Orchards at Tulare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three residents' rooms were free of cracked flooring, damaged door jambs, and chipping and bubbling wall plaster. This failure had the potential to result in an increased risk of Resident 1 and Resident 2 being exposed to accidental lacerations (cuts) and contaminants which can contribute to respiratory illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was made aware of one of three sampled residents (Resident 4)'s request to be sent to the hospital. This failure resulted in Resident 4's rights being violated.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for one of three sampled residents (Resident 4) when eye drops were not initiated. This failure had the potential for Resident 4 to experience discomfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision was provided when 15 minutes checks were not completed for one of three sampled residents (Resident 1) with a history of elopement. This failure resulted in Resident 1 eloping through his bedroom window, found approximately two blocks away and potential for harm.

Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure (P&P) for one of two sampled residents (Resident 1) when written request for Resident 1's clinical records was not provided in a timely manner. This failure resulted in violation of Resident 1's rights and not providing Resident 1's clinical records approximately 14 days after the request date.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the ceiling vents (outlets that allow conditioned air to flow into a room) were clean and sanitary for ten of ten sampled residents' rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]). This failure had the potential to result in the spread of respiratory illnesses to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1) with impaired cognition (problem in ability to think, learn, remember, make decisions). This failure resulted in Resident 1 eloping (leaving facility unsupervised and without prior authorization) from the facility without staff being aware and had the potential for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. A glucometer (used to take residents blood sugar) was not sanitized after use for one of three sampled residents (Resident 1);2. Personal Protective Equipment (PPE-gown, gloves, mask, eye protection) was not worn when entering a droplet precaution (used to prevent the spread of germs transmitted through large respiratory droplets from coughing, sneezing, or talking) isolation room. These failures had the potential for spread and risk of infections to residents, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen when: 1. A brown colored substance and a dead bug were observed between a reach-in freezer and reach-in refrigerator. 2. The ice machine was not sanitized in accordance with manufacturers' guidelines. 3. Baseboards were observed to be peeling away from the wall under a sink leaving a potential entry for pests. These failures placed the residents at an increased risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the Registered Dietitian (RD) accurately and comprehensively assessed nutritional status for one of one sampled resident (Resident 68) in accordance with standard of practice and facility policy and procedure (P&P) related to lack of re-assessing Resident 68's daily calorie, protein and fluid needs after a significant change in condition related to pressure injury and significant unplanned weight loss. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure regarding Advance Directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) for one of one sampled resident (Resident 446) were informed about their right to complete and AD or had evidence of declining to complete an AD. This failure had the potential for responsible parties and/or medical professionals not to honor resident healthcare wishes and to not provide appropriate treatment in the event of an emergency medical situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 32 and Resident 73), personal belongings were replaced within a timely manner once the items were reported loss. These failures resulted in Resident 32 and Resident 73 lost items not being replaced During an interview on 5/6/25 at 10:33 a.m. with Resident 73, Resident 73 stated his watch had been missing since December 2024. Resident 73 stated he had reported his missing watch to the social worker. Resident 73 was told by the social worker that the facility will replace the missing watch. Resident 73 stated he was upset that his watch had been missing, and the facility had not replaced the watch. During a review of Resident 73's admission Record, (AR) dated 5/7/25, the AR indicated Resident 73's admission date was 9/9/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status MDS Assessment (MDS-a federally mandated resident assessment tool; SCSA- a comprehensive assessment completed within 14 days of the identification of a status change) was completed for one of one sampled resident (Resident 68) when Resident 68 had a major decline in two or more MDS areas as evidenced by unplanned significant weight loss and the development of a new wound. This failure had the potential for Resident 68 to have unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Matrix was accurate and up to date for three of eight sampled residents (Resident 1, Resident 23 and Resident 68). This failure resulted in the documentation of an inaccurate assessment and an inaccurate quarterly MDS for Resident 68.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide quality care to one of one sampled resident (Resident 25) when: 1. Resident 25 had a chocking episode that was not immediately identified and addressed by nursing staff who were present in the dining room at the time of occurance. 2. A comprehensive (complete) assessment was not completed for Resident 25 after a chocking episode and delegation (assigning a task) of monitoring Resident 25 for safety was given to nonnursing staff position titled Hospitality Aid (HA). 3. Education was not provided to a family member who routinely fed Resident 25 who was on aspiration precautions (preventive measures taken to reduce the risk of accidental inhalation of food, liquid, or other substances into the lungs) to ensure swallow strategies, as assessed by a Speech Therapist (ST), was implemented. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pain Management, for one of one sampled resident (Resident 77) when Resident 77's pain was not controlled consistently. This failure had the potential for Resident 77's pain not to be correctly managed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation and accountability for the destruction of controlled substances, the facility did not ensure controlled substances were destroyed in the presence of a licensed pharmacist, and destruction was appropriately documented with a nurse and a pharmacist signatures. This failure had the potential to result in diversion or mismanagement of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of twenty eight opportunities for medication administration were performed without error, resulting in an 11% medication error rate. These failures had the potential for: 1. Resident 46, ineffective medication delivery. 2. Resident 46, omissions are inconsistent with manufacturer instructions for use. 3. Resident 34, to rotate injection sites as required.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Follow the planned menu for finger foods diet for one of one sample resident (Resident 18) during lunch trayline (a system of food preparation). 2. Ensure the allotted fluid from dietary was followed as ordered pertaining to a fluid restriction for one of one sample resident (Resident 32). These failures had the potential for Resident 18 to have loss of independence and dignity, and Resident 32 to not have adequate hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident(Resident 68) beverage and/or liquid preferences were obtained to provide sufficient drinks and liquids the resident prefers to help maintain hydration. Facility's failure to obtain Resident 68's beverage preferences placed Resident 68 at an increased risk for dehydration and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system to maintain an accurate and complete medical record (electronic health record/EHR) for one of one sampled residents (Resident 57) when the EHR had not contained documentation that an order for 4 ounces (oz) house nourishment (HN shake) with breakfast was provided to Patient 57. In addition, quantity consumed of HN shake was included in the overall fluid intake from all fluids served for breakfast impeding interdisciplinary team (IDT) ability to identify and assess intake of the planned nutrition intervention. Further, due to a Certified Nursing Assistant (CNA) 1 late entry documentation of fluid intake from the breakfast meal, the EHR contained inaccurate information reflecting Resident 57 consumed fluids from her breakfast meal at 11:03 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for one of one sampled residents (Resident 34) during the administration of an injectable medication. This failure had the potential to increase the risk of exposure to blood-borne pathogens.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was administered antipsychotic (Seroquel-use to treat delusional thoughts) medication as ordered by the physician. This failure resulted in Resident 1 not receiving his medication and the potential for adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow it's own procedure and procedure (P&P) when two of two sampled Certified Nursing Assistant (CNA 1 and CNA 2) were not wearing their required company-issued identification badge while on duty. This failure had the potential for residents and family members to not be able to identify the staff members.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was administered medication as ordered by the physician. This failure resulted in Resident 1 not receiving her medication and the potential for adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to maintain confidentiality of medical records for one of three sampled residents (Resident 1) when a screen shot (a digital image that captures the exact content displayed on a computer or mobile device screen at a specific moment) of Resident 1's medical record was taken and shared by a text message. This failure resulted in Resident 1's personal health information to be viewed by others who was not be involved in Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of twelve sampled residents (Resident 8) was referred to the dermatologist as ordered by the physician. This failure had the potential to result in a delay of treatment.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak was not reported to California Department of Public Health (CDPH-state health department) when two of twelve sampled residents (Resident 3 and Resident 4) were diagnosed with scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). This failure resulted in the CDPH being unaware of the outbreak.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were implemented for one of two sampled residents (Resident 1). This failure had the potential for Resident 1's injuries to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled resident's (Resident 1) fall assessment was accurate. This failure had the potential for staff to be unaware of Resident 1's fall risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 1) was free from physical abuse by facility staff (Certified Nursing Assistant-CNA 1). This failure resulted in Resident 1 sustaining discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh, a bald spot to the back of head, and hospitalization. 2. Ensure one of four sampled residents (Resident 3) was free from verbal abuse by facility staff (Licensed Vocational Nurse-LVN 3). This resulted in staff verbally abused Resident 3 and resulted in Resident 3 feeling angry and frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure for one for four sampled residents (Resident 1), when Resident 1 was not immediately assessed, and Attending Physician (AP) was not notified of Resident 1 ' s discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh. This failure resulted in a delay in treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge instructions were discussed with the responsible party (RP) of one of three sampled residents (Resident 1) when Resident 1 was discharged home. This failure resulted in the RP of Resident 1 being unaware of how to care for Resident 1 and Resident 1 being admitted to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic menu was followed for three of five sampled residents (Resident 4, Resident 5, and Resident 6). This failure had the potential for unmet nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders when the physician was not notified of elevated blood sugars for one of three sampled residents (Resident 1) . This failure had the potential for Resident 1 to experience complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored. This failure resulted in unidentified pills being in the bottom of the medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for one of four sampled residents (Resident 1) when the hospital medical records were not requested after Resident 1 was re-admitted from the hospital. This failure resulted in the facility being unaware of Resident 1 ' s weight bearing status and the need for a follow up appointment, placing Resident 1 at risk for re-injury and a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of a change of condition when one of four sampled residents (Resident 1) had a rash. This failure had the potential for the rash to worsen.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for one of three sampled residents (Resident 1) when a laboratory test was not completed. This failure had the potential for the facility to be unaware of health issues for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow infection prevention and control practices in accordance with Centers for Disease Control and Prevention (CDC, national health organization) guidelines for 92 of 92 residents residing in the facility. 2. Ensure surveillance for infection were properly conducted, data collected, analyzed, track and trended for 92 of 92 residents residing in the facility. 3. Develop and implement water management policies and procedures to assist the facility in the prevention of Legionella (waterborne bacteria that cause serious lung disease) and /or other opportunistic waterborne pathogens. These failures had the potential to transmit infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physicians provided informed consents for four of four sampled residents (Resident 29, Resident 35, Resident 54, Resident 72, and Resident 143) prior to administration of psychotropic medications (used to treat mental health disorders) and ensure the consent and acknowledgement of the informed consents by the resident or the resident's representative were documented on the Informed Consent Form (ICF). This failure violated patients' rights to be fully informed of their treatment and medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 46 sampled residents (Resident 44, Resident 242, Resident 39, and Resident 4) were assessed and provided with the appropriate call light type to call staff when needed. This failure had the potential for residents' needs not being met.

Inspectors wroteBased on interview and record review, facility failed to: 1. Ensure 10 of 13 sampled residents (Resident 54, Resident 80, Resident 29, Resident 143, Resident 72, Resident 36, Resident 78, Resident 45, Resident 82, and Resident 24) or residents' representatives were provided information and allowed to formulate advance directives (AD, a written document that tells the health care providers who should speak for you and what medical decisions they should make if you become unable to speak for yourself). This failure had the potential to result in the residents' wishes or health choices to not be honored. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 142 and Resident 143) and/or the resident representative received a summary of the Baseline Care Plan (BCP-the minimum healthcare information necessary to properly care for each resident immediately upon their admission) within 48 hours of admission. This failure had the potential for unmet care needs for Resident 142 and Resident 143.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of competency and skill performance for six of eight sampled employees (Certified Nursing Assistant [CNA] 5, CNA 7, Restorative Nursing Assistant [RNA] 2, Registered Nurse [RN] 1, Assistant Director of Nursing [ADON], and Infection Preventionist [IP]). This failure had the potential to result in lack of competent and skilled staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure opened food items were labeled with an expiration date. 2. Ensure the ice machine expired water filter was replaced per manufacture's guidelines. These failures had the potential to result in decreased palatability (tastiness) and the potential for spread of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Governing Body: 1. Provided oversight to their Infection Prevention and Control Program (IPCP) and the Infection Preventionist (IP-individual responsible for the facility's IPCP and help prevent the transmission of communicable diseases and infections). This failure resulted in the removal of the personal belongings, memorabilia, and clothing for five of five sampled residents (Resident 29, Resident 35, Resident 54, Resident 72, and Resident 80), which could potentially have a negative effect on the residents' well-being. 2. Established water management program as part of the Infection Control Program under the leadership of the Infection Preventionist. This failure had the potential for transmission of water-borne infections. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the Binding Arbitration Agreement in simple, understandable language or language common to the area other than English. This failure had the potential for residents to not fully understand the terms of the agreement and the nature or the possible consequences as a result of the agreement.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of eight sampled residents, (Resident 45), when Resident 45's room was not maintained in a clean homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide the necessary care to maintain good grooming and personal hygiene for one of eight sampled residents (Resident 4). This failure resulted Resident 4 having long and dirty fingernails. 2. Ensure one of eight sampled residents (Resident 45) was assisted with oral care. This failure resulted in Resident 45 having dental issues and/or tooth decay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 29 and Resident 87) activity choices that met the residents likes and interests in accordance with the residents' assessment and care plan. This failure resulted in Resident 29 and Resident 87's expression of boredom and not meeting the resident's interest to improve their sense of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Social Services followed up on the status of the hearing aids for two of two sampled residents (Resident 29 and Resident 36). This failure had the potential to result in poor communication and loss of hearing abilities.

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly wound assessments were done for one of one sampled resident (Resident 39). This failure had the potential to result in the inability to determine the healing progress of current wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 68) received treatment for contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) in his left hand. This failure had the potential for worsening of Resident 68's contracture.

Inspectors wroteBased on interview and record review, the facility failed to ensure communication and coordination between the facility and dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working) center was complete with assessments of the dialysis access site (surgically created access) on the Dialysis Communication Form for two of two sampled residents (Resident 39 and Resident 49). This failure had the potential to result in complications due to not properly assessing the dialysis site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 54) was assessed to determine the level of risk for bed entrapment (patient is caught, trapped, or entangled in the spaces in or about the bedrail, mattress or bed frame). This failure had the potential for adverse consequences.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician evaluated and addressed weight loss for one of one resident (Resident 80). This failure had the potential for the resident to not receive proper medical care for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure controlled substances (highly abused drugs) were stored in a locked cabinet. This failure had the potential for controlled substances to be diverted. 2. Ensure expired medications were not stored with active stock of medications. This failure had the potential to expose residents to expired medicaitons with unknown potency and efficacy. 3. Ensure destruction of medications were done in accordance with the facility policy. This failure had the potential for employees to divert discarded medications. 4. Ensure the treatment cabinet with medications in Central Supply Room was locked. This failure had the potential for medications to be accessed by unauthorized users.

Inspectors wroteBased on interview and record review, the facility failed to ensure Social Services followed up dental services for three of three sampled residents (Resident 29, Resident 36 and Resident 41). This failure had the potential for unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare a pureed menu item according to the recipe instructions. This failure had the potential to result in food lacking nutritive value.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI-a data driven and proactive approach to quality improvement) Program as evidenced by: 1. Four members of the nursing staff (Licensed Vocational Nurses [LVN] 6, LVN 7, LVN 8, and Staffing Coordinator [SC]) were not familiar with QAPI and the facility's quality improvement projects. 2. The fall interventions had not been fully monitored and evaluated, data collected, analyzed, tracked, and trended, and outcome of the process had not been fully established. 3. The facility did not have performance indicators to monitor quality of care and services in high risk and problem prone areas like Infection Control and Laundry. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain and implement an effective antibiotic (fight bacterial infections) stewardship (coordinated effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) program for one of one sampled resident (Resident 4). This failure had the potential to place residents at risk for harm caused by unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review the facility failed to: 1. Administer the pneumococcal vaccine for one of three sampled residents (Resident 80) after consent was obtained. 2. Obtain vaccine refusal consent forms for one of three sampled residents (Resident 72). These failures had the potential to spread infectious diseases

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was maintained in a safe, clean, homelike environment when: 1. One of two observed bathrooms had a clogged toilet, and two of two observed bathrooms needed sanding and painting. This failure resulted in unsanitary and unsafe conditions for the residents. 2. The kitchen temperature was too hot for three of three kitchen staff (Interim Dietary Supervisor [IDS], Dietary Staff [DS 1 and DS 2]) . This failure had the potential to result in facility kitchen staff experiencing heat-exposure related injuries.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of three sampled residents (Resident 2) when staff placed Resident 2 on the floor to prevent a fall. This failure resulted in staff being unaware of how to care for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when four of eight sampled residents (Resident 1, Resident 2, Resident 4, and Resident 5) presented with rashes. This failure resulted in a delay of care and the potential for scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite) to spread to other residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak was not reported when six of eight sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) were diagnosed with scabies (a contagious skin disease marked by itching and small raised red spots, caused by the itch mite). This failure resulted in the state health department being unaware of the outbreak.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9) Responsible Party (RP) was provided with Resident 9 ' s medical record when requested. This failure resulted in a delay of the medical record being provided.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Resident-to-Resident Altercations for one of two sampled residents (Resident 1). This failure resulted in Resident 2 hitting Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for one of three sampled residents (Resident 1), when Resident 1 was not immediately assessed, and Attending Physician (AP) was not notified of Resident 1 ' s unwitnessed fall. This failure resulted in a delay in treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified for one of three sampled residents (Resident 1) when Resident 1 was not administered prescribed medications. This failure had the potential for Resident 1 to have adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the plan of care was implemented and/or updated after a fall for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for the residents to fall again.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete for one of three sampled residents (Resident 1). This failure resulted in an incomplete medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled staff (Dietary Aide [DA] 1 and Certified Nursing Assistant [CNA] 1) wore their N95 mask (respiratory device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This failure had the potential for residents, staff, and visitors to be at risk for contracting COVID 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the therapeutic menu when cornbread was not served as indicated for five of five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). This failure had the potential for the residents to have unmet nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician's Orders (PO) were implemented for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have an increase in behavior symptoms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services according to the care plan for one of three sampled residents (Resident 1) when Resident 1 was not supervised by staff when walking down the hallways. This failure resulted in Resident 1 being found outside of the facility alone.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) was free from abuse when Resident 1 was tied down in her wheelchair with a blanket (draw sheet-a flat sheet used on top of the bed mattress) to prevent her from getting up. This failure had the potential for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement one of three sampled residents (Resident 1) Comprehensive Care Plan (a written plan developed by an interdisciplinary team [attending physician, registered nurse, dietician, etc.] and the resident, to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being) to prevent a fall incident when Resident 1 was left in the dining room without staff supervision. This failure resulted in Resident 1 falling and sustaining a right inferior orbital wall fracture (a break in the inner wall of the eye socket), requiring a transfer to an acute hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an item on the menu was prepared and served to 34 of 34 residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 8, Resident 9, Resident 12, Resident 13, Resident 16, Resident 18, Resident 21, Resident 23, Resident 24, Resident 26, Resident 28, Resident 29, Resident 32, Resident 34, Resident 35, Resident 37, Resident 39, Resident 40, Resident 41, Resident 42, Resident 44, Resident 45, Resident 51, Resident 52, Resident 55, Resident 58, Resident 59, Resident 60, and Resident 61) on a therapeutic diet. This failure had the potential to alter texture and nutritional value for these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodates resident's preferences and allergies for two of 16 sampled residents (Resident 21 and Resident 54) when: 1. Resident 21, with a lactose intolerance allergy, was being served house nourishments, which contain milk, four times a day . 2. Resident 54 was served two of her food dislikes for lunch. These failures had the potential to result in inadequate intake and possible weight loss for Resident 21 and Resident 54.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 12) responsible party (RP) was properly notified of Medicare benefit changes. This failure had the potential for Residents 12's RP to not make an informed decision regarding Medicare services.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plans for two of 16 sampled residents (Resident 32 and Resident 5 ) when: 1. Resident 32 had a limitation in range of motion (ROM) to his lower extremities. 2. Resident 5 had a physicians' order (PO) for passive range of motion (PROM) to her bilateral lower extremities (BLE). These failures had the potential to result in staff being unaware of residents' needs and Resident 32 and Resident 5 not getting required treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 32 and Resident 44) were assisted with grooming. These failures had the potential for the residents not to maintain their highest practicable level of functioning and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 16 sampled residents (Resident 5 and Resident 21) received restorative care. This failure had the potential to result in decreased safety and independence for Resident 5 and Resident 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the prefilled syringes (single-dose packet syringes) of Morphine Sulfate (medication used to treat moderate to severe pain) were labeled with expiration dates for two of 16 sampled residents (Resident 1 and Resident 31). This failure had the potential to result in residents receiving expired medications. 2. Remove a medication for one time use only from the medication cart for one of 16 sampled residents (Resident 47). This failure had the potential for medication errors. 3. Remove discontinued medication from the medicine cart for one of 16 Residents (Resident 37). This failure had the potential to contribute to adverse consequences to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 15 Ready Care shakes were stored at the proper temperature prior to being served to residents. This failure had the potential to cause foodborne illnesses for facility's residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure breakfast was served at a preferred time for one of 16 sampled residents (Resident 21). This failure had the potential to result in weight loss and inadequate meal intake.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete medical record for one of 16 sampled residents (Resident 48) for his G-Tube (gastrostomy tube - a tube inserted surgically through the abdomen into the stomach for nutrition and medications) bolus feeding (a type of feeding method using a syringe to deliver formula through the G-Tube). This failure had the potential for Resident 48 not to receive the appropriate bolus feeding via G-Tube as ordered by the physician.