physical therapy services as ordered by their physician. This was true for 1 of 3 residents (Resident #12) whose records were reviewed for rehabilitative services. This failure created the potential for Resident #12, who required physical therapy services, to experience decline in their physical functioning and ability to perform activities of daily living (ADL's) when these services were not provided consistently.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure appropriate infection control measures were maintained when handling an insulin pen. This was true for 1 of 1 (Resident #20) who was observed for insulin administration. This failed practice increased the potential for cross-contamination.

Inspectors wroteBased on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were revised to reflect current needs and interventions. This was true for 3 of 12 residents (#26, #30, and #32) whose care plans were reviewed. This placed residents at risk of adverse outcomes if cares and services were not provided as ordered due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to implement comprehensive, resident-centered care plans to accurately reflect services provided and physician orders. This was true for 1 of 12 residents (Resident #32) whose care plans were reviewed. This placed Resident #32 at risk of worsening pressure ulcers due to a lack of information in her care plan.

Inspectors wroteBased on policy review, record review, observation, and staff and resident interview, it was determined the facility failed to ensure professional standards of practice were met related to following physician orders. This was true for 3 of 6 residents (#26, #30 and #38) whose records were reviewed. These failed practices placed Resident #30 and Resident #38 at risk of seizures, diabetic coma, and other medical complications related to blood glucose levels which were too high or too low; and Resident #26 at risk of complications and further disability from contractures.