Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Cascade Park during CMS and state inspections, most recent first.
A resident with a history of atherosclerosis of coronary artery bypass grafts was issued an emergency discharge for endangering the safety of others, but the facility documented the discharge location only as the resident's personal car with no address and did not secure confirmed housing or access to shelter or hygiene facilities. The discharge notice was delivered with law enforcement present, and the resident packed belongings and left the same day. The SW confirmed that no housing placement was arranged before discharge, and the resident later reported being escorted out by police and relying on a POA to obtain temporary motel lodging before staying with a friend.
A resident with multiple complex medical conditions, including a stage 4 pressure wound and significant care needs, was discharged home without proper supports, services, or equipment in place. The discharge was authorized by a family member without legal authority, and no home health or wound-care arrangements were made. Facility staff and the resident's provider had documented concerns about the safety of the discharge, and the resident was subsequently hospitalized due to complications from inadequate care at home.
Two residents with cognitive impairment were observed with their beds either in a low position or placed against the wall, used as physical restraints, without the required Safety Device Evaluation, physician's order, or care plan intervention. Staff confirmed that these steps were necessary but had not been completed or documented.
Three residents with significant cognitive and medical conditions did not have comprehensive care plans addressing key aspects of their care, including use of physical restraints, PTSD, antianxiety and anticoagulant medications, and dementia. Staff confirmed that these care plan elements were missing or delayed, despite ongoing treatment and diagnoses.
A resident with severe cognitive impairment and multiple diagnoses did not receive restorative aid services as recommended after discharge from physical therapy. Despite documented recommendations for specific restorative interventions, there was no evidence in the medical record that these services were provided, and staff interviews revealed a lack of awareness and follow-through regarding the resident's restorative care needs.
The facility did not follow physician orders and care plans for two residents: one resident did not have a required bed rail installed to assist with mobility, and another resident with CHF did not have daily weights consistently recorded or significant weight gains reported to the physician as ordered. Staff confirmed these omissions and the lack of required documentation.
A resident with severe cognitive impairment and dementia was prescribed Lorazepam for anxiety, but staff failed to document monitoring for adverse side effects after administration. Interviews with the Resident Care Manager and DON confirmed that monitoring was expected but not completed, and the necessary order for monitoring was delayed by over a month.
Two CNAs transferred a resident on contact precautions without wearing required isolation gowns, despite a physician order and facility expectations for PPE use during such care.
Nursing hours were not accurately posted or updated throughout the day, as required. Instead, staffing information was corrected the following morning, and staff were unaware that real-time updates were necessary. This resulted in daily postings that did not reflect actual staffing changes.
A resident with Type 2 Diabetes Mellitus was admitted without blood glucose monitoring orders despite being on oral diabetic medications. The resident experienced severe hypoglycemia, leading to hospitalization. Facility staff typically relied on Hemoglobin A1C levels rather than routine glucose checks, contrary to the facility's policy for monitoring residents on oral medications.
A resident with a healing Stage 2 pressure ulcer experienced worsening of the ulcer and developed a new one due to inadequate monitoring and delayed treatment. The facility failed to conduct timely skin audits and Braden Risk Assessments, and did not provide necessary pressure-relieving equipment promptly. Lack of communication and documentation among staff further contributed to the resident's condition deteriorating, leading to hospitalization and surgical intervention.
The facility failed to obtain necessary assessments, consents, and physician orders for beds placed against the wall and the use of bed rails for four residents. Observations confirmed the improper use of restraints without documentation, and staff acknowledged the oversight.
The facility failed to maintain dignity in catheter care for two residents with indwelling catheters. Both residents were observed with uncovered foley catheter drainage bags, despite care plans requiring them to be covered. Staff acknowledged the expectation for bags to be covered and not placed on the floor, indicating a lapse in following care plans.
The facility did not ensure a resident was offered the opportunity to participate in care conferences, as only one was documented despite expectations for quarterly meetings. The resident was alert and oriented, and staff interviews confirmed the expectation for quarterly care conferences, which were not met.
A facility failed to review and maintain advance directives (AD) and Durable Power of Attorney (DPOA) documentation for a resident. Despite being alert and oriented, the resident's ADs were not reviewed for several months. Staff acknowledged that the AD should have been reviewed during a care conference, but this did not happen.
Two residents experienced unresolved grievances regarding lost items due to the facility's failure to adhere to its grievance policy. One resident's manual wheelchair went missing after a hospital transfer, and despite reporting it, the issue was not promptly addressed. Another resident reported missing laundry items, which were not fully recovered despite her efforts. The facility's lack of timely communication and action resulted in unresolved concerns.
The facility failed to provide written bed-hold notices to two residents or their representatives during hospital transfers. One resident, severely cognitively impaired, was transferred without documentation of a bed-hold notice. Another resident, moderately cognitively impaired, was hospitalized and returned without a bed-hold notice. Staff acknowledged the oversight and lack of compliance with the requirement to inform residents or their representatives.
A facility failed to develop a comprehensive care plan for a resident with skin conditions, including abrasions and blisters on the feet. Despite physician orders for specific wound care, the care plan lacked focus areas, goals, or interventions for these conditions. Staff interviews revealed the absence of a documented care plan, with the Resident Care Manager and DON acknowledging the oversight.
A resident with Inclusion Body Myositis experienced discomfort and safety risks due to improper wheelchair fit and positioning. Despite complaints and a vendor's acknowledgment of a broken part, the facility failed to assess and address the wheelchair's fit and functionality. Staff were unaware of repair plans, and temporary fixes did not resolve the issue.
The facility failed to follow infection control practices during wound care for a resident with a Stage 4 pressure ulcer and catheter care for another resident. An LPN did not wash hands between glove changes during a dressing change, and a catheter drainage bag was found on the floor without proper covering or hanging. Staff acknowledged these practices were against facility policy.
Failure to Arrange Safe and Orderly Emergency Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident when it processed an emergency discharge without securing an appropriate discharge location, supports, or housing. Facility policy on Discharge Planning, dated 01/09/2002, required Social Services to arrange or assist in arranging necessary services, identify the discharge location, supports, and equipment, and, for residents without an identified discharge location, enlist the support of the assigned Medicaid case manager and other public agencies to secure appropriate housing. The resident was admitted with diagnoses including atherosclerosis of coronary artery bypass graft(s). The Nursing Home Transfer or Discharge Notice, dated 01/29/2026, documented an emergency discharge under the reason that the safety of other individuals in the facility was endangered. The discharge location was recorded as "Car (Personal)" with the address listed as "NA," and the record did not identify an established discharge address or confirmed housing placement where the resident could access shelter or hygiene facilities. Interviews and record review confirmed that no confirmed housing placement was secured prior to discharge. The Administrator stated the discharge was processed as an emergency discharge with law enforcement present when the notice was delivered, and that the resident packed his belongings and left the facility the same day. The Social Worker stated the discharge was processed as an immediate discharge and confirmed that the discharge location was documented as the resident's car, with no confirmed housing placement arranged beforehand. The resident later reported being escorted from the facility by police on the date of discharge, and that his POA secured motel lodging for several days following discharge before he went to stay with a friend. The Administrator later acknowledged that discharge to a hotel would have been preferable to discharge to the resident's vehicle.
Failure to Ensure Safe and Appropriate Discharge for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for a resident with complex medical needs, including sepsis, encephalopathy, Parkinson's disease, a stage 4 sacral pressure wound, and adult failure to thrive. The resident was non-verbal, required significant assistance with activities of daily living, and was dependent for toileting and lower-body dressing. Despite documentation from the primary care provider and facility staff indicating that the resident required a higher level of care and that discharge home would be unsafe, the resident was discharged home without adequate supports in place. Discharge planning was insufficient, as the resident's daughter, who did not have legal authority to act on her behalf, signed the discharge paperwork. There was no documentation that the resident participated in or consented to the discharge decision. The facility did not arrange for home health or wound-care services, and necessary equipment such as a low-pressure mattress was not provided. The resident's significant other, identified as the primary caregiver, did not receive training or instruction regarding the resident's care needs, and staff expressed doubt about his ability to provide the required level of care. Following discharge, the resident was found at home without appropriate care, experiencing pain and complications from the existing stage 4 wound, which led to hospitalization. The facility staff, including nursing and the physician, believed the discharge was unsafe, and there was no evidence that guardianship or Medicaid application processes were pursued to ensure the resident's needs were met. The discharge was documented as against medical advice, but the facility did not fulfill its responsibility to ensure a safe and coordinated transition, resulting in harm to the resident.
Failure to Obtain Required Evaluation and Orders for Physical Restraints
Penalty
Summary
The facility failed to obtain a Safety Device Evaluation and Consent and/or physician's order for two residents who were using physical restraints, as required by facility policy. For one resident with severe cognitive impairment, the bed was observed in a low position multiple times, but there was no documentation of a Safety Device Evaluation, physician's order, or care plan intervention related to this practice. Staff confirmed that such documentation and orders were required but not present in the resident's electronic health record or care plan. For another resident with moderate cognitive impairment, the bed was observed placed against the wall on several occasions, but again, there was no Safety Device Evaluation, physician's order, or care plan intervention documented. Staff interviews revealed that the bed was moved against the wall at the resident's request to prevent rolling out, but staff were unaware of the need for evaluation and documentation. The Director of Nursing confirmed that it was expected for evaluations, consents, and physician's orders to be in place for beds in low positions or against the wall, but these were not completed for the residents involved.
Failure to Develop Comprehensive Care Plans for Residents with Complex Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with complex medical and behavioral needs. For one resident with severe cognitive impairment and a diagnosis of PTSD, the care plan did not address the use of a low bed as a physical restraint, nor did it include a focus, goal, or intervention related to PTSD until several months after admission. Staff interviews confirmed that a care plan for the low bed and PTSD should have been in place upon admission, but these were not initiated until much later. Another resident with severe cognitive impairment and a diagnosis of dementia was prescribed an antianxiety medication, Lorazepam, but the care plan did not address the use of this medication or the resident's dementia diagnosis. The care plan for the antianxiety medication was not initiated until over a month after the medication was ordered, and there was no care plan focus on dementia at all. Staff acknowledged that both the medication and dementia diagnosis should have been included in the care plan from the time of prescription and admission, respectively. A third resident, moderately cognitively impaired and diagnosed with chronic atrial fibrillation, was prescribed an anticoagulant medication, Dabigatran Etexilate Mesylate. The care plan did not include any focus or intervention related to the use of this anticoagulant, despite ongoing administration of the medication. Staff interviews confirmed that the anticoagulant should have been addressed in the care plan, but it was not present.
Failure to Provide Restorative Services as Recommended
Penalty
Summary
The facility failed to provide restorative aid (RA) services to a resident with multiple diagnoses who was severely cognitively impaired and required assistance to maintain their current level of function. Documentation showed that the resident had been recommended for a restorative program following discharge from physical therapy, including specific interventions such as sit-to-stand exercises, use of a transfer pole, and sessions with an Omni Cycle. Despite these recommendations, the resident's electronic health record did not show evidence that the RA services were provided as ordered. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's need for restorative services. The Resident Care Manager/Restorative Therapy Manager stated the resident did not meet requirements for a restorative program, while the Director of Rehabilitation confirmed that restorative services had been recommended after physical therapy discharge. The Director of Nursing was not aware that the resident was not receiving the restorative program. This failure to implement the recommended restorative interventions was not in accordance with the facility's policy to maintain residents' highest level of self-care and independence.
Failure to Implement Physician Orders for Physical Restraints and Weight Monitoring
Penalty
Summary
The facility failed to implement physician orders and care plans for two residents, resulting in deficiencies related to physical restraints and weight monitoring. For one resident with moderate cognitive impairment and a history of unsteady gait and dizziness, the care plan and physician orders specified the use of a right-sided 1/4 size bed rail (mobility bar) to assist with bed mobility and transfers. Observations on multiple occasions revealed that the bed rail was not installed, and both staff and the resident confirmed that it had never been put in place since admission, despite the documented order and consent. Another resident, also moderately cognitively impaired and diagnosed with congestive heart failure, had a physician order for daily weights with instructions to notify the physician if weight gain exceeded specified thresholds. Record reviews showed multiple instances of significant weight gain without documentation of physician notification, as well as repeated failures to obtain daily weights on numerous days across several months. Staff interviews confirmed the absence of required documentation and acknowledged that the physician had not been notified as ordered.
Failure to Monitor for Adverse Effects of Antianxiety Medication
Penalty
Summary
The facility failed to monitor for adverse side effects in a resident who was prescribed an antianxiety medication, Lorazepam 0.5mg as needed for anxiety. The resident, who had multiple diagnoses including severe cognitive impairment due to dementia, was admitted to the facility and began receiving Lorazepam according to a physician's order. However, review of the electronic medication administration records for October and November showed that while the medication was administered, there was no documentation of monitoring for adverse side effects. Staff interviews confirmed that monitoring was expected but not performed, and the required order for monitoring was not placed until 32 days after the medication was initially ordered.
Failure to Use PPE During Resident Transfer on Contact Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident on contact precautions. Specifically, during an observed transfer of a resident who was alert, oriented, and dependent on staff for transfers using a Hoyer lift, two certified nurse assistants (CNAs) assisted with the transfer without wearing isolation gowns as required for contact precautions. The resident had a physician order for contact precautions in place. The Director of Nursing confirmed in an interview that staff are expected to wear PPE when transferring residents on contact precautions.
Failure to Accurately Post and Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nursing hours were accurately posted and updated daily for all days reviewed. Record review showed that the Daily Staffing Hours postings were not updated throughout the day to reflect actual staffing changes, but instead were taken down and corrected the following morning. Interviews with the staffing coordinator and the DON confirmed that staffing numbers and hours for each shift were not updated as changes occurred, and that the postings provided for review were corrected copies from the next day, not real-time updates. The staff involved were unaware that updates were required throughout the day and acknowledged that the postings were not being completed correctly.
Failure to Monitor Blood Glucose in Diabetic Resident
Penalty
Summary
The facility failed to ensure adequate blood sugar monitoring for a resident receiving oral diabetic medications, which led to a significant health event. The resident, who was cognitively intact and diagnosed with Type 2 Diabetes Mellitus without complications, was admitted without orders for blood glucose monitoring despite being prescribed Metformin and Glipizide. On a particular day, the resident exhibited left-sided weakness, prompting staff to suspect a stroke. However, the resident was later found to have severe hypoglycemia with a blood glucose level of 30 upon being taken to the hospital, where symptoms resolved with normalization of blood sugars. Interviews with facility staff revealed that routine blood glucose checks were not performed for non-insulin dependent diabetic residents unless specifically ordered by a physician. Staff members indicated that they typically relied on Hemoglobin A1C levels for monitoring stable residents. The facility's policy, however, suggested more frequent monitoring for residents on oral medications, especially if poorly controlled. The lack of blood glucose monitoring for this resident, despite the facility's policy and the resident's change in condition, contributed to the oversight and subsequent health event.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper care and monitoring of pressure ulcers for a resident, leading to the worsening of an existing ulcer and the development of a new one. Resident 51, who was admitted with a nearly healed Stage 2 pressure ulcer on the coccyx, did not receive documented weekly skin audits for three weeks following admission. Additionally, the Braden Risk Assessments were not conducted consistently, with a significant gap between December 2023 and June 2024. The care plan for skin integrity and nutrition was not initiated until a month after admission, despite the resident being at risk for pressure ulcers. The new pressure ulcer on the right buttock and upper thigh was documented on December 21, 2023, but treatment was not initiated until January 24, 2024, 34 days later. The facility's Wound Management Guidelines were not followed, as the resident's skin alterations were not promptly investigated or addressed. The resident was not provided with appropriate pressure-relieving equipment, such as a special wheelchair cushion or pressure-relieving mattress, until weeks after admission. Staff interviews revealed a lack of communication and documentation regarding the resident's condition and care needs. The Director of Nursing Services was unable to provide an investigation report for the new pressure ulcer, and the Registered Dietitian was not informed of the resident's nutritional risk upon admission. These oversights contributed to the resident's condition deteriorating, resulting in hospitalization for suspected osteomyelitis and surgical intervention.
Failure to Obtain Required Documentation for Bed Restraints
Penalty
Summary
The facility failed to ensure that an assessment, consent, and physician order were obtained for the use of physical restraints, specifically for beds being placed against the wall and the use of bed rails, for four out of five sampled residents. This deficiency was identified through observations, interviews, and record reviews. The facility's policy on the use of restraints, revised in April 2017, mandates that restraints should only be used upon a physician's written order and after obtaining consent from the resident or their representative. Resident 5, who was alert and oriented, was observed multiple times with their bed against the wall and half-length bed rails raised on both sides. However, their electronic health record (EHR) did not contain any physician orders, assessments, or consents for these arrangements. Similarly, Resident 31, who was moderately cognitively impaired, had their bed against the wall without any documented assessment, consent, or physician orders. Observations confirmed the bed's position against the wall on several occasions. Resident 61, who was alert and oriented, also had their bed against the wall without the necessary documentation. When questioned, the resident was unaware of the reason for this arrangement. Resident 189, another alert and oriented resident, had their bed against the wall without any assessment, consent, or physician orders. Staff members, including the Resident Care Manager and the Director of Nursing, acknowledged the lack of required documentation and expressed that assessments, consents, and physician orders should have been completed for these residents.
Failure to Maintain Dignity in Catheter Care
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that promoted residents' dignity, specifically concerning urinary catheter care for two residents. Resident 11, who was moderately cognitively impaired and had an indwelling catheter, was observed multiple times with the foley catheter drainage bag uncovered, contrary to the care plan that required the drainage bag to be covered for dignity. Observations included the drainage bag hanging off the side of the bed uncovered and, at one point, lying on the floor without a hook or privacy bag. Staff members acknowledged that the drainage bags should be covered and not placed on the floor, indicating a lapse in following the care plan. Similarly, Resident 39, also moderately cognitively impaired with an indwelling catheter, was observed with the foley catheter drainage bag uncovered on several occasions, both in bed and in the rehabilitation gym. The care plan for Resident 39 also required the drainage bag to remain covered, yet observations showed the bag uncovered and visible from the hallway. Staff, including the Director of Nursing Services, confirmed the expectation that catheter drainage bags should be covered and not placed on the floor, highlighting a consistent failure to adhere to the dignity-promoting measures outlined in the residents' care plans.
Failure to Conduct and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were offered the opportunity to participate in care conferences, specifically for one resident who was part of a sample of six reviewed for the right to participate in planning care. Resident 53, who was alert and oriented, was admitted to the facility and had a quarterly Minimum Data Set (MDS) assessment conducted. However, the electronic health records (EHR) only documented a care conference on one occasion, despite the expectation that care conferences should occur quarterly, as needed, or during significant changes. Interviews with staff, including the Social Services Coordinator, Social Services Director, and Director of Nursing Services, confirmed that care conferences were expected to be conducted quarterly and documented in the EHR, but this was not done for Resident 53.
Failure to Review Advance Directives
Penalty
Summary
The facility failed to have procedures in place to assist with completing advance directives (AD) and maintaining Durable Power of Attorney (DPOA) documentation for a resident. The resident was admitted to the facility and was noted to be alert and oriented during a quarterly assessment. However, the resident's electronic health record did not show any ADs or documentation that ADs were reviewed since March 2024, despite the resident's care plan indicating they did not want to execute an AD at that time. Staff members acknowledged that the AD should have been reviewed during a care conference in June 2024, but this did not occur.
Failure to Address Grievances on Lost Items
Penalty
Summary
The facility failed to ensure a timely response and resolution to grievances regarding lost items for two residents. Resident 50, who was alert and oriented, reported his manual wheelchair missing after returning from a hospital transfer. Despite informing a Certified Nursing Assistant and filling out a Lost, Misplaced, Damaged Item form, the issue was not promptly addressed. The Social Services Coordinator acknowledged the missing wheelchair and forwarded the matter to the Administrator, who only became aware of the issue much later. This delay in addressing the grievance resulted in the resident not having his concerns resolved in a timely manner. Similarly, Resident 286, also alert and oriented, reported missing personal laundry items shortly after admission. Despite her efforts to retrieve some items from the laundry room, several items remained missing. The Resident Care Manager was unaware of the issue until she found a notification slip in her mailbox, indicating a lack of communication and timely action in resolving the resident's grievance. These incidents highlight the facility's failure to adhere to its grievance policy, leading to unresolved resident concerns.
Failure to Provide Bed-Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide a written bed-hold notice to residents or their representatives at the time of transfer to the hospital for two of the six sampled residents. Resident 36, who was severely cognitively impaired, was transferred to an acute hospital, but there was no documentation indicating that contact was made with the resident or their family regarding a bed-hold. Staff F, the Admissions Coordinator, acknowledged that the bed-hold agreement should have been documented in the electronic health records (EHR), but was unable to find any such documentation for Resident 36. Similarly, Resident 31, who was moderately cognitively impaired, was hospitalized and returned to the facility without any documentation of a written bed-hold notice. Staff F stated that the admissions department is responsible for completing the bed-hold form and making a progress note if they cannot reach the resident or their representative. However, no bed-hold notice was found for Resident 31. Staff B, the Director of Nursing Services, admitted that the facility did not comply with the requirement to follow up with the resident's representative and offer a bed-hold notice.
Failure to Implement Comprehensive Care Plan for Skin Conditions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with skin conditions, specifically abrasions and blisters on the feet. The resident, who was alert and oriented, was admitted with an open lesion on the foot. Physician orders detailed specific wound care instructions for multiple abrasions and a blister on the resident's feet, including cleansing and dressing changes. However, the resident's comprehensive care plan did not include any focus area, goals, or interventions related to these skin conditions. During an observation, the resident was seen with foam dressings on the right foot, and staff interviews revealed a lack of a documented care plan for the resident's skin conditions. The Resident Care Manager acknowledged the absence of a care plan and expressed confusion about why it was missing. The Director of Nursing Services confirmed that it was expected for skin care plans to be in place for residents with such conditions, indicating a lapse in the facility's care planning process.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to provide necessary care and services for proper positioning in a wheelchair for a resident diagnosed with Inclusion Body Myositis (IBM). The resident, who was alert and oriented but had functional impairments, required a motorized wheelchair for mobility. Observations revealed that the resident was leaning to the left side in the wheelchair, with the left armrest misaligned and the wheelchair tilted. The resident reported discomfort and stated that the wheelchair did not fit correctly, causing him to run into his bed and the wall due to the controller's position under his stomach. Despite the resident's complaints and the vendor's acknowledgment of a broken part, no follow-up or assessment was conducted to address the fit and functionality of the wheelchair. Staff interviews indicated a lack of communication and responsibility regarding the resident's wheelchair issues. The Resident Care Manager and Director of Nursing Services were unaware of the plan for wheelchair repair, and the Therapy Director could not find documentation of an assessment for the wheelchair fit. The resident care staff attempted temporary fixes, such as padding the bed frame and removing back support pieces, but these actions did not resolve the underlying issue. The failure to assess and address the resident's wheelchair fit and functionality led to discomfort and potential safety risks for the resident.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control and prevention practices during a dressing change for a resident with a pressure ulcer. Resident 51, who was alert and oriented, had a Stage 4 pressure ulcer on the right ischium. During an observation of wound care, a Licensed Practical Nurse (LPN) did not wash her hands after removing the old dressing and before putting on clean gloves to continue with the wound care. This action was contrary to the expected procedure as stated by the Infection Control Nurse and the Director of Nursing Services, who both emphasized the importance of hand hygiene between glove changes during wound care. Additionally, the facility did not adhere to its policy regarding catheter care for Resident 11, who had an indwelling catheter and was moderately cognitively impaired. The resident's catheter drainage bag was observed lying on the floor, folded in thirds, without a hook to hang it or a privacy bag to cover it. This was against the facility's policy, which required catheter bags to be kept off the floor and covered. Staff members, including a Certified Nursing Assistant and the Resident Care Manager, acknowledged that the catheter bag should not have been on the floor and should have been properly secured and covered.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 557 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vancouver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hudson Bay Health And Rehabilitation | 3.5 mi | ★★★★★ | 14 | 0 |
| Vancouver Specialty And Rehab Care | 3.5 mi | ★★★★★ | 29 | 0 |
| Evergreen Post Acute | 5.1 mi | ★★★★★ | 3 | 0 |
| Lacamas Creek Post Acute | 5.6 mi | ★★★★★ | 4 | 0 |
| Rose City Nursing And Rehabilitation | 5.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avamere Rehabilitation Of Cascade Park.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.