Cascades at Orchard Park

In the surveyor’s words

From the most serious findings on record at Cascades at Orchard Park, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 19, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Mar 6, 2025

  Based 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. Findings included: The facility did not have a policy for fit testing N95 respirators. According to a United States Food and Drug Administration (FDA) publication, dated 10/21/2024, titled N95 Respirators, Surgical Masks, Face Masks, and Barrier Face Coverings, an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. […]

• No harm, potential for more than minimal, patternF609Oct 19, 2023

  Based 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. Findings included: 1. […]

• No harm, potential for more than minimal, patternF761Oct 19, 2023

  Based 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. Findings included: 1. On [DATE] at 7:45 AM, an observation was made of the south hallway medication cart with Registered Nurse (RN) 1, the following medication was located inside: a. A pre-filled pen of Ozempic was open and available for use. The pen had no resident identifier information and no open date could be seen. […]

• No harm, potential for more than minimal, patternF880Oct 19, 2023

  Based 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. […]