Cascades at Orchard Park

Inspectors wroteBased on interview, Centers for Disease Control (CDC) guidelines, and a review of Occupational Safety and Health Administration (OSHA) Respiratory Protection Guide, the facility failed to ensure all facility staff members had been fit tested for N95 respirators. This had the potential to affect 36 out of 36 residents residing in the facility.

Inspectors wroteBased on facility policy review, facility document review, and interview, the facility failed to develop written procedures for investigating allegations of abuse, misappropriation, and exploitation. The policy failed to include the procedures of a thorough investigations to include identification of staff responsible for the investigation; exercising caution in handling evidence that could be used in a criminal investigation; investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred; or providing complete and thorough documentation of the investigation. This affected 1 (Resident #190) of 1 abuse investigations reviewed.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to maintain a medication error rate of less than 5%. Observations of medication pass administration revealed 3 errors out of 30 opportunities which resulted in a 10% (percent) medication error rate. This affected 2 (Resident #21 and #90) of 2 residents observed during medication pass. Resident #21 was given one drop of artificial tears, instead of two drops. Resident #90 was given one drop of artificial tears, instead of two drops; and was administered magnesium 500 milligrams (mg), instead of magnesium 400 mg.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to have evidence that all allegations of abuse were thoroughly investigated for 1 (Resident #190) of 1 resident reviewed for abuse allegations.

Inspectors wroteBased on interview and record review, it was determined, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 33 sampled residents, a resident that reported bruising, swelling, pain, and a fall did not receive an X-ray for three days after the fall that revealed fractures. This resulted in a finding of harm. Resident identifier: 139.

Inspectors wroteBased on record review and interview, it was determined, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency (SSA). In addition, report the results of all investigations to the SSA within 5 working days of the incident. Specifically, for 3 out of 33 sampled residents, exhibit 358 entity reports of two abuse allegations were not submitted to the SSA in a timely manner. In addition, exhibit 359 follow-up investigation report of one resident was submitted to the SSA six working days after the abuse incident was reported. Resident identifiers: 18, 24, and 27.

Inspectors wroteBased on observation and interview, it was determined, that the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, insulin pens were expired, open and available for use, and not labeled with an expiration date. In addition, a medication was not labeled with resident identifier information.

Inspectors wroteBased on observation and interview, it was determined, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 33 sampled residents, staff members were observed to touch the resident's medications with bare hands during medication administration. Medications were replaced in medication cards after being touched with bare hands. Hand hygiene was not used. Medications were dropped on the medication cart and then administered to a resident. And the glucometer was not cleaned in between resident usage and trash was stored in the glucometer holding container. Resident identifiers: 14, 17, and 27.

Inspectors wroteBased on interview and record review, it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility failed to report the results of all investigations to the State Survey Agency (SSA), within 5 working days of the incident. Specifically, for 1 out of 33 sampled residents, the facility did not submit the results of an allegation of neglect within 5 working days when a resident with severely impaired cognitive status was found outside of the facility. Resident identifier: 3.

Inspectors wroteBased on interview and record review, it was determined, that the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, for 1 out of 33 sampled residents, a resident's medications were not administered as ordered by the physician due to the medications not being available by the pharmacy. Resident identifier: 140.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 31 medication opportunities on 10/18/23, revealed two medication errors which resulted in a 6.45% medication error rate. Specifically, for 1 out of 33 sampled residents, an enteric coated (EC) medication was crushed and a resident was given an incorrect dose of a heart medication. Resident identifier: 14.

Inspectors wroteBased on interview and record review, it was determined, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations; and that the resident either received the influenza and pneumococcal immunizations or did not receive the influenza and pneumococcal immunizations due to medical contraindications or refusal. Specifically, for 1 out of 5 sampled residents, a resident who requested to receive the pneumococcal vaccination did not receive it. Resident identifier: 3.

Inspectors wroteBased on interview and observation, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for residents, staff and the public. Specifically, the resident's rooms were only cleaned once weekly and exterior areas were cluttered and dirty.

Inspectors wroteBased on interview and record review it was determined, for 7 of 30 sample residents, that the facility did not assess each resident using the quarterly review instrument specified by the State and approved by Center for Medicare services not less frequently than once every 3 months. Specifically, residents quarterly Minimum Data Set (MDS) were not completed timely. Resident identifiers: 3, 4, 6, 7, 10, 11, and 25. 1. Resident 6 was initially admitted to the facility on [DATE] then readmitted on [DATE] with diagnoses which included, Friedreich ataxia, toxic encephalopathy, scoliosis, unspecified convulsions, poisoning by iron and its compounds, intentional self-harm, muscle weakness, major depressive disorder, generalized anxiety disorder and borderline personality disorder. On 1/11/22, the medical record of resident 6 was reviewed. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 4 of 30 sample residents. Specifically, bandages were not changed as charted, a COVID-19 positive resident was not monitored for additional needs, and care coordination was poor with outside facilities. In addition, residents were not clean when attending dialysis. Resident identifiers: 12, 32, 37 and 97.

Inspectors wroteBased on interview and record review, it was determined for 2 of 30 sample residents that the facility did not ensure that a resident who required dialysis received such services consistent with professional standards of practice. Specifically, there was no ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Resident identifiers: 33 and 97.

Inspectors wroteBased on record review and interview, it was determined, for 4 of 30 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, a resident's medical record contained a progress note about a different resident, a resident's medical record was missing blood glucose measurements, and two residents had incomplete immunization records. Resident identifiers 10, 14, 21, and 31.

Inspectors wroteBased on interview and record review the facility did not conduct COVID-19 testing based on the criteria for conducting testing of asymptomatic individuals, such as the community transmission rate of COVID-19. Specifically, unvaccinated staff members were not tested twice a week when the community transmission rate was high. This occurred for 5 out of 5 sampled staff members.

Inspectors wroteBased on interview and record review, the facility did not maintain documentation of when residents did not receive the COVID-19 vaccine due to medical contraindication or refusal. Specifically there was no documentation of a resident refusing the COVID-19 vaccine due to contraindications communicated to the resident by her physician. Additionally, there was no documentation of a resident being offered, having received or refusing the COVID-19 vaccine. This occurred for 2 out of 30 sample residents. Resident identifiers: 14 and 21.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents had the right to make choices about aspects of his or her life in the facility that were significant to the resident; nor did the facility ensure that residents had the right to choose activities consistent with his or her interests for 1 of 30 sample residents. Specifically, a resident was not able to shower on the days he requested. Resident identifier: 33. Resident 33 was admitted to the facility on [DATE] with diagnosis which included, type II diabetes mellitus with neuropathy, severe morbid obesity, end stage renal disease, generalized muscle weakness, congestive heart failure, and dependence on renal dialysis.

Inspectors wroteBased on interview and record review it was determined for 3 of 30 sample residents, that the facility did not conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity, not less than once every 12 months. Specifically, resident's annual Minimum Data Set (MDS) assessments were not completed every 12 months. Resident identifiers: 4, 97, and 147. 1. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, acute respiratory failure with hypoxia, and vascular dementia. Resident 4's electronic medical record review was completed on 1/10/2022. Resident 4's MDS assessments were reviewed and revealed an Annual MDS dated [DATE]. There was an in progress annual MDS date 11/16/2021. The MDS was not completed or submitted. 2. [...]

Inspectors wroteBased on interview and record review, it was determined the facility did not develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care for 1 of 30 sample residents. Specifically, a resident with many issues, including intravenous antibiotics and dialysis did not have a care plan that included their major issues. Resident identifier: 97.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 30 sample residents, that the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, a resident with multiple issues did not have a comprehensive care plan. Resident identifier: 97.

Inspectors wroteBased on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, a refrigerator for resident's food was not maintained by staff members.

Inspectors wroteBased on interview and record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update the assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility assessment was incomplete.