The Orchard - Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to complete the required Notice of Proposed Transfer/Discharge Form by not documenting the reason or basis for the transfer/discharge for one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1 not receiving a complete written explanation of the basis for the transfer/discharge as required.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary respiratory care and services for two of three sampled residents (Residents 2 and 4) when the facility failed to: 1. Ensure the resident received continuous oxygen therapy as ordered by the physician and in accordance with the facility's policy and procedure titled Oxygen, Use of for one of two sampled residents (Resident 4) when Resident 4's nasal cannula (NC- a small plastic tube placed in the nostrils to deliver supplemental oxygen) was not placed on the resident during bedside hygiene care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by not ensuring the facility's ice machine storage bin was clean that served 150 of 150 residents(Residents 1-150) in accordance with the facility's policy and procedure titled, Infection Control Policy/Procedure-Cleaning, Disinfection and Sterilization, This deficient practice had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) for the residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to routinely inspect and maintain the facility's water softener tank (a device that removes minerals like calcium and magnesium from hard water to prevent buildup and make the water easier to use) to ensure in good functioning condition and without a leak in the system for the safety and sanitary environment of 150 of 150 residents (Residents 1-150) that received water from the water softener tank. This deficient practice had the potential to create an unsafe and unsanitary environment by causing water intrusion, increasing the risk of equipment damage, slip hazards, and disruption of essential water systems, which could negatively affect all 150 residents who rely on the facility to maintain a functional physical environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan addressing noncompliance with oxygen use for one of two residents (Resident 4) to address resident's behavior of removing the nasal cannula (NC- a small plastic tube placed in the nostrils to deliver supplemental oxygen) in accordance with the facility's policy and procedures titled Comprehensive Person-Centered Care Planning. This deficient practice resulted in inconsistent implementation of care related to oxygen therapy that could delay in the delivery of services, or the resident could not receive the needed interventions and care to prevent hypoxia (lack of oxygenation in the body and tissues).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive care plan (CP) was developed for one of three sampled residents (Resident 3) in accordance with the facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Planning, by failing to Initiate a person-centered CP for Resident 3 with a diagnoses of pneumonia (PNA, severe infection of lungs). The deficient practice had the potential to result in inconsistent implementation of care to the residents or delay in the delivery of services.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was implemented for one of two sampled residents (Resident 1), who went out on pass (OOP- an authorized, temporary leave of absence for an admitted inpatient or resident) on 7/8/2026 in accordance with the facility's Policy and Procedure (P&P) titled, Out on Pass/Leave of Absence. This deficient practice had the potential for communication regarding Resident 1's whereabouts to be unaccounted for, and had the potential for Resident 1's safety to be affected since facility staff did not document Resident 1's condition prior to and upon return to the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to implement facility's policy and procedure titled, Abuse: Prevention and Prohibition Against Suspicion of Crime, during the provision of care and services for one of one sampled residents (Resident 1) by failing to: Prevent mental abuse by a male therapist, who made Resident 1 feel uncomfortable. Identify mental abuse. Investigate an allegation of Resident 1 feeling uncomfortable with the male therapist and the way he moved when he was doing the therapy. Report allegation of mental abuse outside of facility and to the appropriate State of Federal agencies in the applicable timeframes. These deficient practices placed residents at risk of further abuse, feeling of intimidation and neglect. Cross referenced to F607Findings: [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to immediately report an allegation of potential abuse for 1 of 1 residents reviewed (Resident 1), when multiple facility staff-including the SSD, DSD, and DOR-failed to report Resident 1's allegation of potential abuse to the State Agency and other required agencies, resulting in a delay in required reporting and placing Resident 1 and other residents at potential risk. This failure resulted in a delay in reporting a potential allegation of abuse and had the potential to place Resident 1 and other residents at risk. Cross referenced to F607Findings: During a review of Resident 1's admission Record (AR), the AR indicated an admission to the facility on 2/11/2026 with diagnoses that included metabolic encephalopathy, abnormalities of gait and mobility, and muscle weakness. [...]

Inspectors wroteBased on interview and record review the facility failed to document a resident's left leg bruising (a mark on the skin caused by broken blood vessels under the surface, which happened after an injury, like a bump or blow) and swelling for one of four sampled residents (Resident 1). This deficient practice that the potential to negatively affect Resident 1's physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure and accurate Minimum Data Set (MDS, a resident assessment tool) assessment for three (3) of 3 sampled residents (Residents 43, 81, and 7) by failing to ensure: 1. The functional limitations (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in range of motion (ROM, full movement potential of a joint) was accurate assessed for Resident 43's left arm. 2. The functional limitations in ROM was accurately assessed for Resident 81's both legs. This deficient practice had the potential to result in delayed or missed identification of joint ROM changes, inaccurate care planning, and inadequate provision of services and treatments for Residents 43 and 81. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a person-centered care plan (a treatment plan that focused on the needs and preferences of a resident or individual) for four of nine residents (Resident 43, 63, 7, and 142) by failing to: 1. Develop Resident 63's care plan related to behavior related to dementia (a progressive brain disorder that results in memory loss, change in personality and thought process that affects the activities of daily living) was developed to address how to supervise and monitor the resident. 2. Develop Resident 7's care plan that addressed how the resident will be monitored while receiving Escitalopram Oxalate (a medication primarily used to treat depression). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe provisions of pharmaceutical services to provide safe storage of medications as indicated in the facility's policy and procedure by failing to: 1. Ensure Resident 84 assessed and have a physician's order to keep Xopenex (a rescue inhaler that provided quick relief for breathing difficulties) at the bedside. 2. Ensure Medication Cart 1 and Medication Cart 2 did not have loose pills in the drawer that licensed nurses could not identify. These deficient practices had the potential for the resident to self administer multiple dosage of medication and cause overdose and/or lead to unsafe consumptions of medication by other residents who could access the medications. Addition the deficient practice could result in medication loss and misuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete and accurate documentation in the medical records for two of nine sampled residents (Residents 63 and 43) by failing to ensure: 1. Resident 63's use of antipsychotic medication (primarily used to treat psychosis [mental state where a a resident has difficulty distinguishing between what is real and what is not]) and antidepressant medications (a medication used to treat depression) on the resident's Nursing Summary Weekly. This deficient practice had the potential to result in Resident 63's lack of or delay in treatment and interrupt the provision of care/intervention to the resident's psychosocial need. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their facility's policies and procedures (P&P) for 1 of 5 sample residents (Resident 3) when Licensed Vocational Nurse (LVN) 6 did not wear personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when administering medication through Resident 3's feeding tube (g-tube, a thin flexible tube used to deliver nutrition, hydration, and medication directly into the stomach when a person is unable to eat or drink on their own). This failure had the potential to result in Resident 6 sustaining an infection from external exposure from other residents, staff, and visitors and the infection could spread throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and hazard free environment for three of five sampled residents (Resident 22, 144, and 159) as evidenced by multiple power strips were plugged in another power strip around Resident 22, 144 and 159's bed. The deficient practice had the potential to lead to power overload, overheat that could lead to fire at the facility that threatens the lives of residents, staffs and visitors and/or put them at risk for injury and harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of nine sampled residents (Resident 84) was assessed to determine if the resident was capable of self-administering medications, and the physician ordered to allow the resident to keep medication at the bedside before the facility allowed the resident keep medications at bedside. This deficient practice had the potential for unsafe medication administration and storage for Resident 84 and result in adverse reaction (undesired effect) or receive expired or too much medication that could lead to overdose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report multiple, consecutive Restorative Nursing Aide (nursing aide program that help residents maintain any progress made after therapy intervention to maintain their function) treatments that was refused by one of seven sampled residents (Resident 43) to the physician. These failures resulted in Resident 43 not receiving services and interventions to improve ROM and address reasons for refusals, prevent contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness), and improve overall mobility and physical functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a communication tool or device that translate to a language the resident could understand for one of three residents (Resident 94) who does not speak the formal language in the facility. This deficient practice prevented Resident 94 from communicating the necessary needs with facility staff that could delay in the resident receiving appropriate care/treatment. A review of Resident 94's admission Record [AR] indicated Resident 94 was admitted to the facility on [DATE], with diagnoses that included prostate cancer (uncontrolled growth and spread of abnormal cells that can invade and damage healthy tissues) and anemia (lower-than-normal number of red blood cells). The AR indicated that Resident 94 primary language was Spanish. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 81) who was assessed as being at risk for pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) was provided a pressure relieving barrier to be placed between Resident 81's overlapping, contracted (loss of motion of a joint associated with stiffness and joint deformity) toes of the left foot as indicated on the facility policy. This deficient practice had the potential to result in Resident 81 developing pressure ulcers on the left foot.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to one of three sampled residents (Resident 142) who was incontinent of bladder (loss of bladder control) and had recent history of urinary tract infection (UTI- an infection in the bladder/urinary tract) was not kept clean and dry. Resident 142's incontinent brief was soaked with urine when observed at 10:35 AM. Certified Nursing Assistant (CNA) 2 stated she changed Resident 142's incontinent brief around 7:45 AM and she was going to check if the resident need to be changed at 11:30 AM. This deficient practice had the potential to result Resident 142 to be at risk for recurrent UTI and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's policy and procedure for Nutrition Status Management to weigh one of four sampled residents (Resident 142) upon readmission for nutrition evaluation and management. Resident 142 was weighed six days after readmitted to the facility on [DATE]. The nutrition evaluation by the Registered Dietitian (RD- professionals who are experts in food and nutrition) review was not conducted and did not identify Resident 142's weight loss until six days later. This deficient practice had resulted in the delayed implementation of the intervention for Resident 142's weight maintenance and nutrition management to prevent further weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to one of five sampled residents (Resident 157) as evidenced by: 1. Failing to administer Entresto (a medication to treat heart failure [a chronic condition in which the heart does not pump blood as well as it should]) to Resident 157 on 6/29/2025 at 9 AM, 6/30/2025 at 5 PM, 7/1/2025 at 5 PM and 7/16/2025 at 5 PM. 2. Failing to document the reason why Entresto was not administered on 6/30/2025 at 5 PM, 7/1/2025 at 5 PM and 7/16/2025 at 5 PM. 3. Failing to notify the physician and obtain an order when Resident 157 did not receive Entresto on 6/29/2025 at 9 AM, 6/30/2025 at 5 PM, 7/1/2025 at 5 PM, and 7/16/2025 at 5 PM due to unavailability of the medication at the scheduled time for administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly provide dental services for one of nine sampled residents (Resident 79) by failing to follow recommendations from the dentist for an oral surgery referral for bone spurs removal (a surgical procedure to remove a bone spur - small sharp pieces of bone that could sometimes detach after a tooth extraction or other oral surgery). This deficient practice resulted in Resident 79 having pain and resorting to eating oatmeal, soups, and pureed food that can potentially result lt in weight loss. [...]

Inspectors wroteBased on observation and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional standards for food service safety by failing to ensure that the Dietary Aid (DA) 1 labeled individually packaged four (4) cups of cottage cheese, 12 cups of yogurt, and four (4) cups of puddings in the refrigerator with the date of Use By. This deficient practice had the potential to cause food unlabeled past safe storage time/ period, and place residents who consume this food at risk for foodborne illness (food poisoning or food illness due to pathogens [harmful organisms that cause illness such as bacteria, viruses, or parasites] and toxins that contaminate food).

Inspectors wroteBased on interview and record review the facility failed to immediately notify the resident's Physician for one of three sampled residents (Resident 2) reviewed for accidents, of a change in condition when Resident 2 had a fall and was currently receiving anticoagulant (a group of medications that decreased your blood's ability to clot) medications. This deficient practice had the potential for Resident 2 to have complications from the use of anticoagulant due to frequent falls and not to receive the necessary interventions and negatively affect the provision of care and services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a resident assessment tool), accurately reflected resident's vision status for one out of three sampled residents (Resident 2), who has visual impairment (a term describing any vision loss that cannot be fully corrected). Resident 2 was assessed having adequate vision (sees fine detail, such as regular print in newspapers/books). This deficient practice had the potential for Resident 2 to not receive care to address Resident 2's visual impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered plan of care for one out of three sampled residents (Resident 2) who was assessed to have visual impairment (a term describing any vision loss that cannot be fully corrected) did not have a care plan to address interventions for the resident's visual impairment. This deficient practice had the potential for Resident 2 not to receive care and services for visual impairment such as keeping the resident safe and to prevent accidents and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented for one out of three sampled residents (Resident 2), reviewed for accidents when Resident 2, who had history of multiple falls at the facility (5/24/2025, 5/25/2025, 6/7/2025, and 6/10/2025), did not have a floor mat in place when the resident was lying in bed, as indicated in the resident's care plan titled Actual Fall. This deficient practice had the potential for recurrent falls for Resident 2 and sustain major injuries as a result of a fall from the resident's bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately document in the Fall Risk Evaluation (FRE) on 6/10/2025 and accurately document in the Minimum Data Set (MDS, a federally mandated resident assessment tool) that one of three samples residents (Resident 2) had visual impairment (a term describing any vision loss that cannot be fully corrected) and was at high risk for accidents and fall due to blindness. This deficient practice had the potential for Resident 2 not to receive care to address Resident 2's visual impairment that could lead to a lack of or delay in delivery of necessary care or services to Resident 2 such as monitoring and supervision to prevent recurrent accidents and falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide necessary care and services for one of 4 sampled resident ( Resident 1) who was at risk for developing pressure ulcer (PU- a skin damage or injury due to poor circulation or prolonged unrelieved pressure) and complications from PU, in accordance with the facility ' s policy and procedure, care plan and the physician ' s order by failing to: 1. Ensure the facility ' s licensed staff was referred and followed up on Resident 1 ' s referral and appointment with a vascular physician (a doctor who specializes in the diagnosis, treatment, and prevention of diseases that affect the blood vessels, including arteries and veins), in accordance with Nurse Practitioner (NP) 1 ' s recommendations on 9/24/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 143) with history of falls (move downward, typically rapidly and freely without control, from a higher to a lower level) was provided supervision, monitoring and assistance as indicated on the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) of high risk for falls and facility's policy and procedure to prevent falls by failing to: 1. Ensure Resident 143's room was well lit and had adequate lighting and not kept dark, in accordance with the resident's care plan dated 6/8/2024, and 6/14,2024 to prevent hazards, falls and accidents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility's policy and procedure for infection control by failing to: 1. Store food in a sanitary manner to prevent growth of microorganisms that causes food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) for residents in the facility by not checking the boxes of fruit and vegetables that was rotten and spoiled items. 2. Ensure the dietary aid to follow hand washing practices consistent with accepted standard of practice after touching trash bin prior to returning to work. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed implement the facility's policy and procedure on infection control to prevent spread of infection for four (4) out of seven (7) sampled residents (Resident 102, 25, 108, and 454) by failing to: 1. Ensure the nasal cannula (NC-a device used to deliver supplemental oxygen to people) tubing was changed at least every 7 days for Resident 102. 2. Ensure the NC was stored properly and not reused after it was observed touching the trashcan and the floor for Resident 25. 3. Ensure the G-tube (A tube inserted through the wall of the abdomen directly into the stomach) formula bottle tubing was dated for Resident 108. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary, and hazard free environment for two (2) out of six (6) residents (Resident 255, and 64) by failing to: 1. Ensure the footrest (a base of support and elevates the legs) of a wheelchair was not placed in the doorway, blocking the residents and staffs from leaving and entering Resident 255 room. This failure had the potential for residents and staffs to be at risk for accident by tripping onto the footrest and result in a major injury. 2. Ensure the facility's staff timely empty two used urinals filled with the resident's urine for Resident 64. This failure resulted in Resident 64's complaint of foul urine odor, feeling unsanitary and uncomfortable with the smell.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 21) were provided dignity and/or privacy during a medication pass. Licensed Vocational Nurse (LVN) 2 did not close Resident 21's door and/or pull the resident's privacy curtain during administration of medication via injection (medication adminitered using needle into the skin or muscle) into the resident's abdomen, while the resident's roommate was sitting across the room in Resident 21. This failure resulted the violation of Resident 21's right for privacy and dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one of one sampled resident (Resident 108) in accordance with the facility ' s policy and procedure by failing to ensure the call light (a device used by residents to signal his or her needs for assistance) was within reach. This deficient practice had the potential for Resident 108 not able to call the facility staff to ask for help or assistance especially during emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident specific comprehensive care plan in the management of dysuria (pain or discomfort when urinating) for one out of thirty sampled residents (Resident 101). This deficient practice had the potential to result in Resident 101 to experience recurrent dysuria and urinary tract infection (UTI, an illness in any part of urinary tract, the system of organs that makes urine).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary care and services to residents who was dependent with the staff to carry out activities of daily living (ADL), maintain grooming, and good personal hygiene for one of two sampled residents (Resident 454) by not shaving his facial hairs after a bed bath. This deficient practice had the potential to negatively affect Resident 454's physical appearance, dignity, and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 90) by failing to label with the date and time when first used and replacing the oral suctioning (a procedure involves inserting a small plastic tube attached to a suction machine into the mouth to remove saliva or secretion) canister (a container used in medical settings to collect waste material during suction procedure) of Resident 90. This deficient practice placed Resident 90 at risk for respiratory infection (any infectious disease of the parts of the body involved in breathing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility policy and procedure titled Resident Care - Recognition and Management of Pain, dated 1/2021, for two (2) out of two (2) sampled residents (Resident 25, and 604) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 6 immediately report to Licensed Vocational Nurse (LVN) 8, Resident 25's complaint of pain to ensure LVN 8 reassess the resident for the pain medication's effectiveness, and reassess Resident 25 ---was observed experiencing pain in his left leg's stump [the basal portion of a bodily part (as a limb) remaining after the rest is removed] on 7/23/2024 at 10:17 AM. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an accessible-hemodialysis (a process of removing toxins and excess fluid in the blood by insering a plastic catheter or tube into the body using a machine ) emergency kit (kit used in the event bleeding was observed in the hemodialysis site) for one of three sample residents (Resident 138) who received hemodialysis. This deficient practice had the potential to delay or unable to immediately provide interventions in an event of emergency to Resident 138 for complications such as trauma, and bleeding on the dialysis access site (a surgically created vein used to remove and return blood to the body during hemodialysis) that could lead to a significant blood loss and decline in the resident's wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical (medication related) services to prevent consequences of medication-related adverse events (undesired effects) for two (2) out of three (3) sampled residents (Resident 21 and Resident 22) by failing to: 1. Administer PreserVision (medication used for dry eye) with food per physician's order for Resident 21. This failure had the potential to cause Resident 21 to have stomach irritation such as stomach pain, nausea, and vomiting. 2. Administer Metformin Hydrochloride (medication given to lower the blood sugar level) was administered with meals as ordered by the physician for Resident 22. This failure had the potential to result in Resident 22 to develop adverse reaction to the medication such as significant drop in blood sugar level.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food served for one of two sampled residents (Residents 354) was palatable and hot food were served hot and/or above 120 degrees °F (°F-a measurement of temperature) as indicated in the facility's policy and procedure titled, Meal Service, dated 2023. This deficient practice had the potential to affect palatability of the food to the residents and to have poor meal intake that could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents ' diagnostic tests were completed as ordered by Resident 1 ' s physician to confirm the diagnosis of dementia (a progressive condition marked by the development of multiple cognitive deficits). This deficient practice had the potential to result in Resident 1 not receiving the adequate dementia care and being able to achieve her highest level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive and person-centered care plan that included measurable objectives and time frames for three residents (Residents 96, 98, and 113). Residents 96, 98, and 113 did not have care plans with measurable objectives and time frames. This deficient practice had the potential to negatively affect the delivery of care and services for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to prevent and/or limit decline in range of motion (ROM) and mobility for five of 28 sampled residents (Residents 30, 36, 52, 91, and 116) who were receiving restorative nursing aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) services. The facility failed to ensure: a. For Resident 30, RNA treatments for both upper extremities (BUE, shoulder, elbow, wrist, hand) passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises five times a week and RNA treatments for sit to stand (moving from a sitting position to standing position) five times a week were provided since 1/13/21, when the order for RNA program was written. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented for the prevention of avoidable accidents for five out of nine sampled residents (Residents 116, 438, 4, 455, and 56). 1. Staff tilted a shower chair backwards onto the two rear wheels while transferring Resident 116 with a Hoyer lift (a mechanical lift that allows a person to be transferred from one surface to another). 2. Residents 438, 4, and 455 did not have a functioning bed and wheelchair alarm (sensor pad connected to an alarm monitor that can be placed on the bed and wheelchair seat. The alarm is triggered and signals the staff if the resident is attempting to get out of bed or wheelchair) to alert the staff if the residents attempted to get out of the beds or wheelchairs. 3. [...]

Inspectors wroteBased on observation, interview, and review of documents, the facility failed to ensure safe disposition of medications. 1. During an inspection of one of four medication carts (Medication Cart 4C), the Narcotic and Hypnotic Record for tramadol (a controlled substance medication used to treat moderate to severe pain) was not disposed of with two licensed nurses as witnesses as indicated in the facility's policy and procedure. 2. During an inspection of Medication Cart 2, three unknown oral medications were observed in a sharps container (a puncture-resistant and leak-proof container with a one-way top used to dispose of sharps) . These deficient practices had the potential for diversion of controlled substance drugs and accidental use of the wrong medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent or greater, as evidenced by the identification of three medication errors out of 25 opportunities for error, to yield a cumulative error rate of 12 percent for two of four sampled residents (Residents 18 and 59). During medication pass observations, the following were observed: 1. Licensed Vocational Nurse 3 (LVN 3) failed to provide food as indicated on the physician`s order for the administration of Sevelamer [medication used to lower the amount of phosphorus (a mineral found in the bones and needed to build strong healthy bones) in the blood for residents receiving kidney dialysis (machine used to remove waste and extra fluid from the body)] for Resident 59. 2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by failing to discard expired food items. During an inspection of the dried food storage, the following items were observed expired: 1. Hamburger buns with a best before date of 11/23/21. 2. Hotdog buns with best before date of 12/1/21. 3. Hotdog buns with best before date of 12/6/21. This deficient practice had the potential to result in foodborne illness to residents.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with the hospice the development, implement, and revision of the hospice visits calendar and provide documentation of the resident's hospice plan of care for two of two residents (Residents 96 and 98). This deficient practice had the potential to negatively affect the delivery of care and services related to the end-of-life status for hospice residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement recommended practices to prevent the spread of Covid-19 (Coronavirus disease, a severe respiratory illness caused by a virus and spread from person to person) and to implement their Infection Prevention and Control Policy and Procedure and Centers for Disease Control and Prevention (CDC) guidelines for three of 12 sampled residents (Residents 4, 62, and 13) in the [NAME] Zone (Non-Covid-19 area) when: 1. Staff failed to instruct Resident 4 to wear a face mask to cover the nose and mouth and replace a face mask when soiled. 2. Residents 62 and 13 were not provided hand washing prior to eating lunch. These deficient practices had the potential to spread infection to residents, staff, and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete routine surveillance Coronavirus Disease 2019 (COVID-19, a new infectious viral disease that can cause respiratory illness) testing for three of three unvaccinated staff [Certified Nursing Assistants (CNAs) 3, 4, and 5] according to the local state Department of Public Health requirements when: a) CNA 3 did not test 48 hours prior to the start of the shift on 11/29/21. b) CNA 4 did not test 48 hours prior to the start of the shift on 12/6/21. c) CNA 5 worked more than one shift and did not test twice during the week of 11/22/21 to 11/28/21. These deficient practices had the potential to spread COVID-19 to the facility staff, residents, and/or visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for one of the seven sampled residents (Resident 30). This deficient practice violated the resident's and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were provided with a safe, clean, comfortable, and homelike environment for one of seven sampled residents (Resident 62). Resident 62's wheelchair was observed with a worn right arm rest, the left arm rest had no cushion, and the chair back and seat had torn spots. This deficient practice had the potential to make the resident feel like they were not in a comfortable homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing program of activities designed to meet the needs for one of three residents (Resident 113). The facility did not provide regular in room visits for Resident 113 as indicated on the residents's care plan. This deficient practice had the potential to negatively affect the overall well-being of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage a resident's pain for one of two sampled residents (Resident 455) for three days (from 12/6/21 to 12/8/21). The facility failed to reassess the resident's pain and notify the resident's physician that Resident 455's ordered pain medications did not alleviate the pain. This deficient practice resulted in the resident experiencing unnecessary pain which affected the resident's daily activity and ability to sleep well.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label one opened medication packet of multidose vials with an opened date. During an inspection of a medication cart 2, an opened packet of Ipratropium Bromide/Albuterol Sulfate (used to prevent and treat wheezing and shortness of breath caused by breathing problems) did not have a label of when it was opened. There were four of five doses remaining in the package. This deficient practice had the potential for use of expired medications which could adversely affect the residents.