F-F689. Due to the facility ' s corrective measures, the noncompliance was determined to be past noncompliance.

The facility ' s corrective action plan, which was developed and implemented by April 9, 2025, included the following measures:

a. Removing Certified Nursing Assistant (CNA) 1 from the facility staff.

b. Adding a call light to Resident 3 ' s shower.

c. Evaluating all current residents to ensure call lights were accessible in areas required based on their specific needs and care plans.

d. Reeducating staff on Resident 3 ' s care preferences.

Findings Include:

The surveyor interviewed Resident 3 on May 22, 2025. Resident 3 stated that it was his preference to be helped into and out of the shower, but to complete his shower by himself. Resident 3 stated that CNAs would assist him into the shower, and then check in periodically to see if he needed assistance or was done and needed help out of the shower. Resident 3 stated that on March 4, 2025, CNA 1 recently helped him into the shower and then left. Resident 3 stated that he completed his shower and was calling out for assistance, but nobody was there to help. Resident 3 stated that he was unable to reach the call light from his position on

the shower chair. Resident 3 stated that he used the shower head to hit the wall to signal for assistance. Resident 3 stated that a different CNA eventually came in and helped him back into his bed. Resident 3 stated that after the incident, staff had added an additional call light button in the shower.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 2 465184 Department of Health & Human Services Printed: 08/26/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 465184 B. Wing 05/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Riverwalk 1012 West Jordan River Boulevard Midvale, UT 84047

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The surveyor observed Resident 3 ' s bathroom. The bathroom had a shower chair, and the bathroom call light was next to the toilet. The bathroom call light appeared to be out of reach from where the shower chair Level of Harm - Minimal harm or was placed. The licensor observed an additional, portable call light in the shower, within reach of where the potential for actual harm shower chair was placed.

Residents Affected - Few The surveyor reviewed Resident 3 ' s medical records, and the following entries were observed:

a. The Minimum Date Set from May 20, 2025 revealed that Resident 3 required a one person extensive assistance with transfers.

The surveyor interviewed CNA 4 on May 22, 2025. CNA 4 stated that Resident 3 preferred to have assistance getting into the shower, and then to be left alone until he was ready to get out or if he needed assistance. CNA 4 stated that Resident 3 preferred for CNAs to wait outside the door until he was done. CNA 4 stated that Resident 3 often took long showers, sometimes exceeding an hour long, so CNAs would often complete other tasks while waiting for Resident 3 to finish his shower. CNA 4 stated that the CNAs would let Resident 3 know if they had to step away to help another resident. CNA 4 stated that she was aware of the incident where Resident 3 requested help and CNA 1 was unavailable. CNA 4 stated that a new call light button had been added to the bathroom shower so Resident 3 can easily call for help.

The surveyor interviewed the Administrator (Admin) on May 22, 2025. The Admin stated that Resident 3 had requested that CNAs leave him in the shower and check on him periodically, because Resident 3 preferred to take long showers. The Admin stated that Resident 3 had filed a grievance regarding CNA 1 leaving him in

the shower for too long, and Resident 3 did not have a way to signal for help. The Admin stated that he interviewed CNA 1 about the incident, and CNA 1 stated that another resident required help, and he was busy helping someone else. The Admin stated that a new call light was added to Resident 3 ' s shower. The Admin stated that CNA 1 no longer worked at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 2 465184