Cascades at Desert View

Inspectors wroteBased on review of the Grievances, Resident Council Meeting minutes, resident's interview, review of records, policy review, and staff interview, it was determined the facility failed to ensure grievances were responded to and investigated. This was true for 2 of 2 residents (#5 and #25) reviewed for grievances. This failure created the potential for psychosocial harm if residents' grievances were not acted upon.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure sufficient RN services at least eight consecutive hours per day, every 24 hours, seven days a week, as required. This failure had the potential to affect all residents in the facility who may require higher level of nursing assessment and intervention.

Inspectors wroteBased on observation, FDA 2022 Food Code, and resident and staff interviews, it was determined the facility failed to ensure resident meals were palatable and maintained their correct temperature. This directly impacted all residents 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, interview, policy review, and review of the FDA 2022 Food Code, the facility failed to appropriately wear beard nets, clean kitchen surfaces, dishes and skillets, store, distribute, and label foods. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on observation, policy review, CDC Legionnella guidelines, OSHA Legionella guidelines, and staff interview, the facility failed to ensure adherence to infection control and prevention practices to provide a safe and sanitary environment when, 1. staff had not used barrier protection, 2. perform hand hygiene, 3. had not tested swamp cooler water.

Inspectors wroteBased on interviews, the facility failed to employ a certified Activities Director. This failure had the potential to affect residents' quality of life when design of activities appropriate for residents was not implemented.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed for 7 of 14 residents (#2, #4, #8, #10, #18, #23, and #38) reviewed for physician orders and bowel and bladder care, This failed practice created the potential for residents to experience discomfort when medications were not administered according to the physician's order.

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, 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 14 Residents (#8 and #23) reviewed for respect and dignity issues. This deficient practice placed residents at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents and/or their representatives were informed in advance of the risks and benefits of psychotropic medications and alternative treatment options. This was true for 1 of 5 Residents ( Resident #43) reviewed for unnecessary medications. This deficient practice created the potential for residents of receiving psychotropic medications without knowledge of the impact the medications could have on their physical and mental health.

Inspectors wroteBased on observation and staff interviews, it was determined the facility failed to ensure that residents' drinking water was within their reach. This was true for 1 of 1 resident (Resident #28) reviewed for accommodation of needs. This deficient practice had the potential for residents to experience urinary tract infection, confusion and other health conditions if they were not able to maintain their hydration.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC CMS-10123) within the CMS required timeframe to 1 of 3 residents (Resident #19) reviewed for beneficiary protection notification. This deficient practice had the potential to cause financial harm or distress for residents when they were not informed of their potential liability for payment when their Medicare Part A benefits ended.

Inspectors wroteBased on record review and policy review, and interview, it was determined the facility failed to ensure residents were monitored for the adverse effects of their psychotropic and opioid medications. This was true for 1 of 5 residents (Resident #43) reviewed for unnecessary medications. This deficient practice created the potential for harm if residents experienced side effects of the medication and were undetected due to lack of appropriate monitoring.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to 1) ensure residents who were discharged home were provided with the necessary discharge information to ensure a smooth and safe transition of care. This was true for 1 of 1 resident (Resident #3) whose record was reviewed for planned discharge and 2) provide hospital transfer documents for 1 of 3 residents (Resident #5) whose records were 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 policy review, record review and staff interview, it was determined the facility failed to ensure a resident with positive PASARR Level 1 screening for mental illness was referred for further evaluation to the appropriate state-designated authority. This was true for 1 of 2 residents (Resident #5) whose PASARR I was reviewed. This deficient practice 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 record review, policy review, and interview, it was determined the facility failed to ensure a baseline care plan was developed within 48 hours of resident's admission. This was true for 1 of 3 residents (Resident #44) reviewed for baseline care plan. This failure created the potential for harm when the care plan failed to provide direction for care.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure comprehensive resident-centered care plans included the use of splint and RNA program of a resident. This was true for 1 of 14 residents (Resident #5) whose care plans were reviewed. This deficient practice created the potential for residents to receive inadequate or inappropriate care due to missing information in their care plan.

Inspectors wroteBased on policy review, observation, record review, and interview, it was determined the facility failed to ensure residents' comprehensive care plans were revised timely and as needed. This was true for 1 of 14 residents (Resident #5) whose care plans were reviewed. This deficient practice created the potential for residents to receive inappropriate care due to inaccurate information in their care plans.

Inspectors wroteBased on observation, Advair website, 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 2 of 5 residents (#18 and #31) observed during medication administration. This created the potential for residents to develop yeast infection when they did not rinse their mouth with water after taking their inhaler medication.

Inspectors wroteBased on observation, policy review, record review, and staff interview, it was determined the facility failed to ensure residents received treatment and services to prevent further decrease in range of motion (ROM). This was true for 3 of 3 residents (#5, #27 and #28) reviewed for treatment and services related to ROM. This failed practice placed residents at risk of harm when they did not receive their restorative program as care planned to prevent further deterioration of their existing ROM limitations.

Inspectors wroteBased on observation, record review, and interviews, it was determined the facility failed to provide respiratory services as ordered by the physician. This was true for 2 of 5 residents (#10 and #18) whose records were reviewed for respiratory services. This failure created the potential for residents to experience increased fatigue and low oxygen levels.

Inspectors wroteBased on record review, policy review, and interviews, it was determined the facility failed to ensure residents' identifiable information was not accessible to the public. This was true for 1 of 1 resident (Resident #16) whose care plan was found to be in the Resident Council Meeting minutes. This deficient practice created the potential for residents to experience psychosocial harm due to loss of dignity and emotional distress.

Inspectors wroteBased on observations, staff interviews, and review of the facility's sanitation policy, the facility failed to ensure: A) dishwasher temperatures were maintained to ensure proper sanitation of dishware, B) fire sprinklers and alarms were maintained in clean and sanitary condition, and C) food was stored in an unsanitary manner. These failures created the potential for cross-contamination and adverse health outcomes, including foodborne illness.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure their pest control program was effective in the kitchen. This failure impacted the 33 residents residing in the facility who ate food prepared in the facility's kitchen. The cockroach infestation created the potential for harm.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to a) ensure resident care plans were revised to reflect current needs and interventions and b) ensure residents and their representatives were encouraged to participate in care planning and attend care conferences. This was true for 4 of 16 residents (Resident #8, #11, #21, and #27) 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 resident's needs changed.

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 2 CNAs (#2 and #3) reviewed for sufficient and competent CNA staffing. This failure placed residents at risk of receiving care from staff who are not adequately trained to meet residents' needs.

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 16 residents (Resident #8) 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, policy review, and staff interview, it was determined the facility failed to ensure residents were provided with a clean, safe, homelike environment. This was true for all residents who resided in the facility whose environment were observed. This deficient practice created the potential for harm if: a) residents were embarrassed by and/or felt the disrepair in the facility was unacceptable, disrespectful, or undignified and b) residents were injured due to unsafe areas in the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the MDS assessment accurately reflected resident's status. This was true for 1 of 16 residents (Resident #6) whose MDS assessments were reviewed. This deficient practice had the potential for negative outcomes if residents were not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to refer residents with an exempted hospital stay and have a diagnosed mental disorder to the appropriate state-designated authority for a re-evaluation and determination. This was true for 1 of 3 residents (Resident #8), reviewed for PASRR level II 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 professional standards of nursing practice were followed for 1 of 17 residents (Resident #28) reviewed for quality of care. Resident #28 was at risk for adverse outcomes when her physician order was not written correctly. This failed practice had the potential to adversely affect residents whose care and services were not followed according to accepted standards of practice.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to ensure interventions were put in place and followed to prevent additional falls for 2 of 16 residents (#1 and #6) reviewed for falls. This failure increased the potential for additional falls and potential injury for residents with a history of falls.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1 of 2 medication carts reviewed. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure the attending physician acted upon Pharmacy recommendations for 1 of 16 residents, (Resident #8) whose medication regimens were reviewed for psychotropic medication. This deficient practice placed residents with dementia at an increased risk of death.

Inspectors wroteBased on review of the FDA Black Box Warning, record review, and staff interview, the facility failed to ensure the medical necessity for psychotropic medication administration. This was true for 1 of 16 residents (Resident #8) reviewed for unnecessary medications. This failure created an increased risk of mortality when residents diagnosed with dementia were prescribed antipsychotic medications.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 medications (5.41% error rate) which affected 1 of 3 residents (Resident #142) whose medication administrations were observed. This failed practice placed residents at risk of not receiving their prescribed medication or dosage of their medication.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure controlled medications were stored and kept secure from potential theft and/or diversion. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation, interviews, and review of the Idaho Food Code, it was determined the facility failed to ensure food was stored properly, dated when opened, equipment was stored in a sanitary condition, and ensure infection control protocol was followed during meal tray delivery. This deficient practice had the potential to affect all 39 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not perform proper hand hygiene. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from neglect. This was true for 2 of 2 residents (#191 and #192) reviewed for neglect. This failure caused physical harm to Resident #191 when she suffered a cut to her lower left leg and to Resident #192 when her thighbone was fractured.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 39 residents residing in the facility 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 policy review, record review, and staff interview, it was determined the facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advanced directive. This was true for 3 of 12 residents (Resident #6, #36, and #38) whose records were reviewed for advanced directives. This deficient practice created the potential for harm or adverse outcomes if residents' wishes were not followed or documented regarding their advance care planning.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure a bed hold notice was provided to residents or their representatives upon transfer to the hospital. This was true for 2 of 6 residents (#6 and #30) reviewed for transfer. This deficient practice created the potential for harm if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact 1 of 1 resident (Resident #38) reviewed for catheter care, by placing him at risk for cross-contamination and infection.

Inspectors wroteBased on policy review, record review, and staff interview, it was determined the facility failed to ensure pertinent health information was provided to the receiving hospital. This was true for 2 of 6 residents (#6 and #30) reviewed for transfers. This deficient practice had the potential to result in adverse outcomes if residents were not treated in a timely manner due to a lack of information provided upon transfer.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure appropriate assessments for assistive devices were completed for 2 of 2 residents (#1 and #38). This deficiency created the potential for injury if the residents were not assessed and monitored appropriately.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a residents', PASARR Level I (Preadmission Screening and Resident Review) had correct information and if residents' PASARR Level I indicated the resident had been identified with possible indicators of mental illness and required further screening, a PASARR Level II was to be completed. This was true for 2 of 2 residents (#6 and #30) whose PASARR records were reviewed. This deficient practice had the potential to cause harm if residents' specialized services for mental health needs were not provided due to lack of screening.

Inspectors wroteBased on policy review, observation, and staff interview, it was determined the facility failed to ensure respiratory equipment was changed as indicated. This was true for 1 of 4 residents (Resident #7) reviewed for respirator care. This created the potential for respiratory infections due to growth of pathogens (organisms that cause illness) in respiratory treatment equipment.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure informed consent was given by the resident or their representative for the use of bed rails. This was true for 2 of 2 residents (#1 and #38) reviewed for having bed rails. This failure created the potential for harm when the resident did not understand the risks associated with the use of bed rails.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents were offered the pneumococcal vaccine. This was true for 1 of 5 residents (Resident #20) whose records were reviewed for pneumococcal vaccinations. This failure created the potential for residents to have an increased risk of pneumococcal (bacterial) pneumonia and the potential for severe illness or death.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to regularly inspect bed rails to identify areas of possible entrapment. This was true for 2 of 2 residents (#1 and #38) who were reviewed for the use of bed rails. This failure created the potential for injury or harm if a resident was to become trapped by unmonitored equipment.

Inspectors wroteBased on observation, review of grievance logs, and resident and staff interviews, it was determined the facility failed to ensure all call lights were functioning. This was true for 2 of 2 residents (#7 and #30) reviewed for call lights. This had the potential for harm if residents were unable to summon staff assistance by activating the call light.