The Orchards Post-Acute

Inspectors wroteBased on interview and record review the facility failed to ensure two of 29 sampled residents (Resident 69 and Resident 5), was able to exercise their rights when: 1. Resident 69 was not provided with a shower when requested. This failure resulted in Resident 69 feeling dirty when going to an appointment. 2. Resident 5 was not provided with a hair cut that he had requested. This resulted in a violation of Resident 5's right to dignified care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discharge notice was sent to the Ombudsman (an advocate for residents of nursing homes, board and care centers and assisted living facilities) for one of one sampled residents (Resident 143). This failure had the potential to result in Resident 143 not having an advocate who could inform them of their admission, transfer, and discharge rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 71 sampled residents (Resident 137 and Resident 2) IDT (interdisciplinary) comprehensive, nutrition care plan interventions could be effectively monitored and implemented when there was inconsistent and inaccurate meal, meal substitute and snack consumption documentation. This failure had the potential for unrecognized nutrition care needs to not be addressed in a timely manner to prevent a potential outcome such as weight loss or decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure (P&P), titled Nephrostomy Tube [a thin catheter inserted through your lower back directly into your kidney to drain urine into an external collection bag] Care of, for one of three sampled residents (Resident 11), when Resident 11 had a non-sterile (reduced microbe levels but not completely germ-free) dressing change to her nephrotomy tubes. This failure had the potential for a severe infection in the blood stream with negative outcomes up to and including death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oral care was provided for one of three sampled residents (Resident 156). This failure resulted in Resident 156's lips to be dry and cracked.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of enteral feeding [liquid nutrition delivered through a flexible tube directly into the stomach] when two of three sampled residents (Resident 127 and Resident 97) head of bed (HOB was not positioned between 30-45 degree angle during administration of feeding. This failure had the potential to result in Resident 97 and Resident 127 to aspirate [accidental inhalation of liquids or stomach contents into the airway and lungs] and develop an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed oxygen therapy was administered in accordance with physician orders when:1. Two of two sampled residents (Resident 14 and Resident 78) portable oxygen cylinders were empty. 2. One of two sampled residents (Resident 14) oxygen flow rate did not match physician order. These failures had the potential to result in ineffective respiratory management, respiratory compromise and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards when:The floor of the over the counter (OTC- medications not requiring a prescription) medication storage room was not cleaned. This failure had the potential to spread infection to residents and staff. The OTC medication storage room's temperature was not monitored or recorded. This failure had the potential to affect the potency of all medications stored in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 5) was provided with follow up dental care and treatment in a timely manner. This failure resulted in prolonged dental pain for Resident 5 and the potential for Resident 5 developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Dietary Services (DDS) met state education qualifications to supervise Food and Nutrition Service (FNS) operations when Title 22 (Section 72035) of the California Code of Regulations and CA Health and Safety Code (HSC) 1265.4(b) Pathway 4 (one of the education-and-experience combination used to qualify for higher-grade certification) was not met as required per the federal regulations. This failure had the potential to adversely affect the foodservice operation related to sanitation, food safety and meeting residents' nutritional needs in accordance with recognized dietary practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure competency of their dietary aides of what consists of a full liquid diet for one of two sampled residents (Resident 39). This failure had the potential for Resident 39 to not meet his nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the planned menu for regular diet for one of six sampled residents (Resident 121). This failure had the potential to result in serving low-fat milk to residents on a regular diet which posed a risk for decreased milk consumption. During a concurrent observation and interview on 6/16/26 at 12:25 p.m. with Registered Dietitian (RD) in the kitchen during tray line, a dietary aide placed whole milk or 2% milk on regular diet trays. RD stated, it is regular diet, it can be either or, if no preference indicated. During a review of Resident 121's Meal Tray Ticket (MTT), dated 6/16/26, the MTT indicated, Puree Diet: Preferences Milk for breakfast, lunch and dinner. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the food preferences for two of 15 sampled residents (Resident 2 and Resident 137) when:1. Resident 2's request for sunny-side up eggs was not honored because the facility stopped purchasing the pasteurized shell eggs required to prepare them safely.2. Resident 137 did not receive margarine on vegetables as indicated on his meal tray card during lunch trayline. These failures had the potential to result in decrease nutritional intake and a decline in the quality of life for Resident 2 and Resident 137.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when food items were not covered, were not dated as to when opened, and manufacturer's guidelines were not followed. These failures had the potential to place residents at an increased risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an infection control program was implemented when: 1. Infection surveillance (the systematic, ongoing collection and analysis of data to prevent the spread of healthcare associated infections [HAI]) was not performed. This failure resulted in an increase in urinary tract infections. 2. One of one sampled resident (Resident 101) on Enhanced Barrier Precautions (EBP - gown and gloves are used during care of residents with indwelling medical devices and open wounds, to prevent infection) had foam material wrapped and secured with tape around both upper bed rails. This failure had the potential to result in Resident 101 developing an infection. 3. Two Certified Nurse Assistants (CNA 3 and CNA 4) did not follow EBP for one of one sampled resident (Resident 138) while providing direct care to Resident 138. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach of one of 71 sampled residents (Resident 127). This failure had the potential for Resident 127 not to be able to call for needed care and assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) safety when:1. Physician's order (any time the doctor writes or gives verbal instruction for nursing staff to follow) for bilateral landing mats (high-density foam cushions placed beside beds to reduce injury from falls) was not followed for one of three sampled residents (Resident 1).2. Care plan (CP- a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) for bilateral landing mats was not implemented for one of three sampled residents (Resident 1).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure urine was collected as ordered by the physician after a change of condition for one of four sampled residents (Resident 1) when Resident 1 complained of painful urination. This failure had the potential to result in Resident 1 to receive delay of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents' restrooms (room [ROOM NUMBER]) linoleum floor covering was in good repair. This failure had the potential to place residents at risk for accidents and hazards.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure on Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating to immediately protect all the residents from potential abuse when an alleged (something is claimed or said to be true but hasn't been proven) perpetrator (someone who commits a harmful or illegal act) was allowed to enter the facility after the Administrator was informed of the allegation. This failure had the potential to expose all residents in the facility to harm and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) Ensure three of three sampled clean linen carts were in good repair. 2) Follow the manufacturer's guidelines on how to disinfect the clean linen carts. 3) Ensure the laundry room was clean and sanitary. These failures had the potential for contaminating clean linens and spread of infections to all residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on Surveillance for Infections when: 1) There were no documented signs/symptoms of the infections and antibiotic given in the antibiotic tracking log. 2) There were no tracking of locations of the infections. 3) There were no list of organism (germs) and/or review of indicators of infections on the antibiotic tracking log. These failures had the potential for ineffective infection control and tracking resulting in spread and increase in numbers of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were communicating in a language three of three sampled residents (Resident 74, Resident 88, and Resident 110) were able to understand. This failure had the potential for making residents feel staff were being rude to them and feelings of lowered self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to obtain and complete informed consents for psychotropic (drugs that affect a person's mental state) medication for three of 29 sampled residents (Resident 84, Resident 97, and Resident 77). This had the potential for Resident 84, Resident 97, and Resident 77 not being aware of the risks and benefits of taking psychotropic medication.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman (advocates for the rights and well-being of residents in long-term care facilities) of discharges for three of three sampled residents (Resident 9, Resident 97, and Resident 128). This failure had the potential for unsafe resident transfer and discharge.

Inspectors wroteBased on interview and record review, the facility failed to have daily completed Direct Care Service Hours Per Patient Day (DHPPD) for the month of January 2025 to February 21, 2025. This failure had the potential for all residents not receiving sufficient nursing care.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations for two of five sampled Certified Nurse Assistants (CNA 1 and CNA 2). This failure had the potential for CNA 1 and CNA 2 not being aware of their need for improvement in a certain area which could affect all residents' care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the monthly Medication Regimen Review (MRR- a review of all medications to identify any potential adverse effects and drug reactions) was reviewed and acted upon for the month of January 2025 for four of four sampled residents (Resident 84, Resident 51, Resident 15, and Resident 46). This failure has the potential to affect all residents' well being and result in adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One of three sampled medication cart was free from expired medications. This failure had the potential for the medications to have decrease effectiveness. 2. Medications were stored properly in one of three sampled medication carts. This failure had the potential for the medications to be administered incorrectly and unsafely. 3. Controlled Drug Records (CDR) were signed by two licensed nurses. This failures had the potential for medication errors to occur and possible drug diversion. 4. Safe administration of medication for three of three sampled residents (Resident 8, Resident 9, and Resident 4) when medications were found at resident's bed side table. This failure had the potential for medications to be accessed by unauthorized staff and residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of 24 sampled resident's bathrooms (Resident 72) was clean and sanitary. This failure had the potential to spread infections and/or affect their quality of life.

Inspectors wroteBased on interview and record review the facility failed to have completed quarterly smoking assessments for two of two sampled residents (Resident 84 and Resident 70). This failure resulted in Resident 84 and Resident 70 not being assessed for safety while smoking and had a potential for residents to be burned while smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the plan of care for one of eight sampled residents (Resident 91) fall precaution. This failure had the potential for Resident 91 to sustain serious injuries.

Inspectors wroteBased on interview and record review the facility failed to check blood pressure prior to administration of blood pressure medication for one of one sampled resident (Resident 8). This failure had the potential for Resident 8 experiencing adverse health outcomes such as low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter (a thin, flexible tube inserted into the bladder to drain urine) care for one of two sampled residents (Resident 91) when the catheter tubing and collection bag was not changed in two months. This failure had the potential to result in Resident 91's repeated Urinary Tract Infections (UTI-bladder infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) titled, Oxygen Administration, for one of three sampled residents (Resident 99). This failure resulted in Resident 99 having low oxygen levels.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Social Services Department documented and followed up on one of three sampled residents' (Resident 93) eyeglasses. This failure had the potential for Resident 93 suffering with poor vision.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were available to administer when Licensed Nurse did not reorder medications timely, notify physician of unavailable medication, and obtain alternative orders for two of two sampled residents (Resident 8 and Resident 1). This failure resulted in Resident 8 and Resident 1 not receiving physician ordered medications and had the potential to result in adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a functional call light system for one of 52 sampled residents (Resident 99). This failure had the potential for Resident 99 unable to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 58 residents' rooms (room [ROOM NUMBER]) was in good repair. This failure had the potential to place residents at risk for accidents and hazards.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) after hospitalization. This failure resulted in violation of resident's rights to return to the facility and had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Enteral Feedings (a method of delivering nutrients and fluids to the body for patients who cannot safely chew or swallow) - Safety Precautions, for one of three sampled residents (Resident 1) who was on gastrostomy tube (G- tube- a tube which delivers liquid, nutrition, and medications through a flexible tube that goes directly into the stomach) feeding when G-tube placement was not checked, gastric residual volume (measures the amount of fluid or contents remaining in the stomach after feeding) was not checked, and signs and symptoms of complications were not reported timely to the physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were followed when: 1. Medications were not administered according to physician's order for one of three sampled residents (Resident 2). This failure had the potential for Resident 2's infection (invasion and growth of germs in the body) to worsen. 2. Treatment orders were not administered according to physician's orders for one of three sampled residents (Resident 3). This failure had the potential for Resident 3's wounds to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled staff members (Licensed Vocational Nurse [LVN] 2 and Certified Nursing Assistant [CNA] 2) were competent in caring for residents with gastrostomy tubes (G- tube- the presence of a surgical opening into the stomach to provide fluids, nutrition, and medications). This failure had the potential to negatively affect the residents' well -being related to the lack of staff competence in providing the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow their Five-Day Investigation Report to implement a follow-up monitoring for one of seven sampled residents (Resident 1). This failure had the potential for Resident 1 having further altercations with other residents in the smoking area.

Inspectors wroteBased on interview and record review, the facility failed to provide wound treatment as ordered by the physician for one of three sampled residents (Resident 1). This failure had the potential to result in delayed wound healing for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foley catheter (a device that drains urine (pee) from the urinary bladder into a collection bag outside of your body when you can't pee on your own) care for one of three sampled residents (Resident 1) when Resident 1 ' s foley catheter was not assessed for approximately seven hours. This failure had the potential to result in Resident 1 suffering from abdominal pain, having to call 911, going to the emergency room, and having a UTI (urinary tract infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure titled, Abuse, Neglect, Exploitation, or Misappropriation-Reporting Investigating for one of the six sampled residents (Resident 1), when the facility did not report an allegation of abuse to the California Department of Public Health (CDPH) and did not complete an investigation of the allegation of abuse. These failures had the potential to result in Resident 1 experiencing continued abuse, feeling unsafe, and having feelings of fear.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen was maintained clean and sanitary. This failure had the potential to result in the contamination of food, utensils, and surfaces where food is prepared, and the potential for spread of infectious diseases to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an effective pest control program for three of three sampled resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER]) and the kitchen. This failure had the potential to result in spread of infectious diseases to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide nail care and hand hygiene for one of the five sampled residents (Resident 1). This failure had the potential for Resident 1 to result in skin breakdown and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician was notified timely when one of three sampled residents (Resident 1) fell. This failure resulted in a delay of Physician notification.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for one of three residents (Resident 2). This failure resulted in Resident 2 not receiving her medication.

Inspectors wroteBased on interview and record review, the facility failed to provide showers to one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to have a negative self-image and had the potential for increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Hand hygiene was not provided to residents prior to eating in the dining room. 2. A Physical Therapy Assistant (PTA) did not perform hand hygiene in between glove changes and in between resident's care. 3. Clean linen were not stored in a sanitary manner. 4. A Certified Nursing Assistant (CNA) 8 did not perform hand hygiene in between delivering meal trays. These failures had a potential to spread germs and infections to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for three of 78 sampled residents (Resident 37, Resident 15, and Resident 64). This failure had the potential to affect resident's psychosocial and physical needs.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for six of six sampled residents (Resident 42, Resident 52 Resident 88, Resident 92, Resident 95, and Resident 353). This failure had the potential to affect residents' quality of life and potential for the transmission and development of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to complete and submit comprehensive Annual Minimum Data Set (MDS- standardized assessment tool) assessments annually for six of six sampled residents (Resident 41, Resident 75, Resident 66, Resident 71, Resident 23 and Resident 1). This failure had the potential to result in inaccurate assessments and to contribute to a lack of resident specific care plan interventions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure MDS (Minimum Data Set - assessment tool) quarterly (every three months) assessments were completed for four of four sampled residents (Resident 15, Resident 13, Resident 64, and Resident 37). This failure had the potential for the delay in development and implementation of residents' individualized care plan.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered for five of 78 sampled residents (Resident 64, Resident 15, Resident 7, Resident 93 and Resident 29) when the facility failed to: 1. Complete Interdisciplinary Team (IDT-brings together knowledge from different healthcare disciplines to help residents receive the care they need) meetings for Resident 64 and Resident 15. 2. Develop a care plan for Resident 7 regarding the pulling and dislodgement (detachment) of the gastrostomy tube (G-tube - a tube inserted through the belly that brings nutrition directly to the stomach). 3. Develop a comprehensive person-centered care plan to address Resident 93's psychosocial needs. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 58) dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) assessments were completed. This failure had the potential for dialysis related complications to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective Quality Assessment and Assurance program was in place, when deficient practices still occurred after being identified. This had the potential for identified issues to go unresolved, potentially affecting residents who receive dialysis (procedure to mechanically remove waste products and excess fluid from the blood when the kidneys stop working properly) treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a hazard-free environment when: 1. The overhead light switch was not accessible for four of four sampled residents (Resident 37, Resident 22, Resident 453, and Resident 402) to reach. 2. The vinyl board was peeling off the wall in six of 78 sampled residents' (Resident 458, Resident 203, Resident 85, Resident 15, Resident 65, and Resident 13) rooms. 3. Residents' rooms were not maintained in good repair for four of 78 sampled residents (Resident 1, Resident 88, Resident 92, and Resident 353). These failures had the potential to affect residents' quality of life and place residents at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Behavioral Assessment, Interventions and Monitoring for two of eight sampled residents (Resident 605 and Resident 25) when: 1. Facility did not refer Resident 605 for a Pre-admission Screening and Resident Review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) Level II after he was diagnosed with a serious mental illness. 2. Facility did not follow up after Resident 25's PASRR Level II was not completed. These failures had the potential for residents to be placed in an inappropriate setting and not receive the necessary services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a neurological assessment (checking motor and sensory function following possible head trauma) was not completed after an unwitnessed fall for one of one sampled resident (Resident 29). This failure had the potential to result in a serious head injury going undiagnosed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided for one of 30 sampled residents (Resident 61). This failure had the potential to result in skin injuries, infections, and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure recommendations made by the Registered Dietician (RD) to promote weight gain were carried out within 72 hours for two of three sampled residents (Resident 72 and Resident 88). This failure had the potential to result in further weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavior monitoring was accurately completed according to physicians' orders for one of three sampled residents (Resident 605). This failure had the potential to inaccurately reflect changes in the resident's behavioral health, and lead to unmet behavioral health needs.

Inspectors wroteBased on interview and record review, the facility failed to communicate to social services when the resident lost his ability to make medical decisions and did not have effective family representation for one of one sampled resident (Resident 605). This failure had the potential to result in a resident who lacked decision-making capacity to not be appropriately represented.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled Adverse Consequences and Medication Errors for one of one sampled resident (Resident 604). This failure had the potential to result in an allergic or adverse reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Multi dose medication was labeled after being opened. 2. An unlabeled medication was properly discarded. These failures had the potential for medication errors to occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dishware was stored safely, and food was stored and prepared safely when: 1. The clean plate holder area was observed to have pieces of brown debris inside the compartment. 2. Food was stored on shelves three inches from the floor. 3. Dietary staff was not wearing a beard protector correctly. These failures had the potential to spread foodborne illnesses to residents, and the potential to lead to pest infestation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record accurately reflected the behavioral health concerns for two of two sampled residents (Resident 29 and Resident 605). This failure had the potential for Resident 29 and Resident 605 to not have their behavioral and psychosocial needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, evaluate, and provide a call system appropriate for one of three sampled residents (Resident 37). These failures had the potential for Resident 37's inability to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide warm water for showers/bathing and adequate water pressure for four of four sampled residents (Resident 1, Resident 2, Resident 3, Resident 4). This failure had the potential for residents experiencing discomfort, pain, spread of infection, and feeling of worthlessness during showering/bathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) had a completely covered window blinds for privacy. This failure had the potential for Resident 2 to be seen from the outside when she changes her clothes.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled residents (Resident 1, Resident 2, and Resident 3) were treated with respect and dignity. This failure had the potential for Resident 1, Resident 2, and Resident 3, self-esteem and self-worth to be negatively affected.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Administering Medications for one of three sampled residents (Resident 1). This failure had the potential to result in medication error.

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication according to physician's order for one of three sampled residents (Resident 1) for two days. This failure resulted in Resident 1's pain not being managed effectively.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate needed supplies for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential to result in inability to meet residents needs during care.

Inspectors wroteBased interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received medications as ordered by the attending physician (AP). This failure resulted in Resident 2 not receiving three doses of needed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to accommodate residents needs by not answering call lights timely for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 to not receive timely care and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate two of three sampled residents (Resident 1 and Resident 2) food allergies and preferences. This failure had the potential to result in unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy titled Abuse Investigation and Reporting for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 ' s allegation of financial abuse to not be investigated thoroughly and be at risk for continued abuse.