Orchard Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure medication administration services were provided in accordance with professional standards for one of one sampled resident (Resident 1) when the Registered Nurse (RN 1) directed Certified Nursing Assistant (CNA 1) to administer medication to Resident 1. This failure had the potential to result in Resident 1 receiving medications from unlicensed personnel, increasing the risk for medication administration errors and compromising resident safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of three sampled residents when certified nursing assistant (CNA) 1 was aware that Resident 1 required two person total dependent assistance with turning and repositioning while in bed and CNA 1 performed the task independently causing Resident 1 to roll off of the raised bed onto the floor. This failure resulted in Resident 1 sustaining an injury to the right eyebrow and transferred to the acute care hospital for further evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for food service safety and sanitary conditions, for one of one ice machine, when the facility did not implement Manufacturer's Limited 3 Year Parts And Labor Warranty (MW) and Air- and Water-Cooled User Manual Cleaning, Sanitation and Maintenance (AWM) and the exterior of the ice machine had white, black and green substance. This failure had the potential for the growth of microorganisms which could increase the risk of foodborne illness for all the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food storage was stored under sanitary conditions in accordance with professional standards for food service safety when: 1. A large plastic container of rice was in the dry storage pantry without a label and did not have an opened date or an expiration date. 2. Freezer 1 of 2 was observed without an internal thermometer. Refrigerator 1 of 3 was observed without an internal thermometer (a tool used to measure how hot or cold something is). These failures had the potential to contribute to the growth of foodborne pathogens (a tiny organism, like a germ, that could cause disease. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive resident-centered care plans for 11 of 24 sampled residents (Residents 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79) when the Activities Director (AD) did not develop resident-centered activity care plans for Residents 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 since their admission to the facility. These failures resulted in Residents' 7, 12, 18, 21, 32, 39, 45, 53, 76, 78, and 79 not having activities they could engage in, which could lead to boredom, loss of interest, inactivity, depression, feelings of isolation and decreased socialization with others while residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of quality of care for seven out of 12 sampled Residents (Residents 24, 27, 29, 48, 56, 58, and 143) when: 1. Resident 24 and Resident 29's oxygen (a colorless, odorless, tasteless gas essential to living organism) flow rate (the amount of oxygen being delivered to the body) were not administered according to their physician order. These failures resulted in Resident 24 and Resident 29 to not received the prescribed amount of oxygen via oxygen concentrator (a machine that pulls in oxygen from the surrounding air) and placed Resident 24 at risk for breathing problems which could include difficulty breathing, headache, and confusion. 2. No Oxygen in Use signage outside of Resident 143's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a hazard free environment and adequate supervision to prevent accidents was provided for two of three sampled residents (Resident 23 and Resident 27) when: 1. Resident 23 was using two phone books covered with duct tape as a step-stool to assist in getting up into bed that were made by therapy staff. This failure put Resident 23's safety at risk by creating a hazardous environment that could have caused an accident or fall. 2. The facility failed to ensure Resident 27 received adequate supervision to prevent accidents despite being identified as a high fall risk. This failure resulted in repeated falls and unsafe situations, with an increased risk of potential bodily harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Answering the Call Light, for six of 12 sampled residents (Residents 7, 14, 46, 59, 78, and 293) when the staff did not response to Residents 7, 14, 46, 59, 78, and 293's call lights within 5 minutes. These failures had the potential to result in Residents 7, 14, 46, 59, 78, and 293 not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's Policy and Procedure (P&P) Medication Storage when two of four sampled medication carts ((Cart 1 and Cart 2) were left unlocked and unattended by Licensed Nurses (LNs). These failures had the potential for residents, staff, and visitors to have unauthorized access to resident medications resulting in theft, overdose, and/or residents not having access to their medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for four of 25 sampled residents ( Resident 27, 41, 76, and 193 ) when: 1. Resident 41's urinary catheter bag (a bag attached to a urinary catheter, which is a thin tube inserted into the bladder to drain urine when someone can't urinate normally) and urinary catheter tubing (a thin, flexible tube inserted into the bladder to drain urine) was observed to be on the floor. This failure placed Resident 41 at risk for cross-contamination ( the unintentional transfer of harmful substances from one person, object, or place to another) which could result in infections and illness. 2. [...]

Inspectors wroteBased on observation, interview and recorded review, the facility failed to ensure one of two sample residents (Resident 56) received a written notice, including the reason for the room change, prior to being moved to a different room with the facility, when Resident 56 was moved without receiving written communication explaining the change. This failure resulted in Resident 56 being moved without appropriate written communication which had the potential to result in emotional distress and a violation of Resident 56's rights to make informed decision regarding her care and environment.

Inspectors wroteBased on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may be paid for Medicare and assume responsibility) for one three sampled residents (Resident 78) when the Medicare coverage was terminated for Resident 78. This deficient practice resulted in not protecting Resident 78's rights and Resident 78's Representative (RR) right to appeal the termination of Medicare Part A and possibly denying Resident 78's needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to report unusual occurrences for two of three sampled residents (Residents 28 and 244) when: 1. Resident 28 was attacked by Resident 29 (squeezed his toes and punched him 4 to 6 times in the lower left leg) and the facility did not contact local law enforcement or report the resident-to-resident abuse to the State Survey Agency. This failure put Resident 28's safety at risk, possibly other residents, as well as family and staff members in the facility. 2. Resident 244 was found on the floor by her bed, deceased and the facility did not report this unusual occurrence to the resident's responsible party (RP- a family member of designated person who is the point of contact for the nursing home staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 21) when Resident 21's deep tissue injury (DTI-localized area of discolored, intact skin, often purple or maroon, or a blood-filled blister due to damage to the underlying tissues) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 21's care needs not met and the potential for DTI to worsen.

Inspectors wroteBased on interviews and record review, the facility failed to follow-up with a positive Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of three sampled residents (Resident 52) when Resident 52's PASARR level I screening required PASARR Level II mental health evaluation on 9/24/24 and was not completed. This failure had the potential for Resident 52 to not receive the appropriate services related to her mental disorder.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan (a plan that provides direction for individualized care of the resident) within 48 hours of resident's admission for one of two sampled residents (Resident 79) when Resident 79's care plans was not created for the oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy per physician's order. This failure had the potential for Resident 79 to not receive oxygen therapy as prescribed by the physician which had the potential to result in hypoxia (a condition where tissues and organs don't receive enough oxygen) and respiratory failure (a condition where the lungs are unable to adequately provide oxygen to the blood or remove carbon dioxide).

Inspectors wroteBased on interview and record review the facility failed to ensure services were provided that met professional standards of quality for one of four sampled Residents (Resident 1), when Licensed Nurses did not document Resident 1 's change of condition for an episode of hypoglycemia (low blood sugar) on 12/16/24 in accordance with facility's policy and procedure on nursing documentation and change of condition. This failure resulted in an incomplete documentation and assessment for Resident 1 and had the potential for delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standard of practice for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 and LVN 2 did not administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) per physician's order. This failure had the potential to cause Resident 1 to experience episodes of unstable blood sugar levels such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could have a serious outcome affecting resident ' s health and wellness.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] and 10/28/24 and no inventory of personal belongings was completed, and the facility did not follow their policy and procedure (P&P) titled Personal Property. These failures resulted in Resident 1's personal belongings not being inventoried and the risk for Residents 1's wallet, checkbook and bankcard getting lost.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for five of 15 sampled residents (Resident 19, Resident 24, Resident 38, Resident 40 and Resident 337) when: 1. Resident 40 was administered 2.5L/min (two point five liter- unit of measurement)/min (minute) oxygen via nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 3L/min of oxygen per physician's order. This failure resulted in Resident 40's oxygen needs going unmet and caused Resident 40 received oxygen at different rate. 2. Resident 38 was started on antibiotic (medicines that fight bacterial infections in people) without obtaining a wound (an injury to the skin) culture (a test to find germs such as bacteria, a virus, or a fungus). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. One medication cart (out of four) was left unlocked and unattended by Licensed Vocational Nurse (LVN) 3. This failure resulted in a potential for residents and staff to have unauthorized access to medications. 2. One emergency kit (E-kit- emergency medication stored in container) was found without second zip tie in the medication storage room. This failure had the potential for unauthorized access to medication and missing medication. 3. A package containing hearing aid batteries were stored with medication in the medication cart number 4. This failure had the potential for medications and hearing aid batteries to be mixed together. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety for 91 of 96 residents when: 1. A plastic container of dry bran cereal was uncovered in the dry food storage. 2. An uncovered Styrofoam cup with brown liquid was left on top of an ice chest in the dry food storage. 3. No air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the sink where food was being prepared. 4. The food thermometer (a tool to measure temperature), was not calibrated (verifying the capability and performance of an item of measuring and test equipment by comparison to traceable measurement standards), prior to use during lunch service. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedure Food-Related Garbage and Refuse Disposal for one of three outside trash bins, when one of the trash bins was uncovered, and a large amount of plastic and debris was noted on the ground behind the trash bin. This failure had the potential to attracts animals, insects and pests which could lead to infestations, unsanitary conditions, and the spread of disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for two of three sampled residents (Resident 14 and Resident 67) when: 1. Licensed Vocational Nurse (LVN) 2 did not address Resident 14 by her name. This failure had the potential for Resident 14 to feel disrespected. 2. Resident 67' foley catheter (an indwelling urinary catheter (a thin tube placed in the bladder to drain urine into a bag) drainage bag was without a dignity cover (a cover used to cover and hold the catheter drainage bag so it is not visible). This failure violated Resident 67's right to dignity and privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 59) when Resident 59's functional limitation in range of motion was inaccurately coded on the quarterly MDS assessment dated [DATE] and 5/23/24. This failure had the potential to result in Resident 59's care needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan (CP -a detailed approach to care customized to an individual resident's needs) for five of six residents (Residents 25, 31, 58, 67, and 74) when Residents 25, 31, 58, 67 and 74 did not have a baseline care plan for the monitoring of anti-platelet medication (medication that prevents blood clots from forming). These failures placed Residents 25, 31, 58, 67, and 74 at risk for complications resulting from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. These failures placed Residents 25, 31, 58, 67, and 74 at risk for bleeding and signs of bleeding to go unidentified.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for three of 22 sampled residents (Resident 55, 47, and 387 ) when: 1. Resident 55 did not have a care plan for diagnosis of psychosis (mental disorder characterized by a disconnection from reality). This failure placed Resident 55 at a potential risk for not monitoring behavior which could lead to psychotic breakdown. 2. Resident 47's use of hearing aids was not care planned. This failure had the potential to cause staff to be unaware of Resident 47's need for the usage of hearing aids and resulted in Resident 47 not wearing her hearing aids. 3. Resident 387 did not have a care plan for communication for a foreign language. This failure had the potential for Resident 387's needs to go unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Licensed nurses did not maintain one of one medication rooms in a sanitary manner in accordance with the standards referenced by the Centers for Disease Control and Prevention (CDC) and facility policy. This failure resulted in the potential harm of cross contamination. 2. Powder was observed on the surface areas around four of four pill crushers and Licensed Vocational Nurses (LVN's) did not use appropriate cleaning disinfectant as per manufacturer guidelines. This failure resulted in the potential harm of cross contamination. 3. A certified nursing assistant (CNA) did not perform hand hygiene after handling a bag with feces. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure physician obtained informed consents (a process in which residents are given important information of the possible risk and benefits of the use of medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) and antipsychotic medication (a medication used to treat certain types of mental health problems) were completed for one of six sampled residents (Resident 31) when Resident 31 received Citalopram hydrobromide (an antidepressant medication used to treat a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and Resident 31 received Quetiapine (an antipsychotic medication that can treat several mental health conditions such as bipolar disorder [a disorder associated with episodes of mood swings [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of five sampled residents (Resident 59) when Certified Nursing Assistant (CNA) 8 stood over Resident 59 while spoon feeding her breakfast while lying in bed. This failure resulted in Resident 59 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for three of eight sampled residents (Residents 19, 44 and 137) when meals were served on plastic trays. This failure did not enhance or promote the rights of the residents to live and experience dining in a manner or environment that was homelike.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for one of five sampled residents (Resident 55) when the Minimum Data Set Nurse (MDSN) did not complete or transmit discharge and readmit MDS tracking assessment for Resident 55. This deficient practice resulted in the potential harm of residents' needs upon discharge going unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise and implement a person centered comprehensive care plan for one of four sampled residents (Resident 34) when Resident 34 had a decrease in meal intake and care plan interventions were not revised. This failure had the potential for Resident 34's nutritional needs to go unmet.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate resident meal preferences and provide an appropriate alternative for one of 18 sampled residents (Resident 35) when Resident 35 received a sandwich on white bread instead of wheat bread. This failure resulted in Resident 35 refusing to eat lunch and missing out on the nutritional value of the meal and had the potential to cause Resident 35 to experience weight loss as a result of not eating.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete and accurately documented records for one of 18 sampled residents (Resident 47) when, Resident 47's hearing aids were not documented on her inventory sheet. This failure resulted in Resident 47 not wearing her hearing aids and staff being unaware of where they were located causing Resident 47 to think they went missing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of ten sampled residents (Resident 1) when Registered Nurse (RN) 1 left Resident 1's three medications (2 tablets and 1 capsule) in a plastic cup on top of the medication cart unattended. This failure had the potential for other residents to take and administer Resident 1's medications which could result in undesired effects and harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a home like environment for four of 43 sampled residents (Residents 49, 76, 77, and 93) when, the laundry department did not have towels and linens readily available for resident care, and personal clothes were misplaced in the laundry and delayed in getting back to residents. This failure resulted in not meeting residents' basic needs and prefrence by not providing clean linen, towel and personal clothes.

Inspectors wrote2. During an observation on 1/18/21, at 10:57 a.m., in Resident 59's room, Resident 59 was lying in bed asleep with oxygen at 2 Liters Per Minute (LPM- unit of volume flow measurement) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). During a review of Resident 59's Order Summary Report, dated 11/29/21, the Order Summary Report indicated, .Oxygen (O2) at 2 Liters Per Minute (LPM) via Nasal Cannula prn (as needed) per concentrator (a medical device that concentrates oxygen from ambient air) every shift . During a review of Resident 59's Minimum Data Set (MDS-assessment of healthcare and functional needs) assessment dated [DATE], indicated, .Section C . Cognitive Patterns. Section C0500 . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled Residents (Resident 11 and 79) received the necessary care and respiratory services, consistent with professional standards of practice when: 1. Resident 11's nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and humidifier (to humidify the air you breathe) did not have dates to indicate when it was changed. 2. Resident 79's suction catheter (oral suctioning tool made with firm plastic tip used to suction oral secretions to prevent aspiration) connected to the suction machine at bedside did not have date when it was changed and the suction catheter tip was unprotected. These failures had the potential to put Residents 11 and 79 at risk for developing respiratory infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served met the daily nutritional needs for seven of 77 residents (Residents 4, 14, 45, 65, 77, 78 and 83) when: 1. Residents on large portion diets (Residents 4, 14, 45, 65, 77 and 78) were served more than the required portion size of the mashed potatoes based on the facility's menu. This failure had the potential to result in Residents 4, 14, 45, 65, 77 and 78 to receive more than the recommended daily calorie intake based on the Medical Doctor's order and Registered Dietitian's (RD) assessment of residents' nutritional dietary needs and the potential for unintended weight gain. 2. Resident 83 did not receive a fortified (foods with nutrients added to help boost nutritional value and benefit health) diet as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for one of eight sampled residents (Resident 89) when Humalog Lispro Insulin (is a fast-acting insulin that controls blood sugar around mealtimes for both type 1 and type 2 diabetes) was given without food per professional standard of practice. This failure placed Resident 89 at risk for a low sugar event with the potential to develop symptoms of hypoglycemia (low blood sugar) including dizziness, headache, feeling weak, shaking, fast heartbeat, confusion, hunger, sweating or change of consciousness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of accidents for one of three sampled residents (Resident 83) when Resident 83, who was assessed to require two-person assist for transfers, was transferred by one Certified Nursing Assistant (CNA) on 12/18/21 and did not follow the facility policy and procedure. This failure resulted in Resident 83's fall on 12/18/21 and the potential injury from the fall.

Inspectors wroteBased on interview and record review, the facility failed to implement non-pharmacological interventions (individualized approaches to care other than by administering medications, including supportive physical and psychosocial methods) for two of seven sampled residents (Resident 69 and 295) when Resident 69 and 295 had no documented evidence non-pharmacological interventions were tried or attempted first before starting antipsychotic medications (class of medications to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality). These failures put the residents 69 and 295 at risk for experiencing adverse medication side effects and receiving unnecessary psychotropic medications without the appropriate indication.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when Dietary [NAME] (DC) did not wear a hairnet while inside the kitchen preparation area per facility's policy and procedure (P&P). This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object or place to another) and foodborne illness (caused by consuming contaminated foods or beverages) to 74 of 77 sampled residents who consumed food from the kitchen.