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Cove of Cascadia: Narcotic Tracking Failures - ID
The violations affected all residents receiving controlled medications at the facility....
Latest reports, citations, and penalties from CMS data
The violations affected all residents receiving controlled medications at the facility....
Resident #1 lived with malignant cancer and lumbar radiculopathy, a condition causing nerve compression in the lower back....
The staffing shortage created a cascade of care failures....
Resident 1 had been admitted to the facility after experiencing falls....
The assessment is required to identify what resources are necessary to care for residents during normal operations and emergencies....
The falsified documentation at Lutheran Home came to light when an outside infusion clinic contacted facility administrators....
The resident, identified in inspection records as R1, woke up one morning to find her wedding ring gone from her left hand....
The plumbing breakdown left residents on C and D halls without hot water in their rooms while facility leadership scrambled to get repair quotes....
The missed 6 AM dose was never mentioned during shift report, the nurse told inspectors....
But staff were following incomplete orders anyway....
The resident had intact cognition with a score of 15 on cognitive testing....
The facility's director of nursing pulled the complete staff list and found no employee assigned those initials....
The resident, identified as Resident #1 in the November inspection report, scored 15 on a cognitive assessment indicating he was mentally intact....
The safety violations put residents at risk of falls and medical emergencies without any way to contact nursing staff for assistance....
The facility terminated Dietary Manager B on October 6 following 28 formal complaints about the dietary department in just two months....
Record review showed the facility conducted emergency staff training on September 26 specifically to address the cold meal incident....
The violation centered on Resident #2, who required continuous oxygen therapy with humidification....
Yet nursing staff gave him uncrushed pills without proper physician orders....
During evaluation, the resident held food and liquids in his mouth, making swallowing difficult and requiring a double swallow technique....
The facility's own MDS Nurse acknowledged the oversight could have led to choking and death....