Orchardview Post-Acute and Rehabilitation Center

Inspectors wroteBased on facility policy review, medical record review, and interviews, the facility failed to notify the physician of abnormal laboratory (lab) results for 1 resident (Resident #19) of 3 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure insulin medications were labeled appropriately to include an open date for 2 residents (Resident #62 and Resident #67) of 7 residents reviewed for insulin storage.

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility staff failed to perform appropriate hand hygiene when serving residents' meal service for 2 residents (Residents #18 and #22) on 1 of 2 units observed for meal tray distribution.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #30 and Resident #31) of 67 residents reviewed for abuse. The facility's failure to prevent resident to resident abuse resulted in actual HARM for Resident #31.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to ensure dented cans (3 of 3) were discarded and not available for resident use, which had the potential to affect 67 of 67 residents.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) timely for 2 residents (Resident #5 and Resident #65) of 3 residents reviewed for beneficiary notification.

Inspectors wroteBased on facility policy review, facility documentation review, medical record review, and interview the facility failed to protect 1 resident (Resident #421) from exploitation of 67 residents reviewed for exploitation.

Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, and interviews, the facility failed to report an allegation of abuse to the required state entities within 2 hours for 2 residents (Residents #52 and #30) of 67 residents reviewed for abuse.

Inspectors wroteBased on facility contract review, facility policy review, medical record review, and interview, the facility failed to ensure a coordinated plan of care with the hospice provider was available in the medical record for 1 residents (Resident #19) of 3 residents reviewed for hospice services.

Inspectors wroteBased on policy review, medical record review, and interviews, the facility failed to ensure proper infection control practices were followed during a noon and a breakfast meal for 2 residents (Residents #67 and #17) and during housekeeping services for 2 residents (Residents #16 and #54) of 21 residents reviewed for COVID-19 Transmission-Based Precautions.

Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from sexual abuse for 1 resident (Resident #2) by Resident #3 and physical abuse for 2 residents (Residents #4 and #5) by Resident #1 of 7 residents reviewed for abuse. The abuse resulted in actual harm to residents #4 and #5 when Resident #1 threw a chair at Resident #4 and #5 resulting in Resident #4 receiving a scrape down his left shin and Resident #5 receiving a bruise and swelling on his right knee.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure 1 resident (Resident #1) of 5 residents reviewed for medication administration was free of a significant medication error after receiving another resident (Resident #2's) prescribed medication which resulted in actual harm to Resident #1.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to revise a comprehensive person-centered care plan related to falls for 1 resident (Resident #12) of 16 residents reviewed for comprehensive care plans.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to implement new fall interventions for 1 resident (Resident #12) of 4 residents reviewed for falls.

Inspectors wroteBased on facility policy review, medical record review, and interviews the facility failed to ensure the medical record was accurate and complete for 4 residents (Resident #7, #17, #3, and #12) of 8 residents reviewed for blood glucose monitoring and insulin administration.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure oxygen settings were maintained as ordered by the physician on 2 residents (Resident #1 and Resident #47), failed to secure portable oxygen cylinders for 1 resident (#47), and failed to provide oxygen humidification for 2 residents (Resident #1 and Resident #52) of 7 residents reviewed for supplemental oxygen use.

Inspectors wroteBased on medical record review and interview, the facility failed to develop a comprehensive care plan for 1 resident (Resident #65) of 21 residents reviewed for comprehensive care plans.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to ensure hand hygiene and nail care was provided for 1 resident (Resident #1) of 25 residents reviewed for Activities of Daily Living (ADL) care. The findings Include: Review of the policy titled, Activities of Daily Living (ADLs), Supporting revised 2018, showed .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents .in accordance with the plan of care, including .hygiene .grooming .elimination (toileting) . [...]

Inspectors wroteBased on facility policy review, medical record review, observation and interview the facility failed to ensure 1 resident (Resident #1) received house shakes and failed to implement dietary recommendations for 1 resident (Resident #45) of 6 residents reviewed for nutritional status.

Inspectors wroteBased on medical record review and interview, the facility failed to maintain complete and accurate medical records for 3 residents (Resident #1, Resident #60, and Resident #65) of 27 residents reviewed for medical records.

Inspectors wroteBased on facility policy review, review of the most recent Plan of Correction (POC), current survey findings, and interview, the facility failed to maintain sustained compliance with the prior plan of correction related to performance improvement after identifying inaccuracies with Tennessee Physician Orders for Scope of Treatment (POST) forms. The Quality Assurance Performance Improvement (QAPI) committee failed to monitor the ongoing concern of POST forms for 2 residents (Resident #1 and Resident #65) of 26 POST forms reviewed.