Orchards of Cascadia, the

Inspectors wroteBased on policy review, record review, interviews, and BFS portal review the facility failed to ensure a thorough investigation was completed to prevent further resident to resident abuse incidents. This was true for 1 of 3 (Resident #38) and had the potential to cause psychosocial and physical harm to those residents residing in the facility.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to investigate resident grievances in a timely manner for four of four resident (Resident (R) 70, R15, R57, and R59) reviewed for resident council and eight of eight residents (R48, R8, R61, R77, R82, R4, R27, and R14) reviewed for repeated grievances of noise at night and concerns about customer service of 31 sample residents. This deficient practice had the potential to allow grievances to not be responded to in a timely manner for 93 residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure an allegation of physical abuse was reported timely to the Administrator and to the State for one out of four Facility Reported Incidents (FRIs) (Resident (R) 82) reviewed for abuse of 31 sample residents. This failure had the potential for abuse to occur and/or continue.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to ensure the resident did not receive the wrong dose contributing to a significant medication error for one of 31 sampled residents (Resident (R) 106) reviewed for medication orders. This deficient practice had the potential to over medicate residents by not following the physician orders.

Inspectors wroteBased on observations, document review, staff interviews, and facility policy review, the facility failed to ensure appropriate storage of medication and vaccine supplies in one of two facility medication rooms. This failure created the potential for residents to experience a negative outcome related to potentially expired/undated and/or improperly refrigerated medications, immunizations, or immunization supplies.

Inspectors wroteBased on observation, interview, record review, and facility policy review, revealed the facility failed to ensure enhanced barrier precautions (EBP) and hand hygiene were performed after emptying a nephrostomy bag and performing incontinent care for one of 31 sampled residents (Resident (R) 9) reviewed for infection control. This deficient practice had the potential to allow residents to be exposed to pathogens that could cause an infection.

Inspectors wroteBased on policy review, record review, the facility's Incident and Accident (I&A) Report, and staff interview it was determined the facility failed to ensure a resident receiving dialysis services were provided appropriate monitoring, emergency response, and staff intervention consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. This was true for 1 of 3 residents (Resident #103) reviewed for hemodialysis. This deficient practice caused actual harm to Resident #103 when her central venous catheter (CVC) experienced a bleeding emergency, followed by loss of consciousness and a Full Code where Cardiopulmonary Resuscitation (CPR) was initiated, EMT called, and she was sent to the hospital where she was pronounced deceased after extensive interventions. [...]

Inspectors wroteBased on policy review, record review, facility Incident Report review, staff interview, and resident and resident representative interview, it was determined the facility failed to ensure adequate supervision and intervention was provided during a resident's transfer to prevent falls. This was true for 1 of 3 residents (Resident #44) reviewed for falls. This resulted in harm to Resident #44 who sustained a hematoma on the right side of her face, eye, and jaw, and chest pain.

Inspectors wroteBased on policy review, record review. observation, and resident and staff interview, it was determined the facility failed to ensure a resident's right for self-determination was honored. This was true for 1 of 2 residents (Resident #63) reviewed for choices. This deficient practice had the potential for Resident #63 to experience a decreased sense of well-being, lack of self-worth, and frustration when his preference for bed placement was not accommodated.

Inspectors wroteasBased on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to implement storage of resident smoking materials as directed by residents' care plans. This was true for 2 of 2 residents (#57 and #67) whose care plans were reviewed for smoking. These failures placed residents in the facility at risk of negative outcomes if smoking materials were not stored safely due to lack of information in their care plan.

Inspectors wroteBased on policy review, observation, review of the medication refrigerator temperature and maintenance logs, and staff interview, it was determined the facility failed to ensure expired medications were not available for administration, expired biological supplies were removed for resident use, multi-dose vials were dated when opened, and proper refrigerator temperature controls were within range for safe storage. This was true for 2 of 4 medication storage rooms and 2 of 3 refrigerators reviewed for safe storage and labeling medication. This failure created the potential for harm to all residents in the facility should residents receive medications with decreased efficacy, potency and safety.

Inspectors wroteBased on observation, staff interviews, and policy review, it was determined the facility failed to ensure: a) Clean mechanical lift slings were stored on the clean side of the laundry area, b) Staff personal protective equipment was stored on the dirty side of the laundry room, and c) Ventilation in the laundry area did not blow air from the contaminated laundry side to the clean side of the room. These failures created the potential for harm due to the increased the risk of cross contamination, and had the potential to affect all residents in the facility.

Inspectors wroteBased on policy review, observation, resident and staff interview, and review of the Facility's Assessment, it was determined the facility failed to ensure residents' clothing was appropriately separated by color, washed, sorted, and returned to residents in a timely manner. This was true for 7 of 13 residents (#4, #21, #27, #56, #60, #67, and #71) reviewed for laundry services. This failure placed residents at risk of diminished quality of life and lack of clean and appropriate clothing. The failure also had the potential to place a financial burden on residents if they had to buy new clothes because their clothes were lost or misplaced.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure: residents were assisted to formulate Advance Directives if necessary, residents' records included documentation of this process, and a copy of the residents' Advance Directives, or documentation of their decision not to formulate Advance Directives, was documented in their clinical record. This was true for 3 of 24 residents (#31, #35, and #44) whose records were reviewed for Advance Directives. These failures increased the residents' risk of not having their decisions honored and respected when unable to make or communicate health care preferences.

Inspectors wroteBased on policy review, record review, review of grievances, and resident, family, and staff interview, it was determined the facility failed to ensure grievances were responded to, investigated, and prompt corrective action was taken to resolve the grievances. This was true for 1 of 17 residents (Resident #30) reviewed for grievances. This failure created the potential for harm if the resident grievance, both verbal and written, was not acted upon and the resident did not receive appropriate care.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure the required documentation was completed and the appropriate information was communicated to the receiving facility when a resident was transferred to the hospital. This was true for 1 of 3 residents (Resident #35) reviewed for transfer to the hospital, and had the potential to cause harm if the resident was not treated appropriately or in a timely manner due to a lack of information.

Inspectors wroteBased on record review, policy review, observation, and staff interviews, it was determined the facility failed to ensure there was documented evidence for 3 of 3 residents (#35, #45, and #74) reviewed for hospital transfers, that the resident, and/or the resident's representative, was provided a written transfer notice when the resident was transferred to the hospital. This failure created the potential for harm if residents were not made aware of or able to exercise their rights related to transfers.

Inspectors wroteBased on record review, policy review, observation, and resident and staff interview, it was determined the facility failed to ensure the bed-hold policy was provided to residents. This was true for 2 of 3 residents (#35 and #74) reviewed for transfers to the hospital. This failure 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 record review, policy review, and resident and staff interview, it was determined the facility failed to ensure residents' care plans were updated to maintain consistency and accuracy. This was true for 1 of 18 residents (Resident #31) whose care plans were reviewed. This failure created the potential for harm if cares and/or services were not provided due to inaccurate information on the care plan.

Inspectors wroteBased on observation, record review, policy review, review of Incident and Accident Reports, and staff interviews, it was determined the facility failed to ensure professional standards of practice for completion of neurological assessments after a fall, medications were administered to residents prior to being documented as given, and pain medications were administered timely. This was true for 1 of 18 residents (Resident #31) reviewed for quality of care and 2 of 23 residents (#60 and #61) reviewed for medications. This failure placed residents at risk of a) adverse outcomes if medications were administered when contraindicated, b) increased pain due to delays in administering pain medication, and c) undetected neurological changes after falls.

Inspectors wroteBased on observation, staff interview, policy review, and record review, it was determined the facility failed to consistently follow physician orders for treatment of a pressure ulcer for 1 of 3 residents (Resident #44) reviewed for pressure ulcers. The failure created the potential for Resident #44 to experience delayed healing, or further deterioration, of a Stage 4 pressure ulcer, and/or develop additional pressure ulcers.

Inspectors wroteBased on observation, staff interview, policy review, and record review, it was determined the facility failed to ensure residents received proper treatment and care to maintain good foot health. This was true for 1 of 14 residents (Resident #7) reviewed for foot care. This failed practice created the potential for harm should residents experience complications from their medical condition related to the lack of proper foot care.

Inspectors wroteBased on observation, record review, policy review, and staff interviews, it was determined the facility failed to ensure residents received respiratory care as ordered by a physician. This was true for 1 of 5 residents (Resident #7) reviewed for oxygen therapy. This failure created the potential for harm if residents did not receive oxygen therapy to maintain adequate oxygen levels.