Deficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 6, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging sexual abuse of Resident #190 by a male staff member on 10/29/2024.
Complaint Details
The complaint involved a report of sexual abuse by Resident #190 on 10/29/2024, alleging inappropriate touching by a male staff member. The facility submitted a two-hour state reportable notification and a five-day follow-up report concluding the allegation could not be verified. Interviews and investigation documentation were incomplete and insufficient to substantiate the allegation.
Findings
The facility failed to develop and implement written policies and procedures for thorough investigations of abuse allegations. The investigation of the sexual abuse allegation involving Resident #190 lacked documented evidence of thorough interviews and did not identify the alleged perpetrator. The facility concluded the allegation could not be verified due to insufficient investigation documentation.
Deficiencies (2)
F 0607: The facility failed to develop written procedures for investigating allegations of abuse, neglect, and exploitation, including identification of responsible staff, handling evidence, interviewing involved persons, and thorough documentation. This affected 1 resident abuse investigation.
F 0610: The facility failed to have evidence that all allegations of abuse were thoroughly investigated for 1 resident. Documentation was incomplete and interviews were not properly recorded or conducted with all relevant persons.
Report Facts
Residents Affected: 1
Dates: Oct 29, 2024
Dates: Oct 31, 2024
Dates: Nov 6, 2024
Inspection Report
Routine
Deficiencies: 3
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding abuse prevention, medication administration, infection control, and respiratory protection in the nursing home.
Findings
The facility failed to develop adequate policies and procedures for abuse investigations, resulting in incomplete investigations. Medication error rates exceeded 5%, with errors in dosage and administration observed. The facility also failed to ensure all staff were fit tested for N95 respirators, lacking a respiratory protection program.
Deficiencies (3)
F 0607: The facility failed to develop written procedures for investigating allegations of abuse, neglect, and exploitation, lacking thorough investigation steps and documentation. This affected one resident's abuse investigation.
F 0759: The facility failed to maintain a medication error rate below 5%, with 3 errors in 30 opportunities (10%). Errors included incorrect dosage of artificial tears and magnesium for two residents.
F 0880: The facility failed to ensure all staff were fit tested for N95 respirators, lacking a policy and respiratory protection program. This potentially affected all 36 residents in the facility.
Report Facts
Medication error rate: 10
Residents affected by N95 fit testing deficiency: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered incorrect medication dosages during medication pass |
| Administrator | Interviewed regarding abuse investigation and fit testing policies | |
| Director of Nursing | DON | Interviewed regarding abuse investigation and medication administration processes |
| Infection Preventionist | IP | Interviewed regarding lack of N95 respirator fit testing |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to investigate multiple allegations of abuse, neglect, medication errors, and infection control issues at the nursing home.
Complaint Details
The investigation was triggered by multiple abuse allegations involving residents 18, 24, 27, and 3, including sexual incidents, neglect, and elopement. The facility was found to have delayed reporting abuse incidents and investigation results to the State Survey Agency. Additional complaints included failure to provide adequate supervision to prevent accidents, medication errors, and infection control deficiencies.
Findings
The facility failed to timely report abuse allegations and investigation results to the State Survey Agency. There were medication administration errors, improper medication labeling, inadequate infection control practices, delayed medical response to a resident's fall, and failure to provide pneumococcal vaccination to a resident who requested it.
Deficiencies (8)
F 0609: The facility did not timely report suspected abuse and the results of investigations to proper authorities for multiple residents.
F 0610: The facility failed to report the results of all investigations of abuse allegations to the State Survey Agency within 5 working days.
F 0689: A resident who reported bruising, swelling, pain, and a fall did not receive an X-ray for three days, resulting in actual harm.
F 0755: The facility did not provide routine and emergency drugs to a resident as ordered due to medications not being available from the pharmacy.
F 0759: Medication error rate exceeded 5% when an enteric coated medication was crushed and a resident was given an incorrect dose of a heart medication.
F 0761: Insulin pens were expired, open, not labeled with resident identifiers or open dates, violating medication labeling and storage standards.
F 0880: Infection prevention program was inadequate; staff touched medications with bare hands, reused medications improperly, and did not clean glucometers between residents.
F 0883: The facility failed to ensure a resident received the pneumococcal vaccination after requesting it and did not document education about immunizations.
Report Facts
Residents sampled: 33
Medication opportunities observed: 31
Medication errors observed: 2
Medication error rate: 6.45
Days late for abuse report submission: 1
BIMS score: 3
BIMS score: 2
Pain scores: 10
X-ray delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 5 | Registered Nurse | Observed crushing enteric coated medication and improper medication handling |
| RN 1 | Registered Nurse | Interviewed regarding medication administration and glucometer cleaning practices |
| RN 4 | Registered Nurse | Provided statement regarding delayed response to resident 139's leg pain |
| CNA 1 | Certified Nursing Assistant | Involved in resident 139's transfer incident |
| CNA 2 | Certified Nursing Assistant | Involved in resident 139's transfer incident |
| RNC 1 | Regional Nurse Consultant | Interviewed about medication and infection control practices |
| RNC 2 | Regional Nurse Consultant | Interviewed about medication availability and immunization policies |
| Administrator (ADM) | Administrator | Interviewed regarding abuse reporting and investigation delays |
| Resident Advocate (RA) | Resident Advocate | Interviewed about abuse investigation procedures |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to investigate allegations of abuse, neglect, exploitation, and failure to provide adequate supervision and pharmaceutical services at Cascades at Orchard Park nursing home.
Complaint Details
The complaint investigation substantiated multiple failures including late reporting of abuse allegations and investigation results, inadequate supervision leading to injury, and failure to provide medications as ordered. Specific residents involved were identified by numbers 3, 18, 24, 27, 139, and 140.
Findings
The facility failed to timely report abuse allegations and investigation results to the State Survey Agency, did not ensure adequate supervision to prevent accidents resulting in harm, and did not provide medications as ordered due to pharmacy supply issues. Multiple residents were affected by these deficiencies.
Deficiencies (4)
F 0609: The facility did not timely report suspected abuse and the results of investigations to proper authorities for 3 residents, with reports submitted late beyond required timeframes.
F 0610: The facility failed to report the results of an abuse investigation within 5 working days for 1 resident with severe cognitive impairment who eloped from the facility.
F 0689: The facility failed to ensure a safe environment and adequate supervision, resulting in a resident with bruising, swelling, pain, and fractures who did not receive an X-ray for three days after a fall.
F 0755: The facility did not provide routine and emergency medications as ordered for 1 resident due to pharmacy supply issues and failure to clarify orders with the hospice company.
Report Facts
Residents sampled: 33
Abuse allegations not timely reported: 3
Investigation report late: 1
Pain scores: 10
Days delay for X-ray: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding X-ray procedures and timelines |
| RN 4 | Registered Nurse | Provided statement about delayed follow-up for resident 139's leg pain |
| CNA 1 | Certified Nursing Assistant | Reported details of resident 139's transfer and fall incident |
| CNA 2 | Certified Nursing Assistant | Assisted CNA 1 with resident 139's transfer and fall incident |
| RNC 1 | Regional Nurse Consultant | Interviewed about investigation report submissions and X-ray procedures |
| RNC 2 | Regional Nurse Consultant | Interviewed about medication issues and resident 139's injury |
| ADM | Administrator | Interviewed about abuse reporting and investigation processes |
| RA | Resident Advocate | Interviewed about abuse investigation procedures and incident reporting |
Inspection Report
Routine
Deficiencies: 13
Date: Jan 13, 2022
Visit Reason
Routine inspection of Cascades at Orchard Park nursing home to assess compliance with regulatory requirements including resident rights, care planning, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident choice for shower scheduling, inadequate housekeeping and maintenance, incomplete and untimely resident assessments and care plans, poor communication with dialysis providers, failure to maintain resident medical records accurately, inadequate COVID-19 testing of unvaccinated staff, and incomplete documentation of COVID-19 vaccination refusals.
Deficiencies (13)
F 0561: The facility did not ensure residents had the right to make choices about significant aspects of their life, including shower scheduling for resident 33 who requested showers on non-dialysis days.
F 0584: The facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment; resident rooms were cleaned only once weekly and exterior areas were cluttered and dirty.
F 0636: The facility did not conduct comprehensive, accurate, standardized assessments of residents' functional capacity at least annually for 3 residents (4, 97, 147).
F 0638: The facility did not update residents' assessments at least quarterly for 7 residents, with assessments overdue by up to 39 days.
F 0655: The facility failed to develop and implement baseline care plans within 48 hours of admission for resident 97, omitting major issues and goals.
F 0656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for resident 97, despite multiple complex care needs.
F 0684: The facility did not provide treatment and care according to orders, resident preferences, and goals for 4 residents; issues included unmonitored bandages, poor communication with dialysis providers, and residents attending dialysis unclean.
F 0698: The facility did not ensure safe, appropriate dialysis care and services for residents 33 and 97, including lack of communication and collaboration with dialysis centers.
F 0812: The facility did not maintain the residents' refrigerator in accordance with food safety standards; multiple expired and unlabeled food items were found and staff were unclear about responsibilities.
F 0838: The facility assessment was incomplete and did not address critical elements such as admission decision processes, cultural factors, policy evaluation, staffing plans, third-party agreements, health IT resources, infection control systems, and risk assessments.
F 0842: The facility did not maintain complete and accurate medical records for residents 10, 14, 21, and 31, including missing blood glucose documentation, progress notes for wrong residents, and incomplete COVID-19 vaccination records.
F 0886: The facility did not conduct required COVID-19 testing for unvaccinated staff at the frequency prescribed during high community transmission; 5 of 5 sampled staff were not tested twice weekly.
F 0887: The facility did not properly document COVID-19 vaccination refusals or contraindications for residents 14 and 21, despite residents refusing vaccination based on physician advice.
Report Facts
Sample residents: 30
Unvaccinated staff tested: 5
Days overdue: 39
Food items: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Corporate Resource Nurse | Infection Preventionist | Interviewed regarding shower scheduling, dialysis communication, COVID-19 testing, and medical record issues |
| Assistant Director of Nursing | ADON | Interviewed regarding care planning, medical record documentation, phone system issues, and COVID-19 vaccination documentation |
| Housekeeping Manager | HKM | Interviewed regarding exterior facility cleanliness and housekeeping issues |
| Dialysis Worker 1 | Interviewed regarding dialysis care and communication problems | |
| Dialysis Worker 2 | Interviewed regarding dialysis care and communication problems | |
| Transportation Director | TD | Interviewed regarding dialysis transportation and communication |
| Director of Nursing | DON | Interviewed regarding refrigerator maintenance and cleaning responsibilities |
| Human Resources Director | HRD | Interviewed regarding phone system and call handling procedures |
| Dialysis Worker | DW | Interviewed regarding resident dialysis care and communication |
| Same Day Surgery Worker | SDSW | Interviewed regarding communication difficulties with facility for resident surgery coordination |
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