Orchard Manor

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent or heal pressure injuries (PI) for 2 of 2 sampled residents (R9 & R3) reviewed for pressure injuries out of a total sample of 12. R9 was admitted with bilateral heel pressure injuries. The facility did not implement immediate offloading of the bilateral heels and the heels deteriorated. R9's wounds were not measured weekly, and her physician was not updated timely on changes to her wounds. R9 was observed not having her heels offloaded while seated in her recliner. R3 developed a facility acquired PI. The facility failed to measure and assess the PI weekly. R3's PI became infected multiple times requiring antibiotics. The facility states R3 has a Stage 3 PI - R3's medical record indicates PI, abscess, and diabetic wound. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 2 of 2 sampled residents (R3, R9), and 2 of 2 supplemental residents (R11, R27) reviewed for diabetic foot checks. R11 has no documentation of diabetic foot checks. R27 has documentation of once per month diabetic foot checks. R3's diabetic foot checks are not done daily. R9's diabetic foot checks are not done daily. This is evidenced by: The facility's Policy and Procedure entitled Foot Care Guideline dated 7/15/21 with last revision date of 5/9/24 states in part: .The nursing staff will provide residents' foot care with licensed nurses performing nail care for the diabetic individual .Objectives: To prevent infection of the feet .To assess skin integrity . Of note: [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. the facility failed to ensure that all alleged abuse violations are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 2 sampled residents (R13) and 1 of 1 (R34) supplemental residents reviewed for abuse. On 5/5/24, the facility became aware of an alleged violation of abuse between R13 and R34. This allegation of abuse was not reported to the administrator or state agency. Evidenced by: The facility policy, Reporting Abuse to the Facility Management, with a revision date of 4/20/23, indicates, in part: Policy Statement: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, all alleged violations were thoroughly investigated for 1 of 2 sampled residents (R13) and 1 of 1 (R34) supplemental residents reviewed for abuse. On 5/5/24, the facility became aware of an alleged violation of abuse between R13 and R34 and did not conduct an investigation. Evidenced by: The facility policy, Abuse Investigation Protocol, with a reviewed date of 3/20/24, indicates, in part: Policy Statement: All reports of alleged resident abuse in any form .resident-to-resident abuse .are promptly and thoroughly investigated by facility management .Policy Interpretation and Implementation: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure provision of an environment free from accidents and hazards for 1 of 1 sampled residents (R3) with a power wheelchair out of a total sampled of 12 residents. R3s electric wheelchair was being charged in R3's room. This is evidenced by: Facility policy entitled Motorized scooter/wheelchair, revision date 5/9/24, does not address where electric chairs are to be charged. R3 was admitted on [DATE]. R3's Minimum Data Set (MDS) dated [DATE], indicates R3 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, which indicates R3 is cognitively intact. On 8/13/24 at 9:45 AM, Surveyor observed R3 to be in her recliner sleeping and the electric wheelchair appeared to be plugged in to a cord behind the nightstand. On 8/13/24 at 10:01 AM, Surveyor observed R3 to have an electric wheelchair in her room. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the residents' physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 17 residents (R48). R48 had a change in weight status and the facility did not consult R48's physician per physician orders, resulting in R48 having to go to the emergency room with CHF (Congestive Heart Failure) exacerbation requiring medical intervention and a hospital stay. This is evidenced by: Facility policy entitled, Physician Notification, reviewed 4/6/22, includes, in part: The professional nursing staff will notify the resident's physician when a change in the resident's condition has occurred. Sometimes the telephone contact to the physician is one of urgency while at other times it may be less urgent but still necessary to obtain a new order. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure the preparation of food in a clean and sanitary environment with potential to affect all 47 residents residing in the facility. Surveyor observed the facility's downstairs freezer to have liquid dripping from the ceiling into boxes of food that was no longer sealed by the manufacturer. Surveyor observed [NAME] K wet stacking clean cups. [NAME] K indicated she was talked to the previous year by Surveyors for not allowing the dishes to air dry completely and knows she should allow them to dry completely before stacking them. This is evidenced by: Facility policy, entitled Dish Machine, reviewed 5/17/23, includes, in part: Dishes/glasses should be air dried in racks on shelf until completely dry. Recommendations for use of the [NAME] High temperature Dishwasher, includes, in part: . [...]

Inspectors wroteBased on interview and record review the facility staff failed to adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 (R15) of 2 residents reviewed for pain out of a total sample of 17. R15 reported to Surveyor to be in 8 out of 10 pain and was observed crying. R15 reported to CNA I (Certified Nursing Assistant) and CNA J that she had pain in her shoulder that started during an EZ stand transfer. CNA I voiced she was aware of R15 crying and in pain after EZ stand transfer and did not report this pain to RN H. RN H indicated CNA J reported R15 was experiencing 5 out of 10 pain. RN H (Registered Nurse) did not immediately perform a thorough RN assessment into this pain, including a visual assessment, a descriptive assessment, or a root cause analysis. [...]

Inspectors wroteBased on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 sampled residents (R3). Staff did not complete appropriate hand hygiene during wound care for R3. This is evidenced by: The facility policy titled, Infection Prevention and Control Manual, Standard Precautions, Hand Hygiene, with a revised and/or reviewed date of 4/12/23, states, in part: Policy: It is the policy of this facility that hand hygiene (HH) (e.g., hand washing and/or Alcohol-based hand rub (ABHR) .is to be performed consistent with accepted standards of practice in order to reduce the potential of the spread of pathogens . Procedure: There are 2 methods for hand hygiene: 1. [...]