Cove of Cascadia, the

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to follow physician orders of delivering specific medications when residents do not have BM within 72 hours for 4 of 12 residents (#17, #20, #24, and #30) whose records were reviewed for 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, record review, 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 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 observation, record review and interview, the facility failed to ensure residents were free of medication preparation and administration errors for 1 of 1 resident (Resident #9) observed for medication preparation and administration of insulin. This failed practice placed the resident at risk for not receiving their prescribed medication dosage and other adverse outcomes.

Inspectors wroteBased on observations, State Operations Manual Appendix PP, and staff interviews it was determined the facility failed to ensure medications were properly stored, not expired, and biologicals were labeled when opened. This was true for the [NAME] Unit and the [NAME] Unit. This failure created the potential for residents to receive expired medications with decreased efficacy, use of expired biologicals, and the potential for theft and/or diversion.

Inspectors wroteBased on observation, interview, policy review, and review of the Idaho Food Code, the facility failed to appropriately 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 record review and staff interview, it was determined the facility failed to provide adequate supervision and functioning devices to prevent elopement and fall. This was true for 1 of 6 residents (Resident #29) reviewed for accidents and elopement. This deficiency created the potential for physical harm (Resident #29 was harmed) if residents were not supervised or assistive devices not functioning when residents at risk for elopement left the facility.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, clean, and food was stored in a safe and sanitary manner. Additionally, the facility failed to ensure food was not exposed to cross-contamination while raw food was defrosting over cooked food. These deficiencies had the potential to affect the 69 residents 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 observation, record review, policy review, review of the State Survey Long-Term Care Reporting Portal and interviews, it was determined the facility failed to ensure residents were free from abuse and neglect. This was true for 1 of 2 residents (Resident #8) reviewed for abuse and neglect. Resident #8 experienced physical and verbal abuse from another resident. This failure placed all residents at risk of ongoing abuse, potential physical and psychosocial harm.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated. This was true for 2 of 12 residents (Resident #6 and Resident #32) whose care plans were reviewed. This created the potential for harm if cares and/or services were not provided appropriately due to inaccurate information on the care plan.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure nutrition was administered as ordered by the physician for 1 of 2 residents (Resident #6) whose nutritional needs were reviewed. This deficient practice created the potential for harm when Resident #6 was not provided with physician ordered nutrition.

Inspectors wroteBased on observation, record review, resident and staff interviews, it was determined the facility failed to ensure residents were provided with appropriate devices to support their body positioning while sitting in their wheelchair. This was true for 1 of 1 resident (Resident #11) reviewed for positioning. Resident #11 was at risk of neck and back discomfort when his head and neck were not supported while he was sitting in his wheelchair.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure food was maintained according to safe practices for food storage. These failed practices placed the 31 residents who consumed food prepared by the facility at risk for adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the facility's arbitration agreement (a document that designates a third party to resolve a dispute between others), presented to residents to sign, included the selection of a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) was convenient to both parties and a choice of arbitration services (where the parties can choose an arbiter to use). This was true for 3 of 4 residents (#14, #15, and #183) whose records were reviewed for arbitration agreements. This had the potential to affect all residents in the facility who signed an arbitration agreement.

Inspectors wroteBased on policy review, record review, observation, and resident and staff interview, it was determined the facility failed to ensure resident care was provided in accordance with professional standards of nursing practice. This was true for 3 of 6 residents (Resident #2, #17, and #21) reviewed for quality of care. Specifically: - Resident #2's facial skin condition was not assessed. - Resident #17 and Resident #21's physicians were not notified of their high or low blood sugar levels as ordered. These failures created the potential for harm if care was delayed due to lack of assessment or physician notification.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure residents received respiratory care for a resident receiving oxygen by nasal cannula. This was true for 1 of 4 residents (Resident #10) reviewed for respiratory care. This deficient practice had the potential for harm if the residents experienced discomfort from non-humidified oxygen.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure a licensed nurse had competency for acting upon a significant change in condition of a resident who was unarousable resulting in emergent transfer to the hospital. This was true for 1 of 1 resident (Resident #8) who was observed experiencing a significant change in conditon. This deficient practice placed related to staff failing to recognize the resident's decline and need for emergent medical attention resulting in Resident #8's emergent transfer to the hospital.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure the medication error rate was less than 5%. This was true for 2 of 28 medications (7.14%) which affected 1 of 10 residents (Resident #29) whose medication administration was observed. This failed practice placed residents at risk of not receiving the prescribed dosage of their medication.