Focused Care at Orange

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 medication carts and 3 of 25 residents reviewed for pharmacy services (Residents #42, #61 and #64) (Medication cart for Rooms 109 - Rooms 120, Medication cart for Rooms 217 - Rooms 220 and Medication cart for Rooms 205 - Rooms 216 ). The facility failed to ensure expired medications were removed from 3 of 3 medication carts. These failures could place residents at an increased risk of receiving medications that were not at their intended potency and potential adverse reactions or side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen reviewed for food safety requirements. 1. The facility failed to ensure there were paper towels at the handwashing station.2. The facility failed to ensure the Dietary Manager's hair was inside the hair restraint.3. The facility failed to ensure Dishwasher A wore a beard restraint.4. The facility failed to ensure [NAME] A wore his beard restraint correctly.5. The facility failed to ensure the Dietary Manager, and [NAME] A washed their hands upon entering the kitchen.6. The facility failed to ensure [NAME] B washed her hands after lifting her shirt up and pulling her pants up.7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment for 1 of 3 halls (Hall 100) and 1 of 22 occupied rooms on Hall 100 (room [ROOM NUMBER]) reviewed for a homelike environment. 1. The facility failed to provide a comfortable home-like living room area at the end of Hall 100 with unbroken end table and chairs without stains. 2. The facility failed to ensure the 2 over bed tables in an occupied resident room (#101) were in good repair and did not have lose trim on 1 over bed table and areas of missing laminate on the other over bed table. The failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who need respiratory care were provided with such care, consistent with professional standards of practice for 1 of 25 residents (Resident #5) reviewed for respiratory care. The facility did not ensure Resident #5's oxygen concentrator was set at 3 LPM on 06/02/26 at 8:43 a.m. as ordered. This failure could place residents who required respiratory care at risk of not receiving proper care and treatment and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure it's free of any significant medication errors for 1 of 8 residents (Resident #1) reviewed for significant medication errors. The facility failed to identify Resident #1 medication allergy to Hydrocodone and Resident #1 was administered 10 doses of Hydrocodone. This failure could place residents at risk for having allergic reactions such as skin rashes, itching, or swelling if given medications they are allergic to.

Inspectors wroteBased on observation interview, and record review, the facility failed to ensure correct installation, use, and maintenance of bed rails, for 3 of 7 residents (Residents #70, #87, and #102) reviewed for bed rails. The facility did not have the manufacturers' recommendations and specifications to follow for installing and maintaining the bed rails to prevent large gap in Resident #70's bed rail. The facility failed to develop care plans to address the risk of entrapment and interventions to prevent entrapment due to the use of bed rails for the residents who had histories of falling out of the bed for Residents #70, #87, and #102 The facility did not follow their Bed Mobility Assessments indicating the bed rails were not recommended for use for Residents #70, #87, and #102. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 24 residents reviewed for range of motion. (Resident #48) The facility failed to maintain Resident #48's contractures of the left hand. The resident did not have a palmar cushion (a soft, padded device used to support and protect the palm of the hand and reduce finger flexion contractures) in place to his left hand daily to maintain ROM and prevent a decline on 04/07/25 at 9:30 a.m and 2:30 p.m. and on 04/08/25 at 8:00 a.m This failure could place the residents at risk for not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure all staff wore hair restraints while working inside the kitchen. The facility failed to ensure the fryer was clean and free from brown crusty particles in the fryer baskets above the open cooking oil and brown and black particles along the side ledges and large front ledge surrounding the open oil. These failures could place residents who ate meals prepared in the kitchen at risk of foodborne illnesses.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #100) reviewed for incontinent Care. The facility failed to ensure that CNA F did not wipe Resident #100's perineal (area between the legs) area from back to front while providing incontinent care on 04/07/2025. This failure could place the residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles on 1 of 3 medication carts observed. (Hall 100 Rooms 109 - 120 medication cart) observed in that: LVN B was not aware of a loose pill and scattered debris, powdery and sticky substance in the bottom of the Hall 100 medication cart drawers and did not remove the loose pill or clean scattered debris, powdery and sticky substance in the medication drawers. These failures could place residents at risk of not receiving prescribed drugs or contaminated medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 1ml (20mg) of morphine every 3 minutes from 11:15 a.m. to 11:39 a.m. (180mg) instead of 1ml (20mg) every 30 minutes. 2. The facility failed to ensure Resident #1's morphine order was properly transcribed. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm or death relating to being administered too much medication. Finding Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 2 residents reviewed for PASRR assessments. (Resident #1) The facility did not provide and arrange for a specialized customized manual wheelchair for Resident #1 as recommended and agreed upon by the IDT within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 residents (Resident #5) reviewed for care plans. The facility failed to ensure Resident #5's care plan ADL interventions were implemented on 09/22/24 resulting in serious injury. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation , interview and record review the facility failed to provide supervision and assistance devices to prevent accident for 1 of 17 (Resident #5) residents reviewed for accidents/supervision. The facility failed to ensure CNA C provided ADL care with 2 person assistance. Resident #5 fell out of her bed and sustained a fractured left femur during care on 09/22/24. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 4 of 17 residents (Residents #1, #2, #3, and #4) reviewed for abuse. 1. The facility failed to ensure Resident #3 did not hit Resident #4 on 10/05/24. 2. The facility failed to ensure Resident #1 did not hit and push Resident #2 on 11/11/24. The noncompliance was identified as PNC. The noncompliance began on 10/05/24 and ended on 11/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 4 of 17 residents (Residents #1, #2, #3 and #4) reviewed for reporting allegations of abuse. 1. The facility failed to report an allegation of abuse within 2 hours after Resident #3 slapped Resident #4's face on 10/05/24. 2. [...]

Inspectors wroteBased on interview and record review the facility failed investigate and report the findings of the investigation to the State Survey Agency within 5 working days of the incident for 2 of 17 residents (Residents #1 and #2) reviewed for abuse. The facility failed to investigate and submit the results of their investigation within 5 days after Resident #1 hit and pushed Resident #2. These failures could place residents at risk of abuse, physical harm, mental anguish and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 12 dietary staff (DA J) reviewed for food and nutrition services. The facility failed to ensure DA J had a current Food Handler's Certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure baking sheets did not have brown and/or black baked on build up. * The facility did not ensure steam table pans did not have brown and/or black baked on build up. * The facility did not ensure muffin pans did not have brown and/or black baked on build up. * The facility did not ensure skillets did not have black build up on the outer and inner surface. * The facility did not ensure staff leave their shoes in the kitchen. * The DM and [NAME] G did not ensure food was at a safe temperature prior to serving food to residents. These failures could place residents who eat from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 food scale in the kitchen reviewed for food service. * The facility did not ensure the food scale was in working order. This failure could place residents who eat out of the kitchen at risk for inadequate food amounts, weight loss, and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the right to formulate an advance directive was provided for 3 of 3 residents reviewed for advanced directives. (Residents #26, #91, and #216) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Residents #26, #91, and #216. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an accurate MDS was completed for 1 of 13 residents (Resident #90) reviewed for MDS assessment accuracy. * The facility did not accurately code Resident #90's MDS assessment for bladder and bowel incontinence. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 2 of 21 residents reviewed for resident assessments (Residents #50 and #69). The facility did not have an accurate PASRR level 1 screening (PL1) for Residents #50 and #69 upon admission . This failure could place residents who have a diagnosis of mental disorder, developmental disability, or intellectual disability at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 21 residents. (Residents #50 and #55) The facility failed to develop a care plan for Resident #50's anxiety disorder or anxiety medication. The facility did not develop a care plan to address Resident #55's contracture of the right hand. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 21 residents (Resident #55) reviewed for quality of care The facility did not ensure Resident #55 had interventions in place to prevent a decrease in ROM for the contractures of the right hand. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being and decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 21 residents (Resident #37) reviewed for quality of care. The facility did not administer Resident #37's oxygen via nasal cannula as ordered by the physician. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental services to meet the needs of 1 of 21 residents reviewed for dental services. (Resident #7) The facility did not assist Resident #7, who had missing teeth and dental decay, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 for 1 of 11 residents reviewed for infection control. (Resident #1). The facility failed to place Resident #1 in contact isolation following a wound culture ( a test to determine if microorganisms that cause infections are in the wound) indicating the resident had staphylococcus aureus (a bacteria that causes infections) in her wound. This failure could place residents at risk for being exposed to health complications and infectious diseases.