Eagle Rock Health and Rehabilitation of Cascadia

Inspectors wroteBased on policy review, record review, and staff interviews it was determined the facility failed to ensure pertinent health information was provided to the receiving health facility for 5 of 9 residents (Resident #1, #3, #7, #11, and #28) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if the residents were not treated in a timely manner due to a lack of information provided upon transfer.

Inspectors wroteBased on interview, policy review, and staff interview, it was determined the facility failed to complete a baseline care plan for 2 of 2 residents (#4 and #70). This failure created the potential for harm when staff were not provided direction of care for resident. The facility also failed to provide a resident's baseline care plan to the resident or his/her representative for 5 of 7 residents (#7, #9, #11, #21, and #28) reviewed for baseline care plan. This failure placed residents and their representatives at risk of not being informed and having input in their care plan.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled, dated, and were secure and inaccessible to unauthorized staff and residents; this was true for 2 of 2 medication carts inspected and 1 of 1 treatment carts observed. This failure created the potential for residents to receive expired medications with decreased efficacy, the potential for adverse effects if residents self-administered medications inappropriately, and the potential for residents to obtain prescribed wound care supplies used for other residents and presented the risk for cross-contamination of wound care products stored in the treatment cart.

Inspectors wroteBased on record review, observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. This was true for 1 of 1 resident (Resident #12) and the facility observed for infection control. These failures put residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, policy review, and interviews it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 2 of 2 Residents (#23 and #70) reviewed for respect and dignity. This deficient practice placed residents at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure informed consent was obtained prior to initiation of psychotropic medications for 1 of 3 residents (Resident #12) reviewed for unnecessary medications. This deficient practice placed residents at risk of receiving medications without knowledge of the reason why medications were prescribed, the expected benefits, and the risks associated with the medications.

Inspectors wroteBased on observation, resident and staff interviews, record review, and policy review it was determined the facility failed to assess whether residents had the ability to self-administer their medications for 1 of 1 resident (Resident #59) reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure a resident and their representative received assistance to exercise their right to formulate an Advance Directive. This was true for 1 of 22 residents (Resident #8) whose records were reviewed for Advance Directives. This deficient practice created the potential for harm or adverse outcomes if the residents wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on observations and interviews, it was determined the facility failed to ensure residents were provided with a safe, clean, and homelike environment. This was true for 2 of 22 resident rooms (#211 and #212), shower rooms, and other areas throughout the facility which were observed. This deficient practice created the potential for diminished quality of life and resident safety.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents' hospital discharge instructions were reviewed upon admission to the facility to assure physician orders were in place to meet their medical needs. This was true for 2 of 2 residents (#9 and #37) whose records were reviewed. This failure placed these residents at risk of delayed respiratory care and assessments.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to complete a significant change in condition or status assessment MDS within 14 days to accurately reflect the resident's status. This was true for 1 of 1 resident (Resident #4) whose medical record was reviewed. This deficient practice had the potential for negative outcomes if the resident was not assessed and cared for or monitored due to inaccurate assessments.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a Level 1 Pre-admission Screening and Resident Review (PASARR I), was completed correctly for 1 of 1 resident (Resident #13) reviewed for Level 1 PASARR screenings. This failure created the potential for harm if residents required, but did not receive specialized services for mental health while residing in the facility.

Inspectors wroteBased on observation, policy review, interview, and record review, the facility failed to develop and implement resident's comprehensive person-centered care plan. This was true for 1 of 1 resident (Resident #13) whose care plan was reviewed. This deficient practice of not developing and implementing care plans placed residents at risk to their health and wellbeing with negative outcomes if services were not provided or provided incorrectly.

Inspectors wroteBased on observation, interview, policy review, and record review, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 2 of 22 residents (#2 and #12) whose care plans were reviewed. This placed residents at risk for adverse outcomes if care and services were not provided 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 ensure physician orders were followed. This was true for 2 of 3 residents (#3 and #21) reviewed for quality of care. This failed practice placed residents at risk for discomfort and adverse effects, including potential for infection.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure adequate care and treatment was provided to 1 of 1 resident (Resident #59) reviewed for enteral tube use. This created the potential for harm if complications developed from improper medication administration via enteral access device practice.

Inspectors wroteBased on observation, policy review, manufacturer's PAP user manual, interview, and record review, the facility failed to ensure 3 of 4 Residents (#12, #13, and #53) received respiratory services as prescribed by the physician. This created the potential for residents to experience respiratory difficulties and impaired breathing.

Inspectors wroteBased on policy review, observation, record review, and interviews, it was determined the facility failed to provide adequate pain management. This was true for 1 of 1 resident (Resident #53) whose medical record was reviewed. This failure created the potential for residents to experience continual pain and distress.

Inspectors wroteBased on personnel record review, policy review, facility assessment, resident record review, and staff interviews, it was determined the facility failed to ensure employees were competent to care for resident needs. This was true for 1 of 5 nurses observed for medication administration. This failure had the potential to affect all residents in the facility and increased the risk of harm to residents.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and 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 observation, record review, and interviews, it was determined the facility failed to ensure residents received prior written rationale regarding room changes. This was true for 1 of 3 residents (Resident #5) whose records were reviewed. This deficient practice placed residents at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to ensure a copy of the residents' discharge or transfer notices were sent to the Office of the State Long Term Care (LTC) Ombudsman. This was true for 3 of 3 Residents (#9, #17, #23) reviewed for Ombudsman notification. This failed practice had the potential to affect all residents by; 1) denying residents the added protection from being inappropriately discharged ; 2) providing the residents with access to an advocate who can inform them of their options and rights; and 3) ensuring the Office of the State LTC Ombudsman was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on observation, policy review, resident and staff interview, it was determined the facility failed to ensure resident meals were prepared and accommodated resident allergies, intolerances, and preferences to meet individual resident needs. This was true for 1 of 3 residents (Resident #5) who were interviewed about food services and had the potential to affect all residents with special dietary needs who dined in the facility. This failed practice had the potential to negatively affect residents' nutritional status and psychosocial well-being.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to maintain kitchen sanitation and food storage at least 6 inches above the floor. These deficiencies had the potential to affect the 53 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 and food services equipment.

Inspectors wrote3. Resident #36 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease (COPD - a progressive lung disease characterized by increasing breathlessness). An admission MDS assessment, dated 3/3/24 documented it was somewhat important for Resident #36 to have books, newspapers, and magazines to read; listen to music he likes; to do things with group of people, and be around animals such as pets. Resident #36's care plan, dated 12/14/24, did not address his preferences for his activities. Resident #36 was observed in his room on 2/18/25 at 4:28 PM. A calendar of activities was observed posted on the wall by the door. Resident #36 stated he was not interested in participating in any of the activities in the facility. Resident #36 was again observed to be in his room on 2/19/25 at 10:12 AM, and on 2/20/25 at 9:27 AM, sitting on his bed. [...]

Inspectors wroteBased on observation, record review, 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 17 residents (Resident #8) whose care plans were reviewed. This deficient practice created the risk of adverse outcomes if care and services were not provided due to care plans not being revised as resident's needs changed.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure residents received oxygen therapy per physician orders. This was true for 1 of 4 residents (Resident #36) reviewed for oxygen therapy. This deficient practice created the potential for harm if residents' respiratory needs were not met.

Inspectors wroteBased on record review, medication error reports, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 2 residents (#42 and #48) reviewed for medication errors. This deficient practice created the potential for harm if residents received the wrong dosage of medications.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents were protected from significant medication errors. This was true for 2 of 4 residents (#1 and #3) reviewed for medication errors. This deficient practice created harm for one resident (Resident #1) who was hospitalized , and the potential for harm for one resident (Resident #3), due to receiving the wrong medications.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure physician orders were followed for 1 of 9 residents (Resident #2) whose records were reviewed for quality of care related to following medication and treatment orders. This failure created the potential to adversely affect residents whose care and services were not delivered according to their physician orders.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure medications were reconciled and removed from a medication cart when discontinued for 1 of 3 medication carts observed. This was true for 1 of 19 residents (Resident #105) and created the potential for harm for 19 residents who received medications from the cart due to an increased risk for medication administration errors. Additionally, this failure created an increased risk for medication diversion.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure medications were labeled correctly for 1 of 3 carts observed. This failure created the potential for harm if the resident who was prescribed the medication (Resident #104) received the wrong dose of his medication.

Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure physician orders were obtained for supplemental oxygen use for 1 of 15 residents (Resident #16) and failed to ensure staff changed and dated residents' oxygen tubing and humidification bottles per physician orders and facility policy for 2 of 15 residents (#16 and #37) reviewed for oxygen use. These deficient practices placed Resident #16 and Resident #37 at risk for respiratory infections due to growth of pathogens in oxygen humidifiers or tubing, and Resident #16 at risk for respiratory distress from receiving too little or too much oxygen.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were offered or received influenza or pneumococcal pneumonia immunizations. This was true for 1 of 5 residents (Resident #16) reviewed for immunizations. This failure placed Resident #16 at risk for harm should he experience illness from contracting pneucoccoal pneumonia or influenza.

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 3 of 3 CNAs (CNA #1, CNA #2, and CNA #3) 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.