Orchard Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and recorded review, the facility failed to ensure one of two sample residents (Resident 56) received a written notice, including the reason for the room change, prior to being moved to a different room with the facility, when Resident 56 was moved without receiving written communication explaining the change. This failure resulted in Resident 56 being moved without appropriate written communication which had the potential to result in emotional distress and a violation of Resident 56's rights to make informed decision regarding her care and environment. Findings: During a concurrent observation and interview on 5/15/25 at 11:14 a.m. with Resident 56, in Resident 56's room. Resident 56 stated she was moved to a new room on 5/14/25 but did not receive a written notice of change and was not asked to sign anything. Resident 56 stated it was the second time she had to changed rooms. Resident 56 stated she understood the reason given, and she expressed frustrations being relocated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may be paid for Medicare and assume responsibility) for one three sampled residents (Resident 78) when the Medicare coverage was terminated for Resident 78. This deficient practice resulted in not protecting Resident 78's rights and Resident 78's Representative (RR) right to appeal the termination of Medicare Part A and possibly denying Resident 78's needed services. Findings: During observation on 5/13/25 at 10:13 a.m., in Resident 78's room during the initial tour of the facility, Resident 78 was lying in bed. Resident declined to answer questions. During a review of Resident 78's admission Record, (AR- a document containing resident profile information) dated 5/15/25, the admission Record indicated Resident 78 was admitted to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report unusual occurrences for two of three sampled residents (Residents 28 and 244) when: 1. Resident 28 was attacked by Resident 29 (squeezed his toes and punched him 4 to 6 times in the lower left leg) and the facility did not contact local law enforcement or report the resident-to-resident abuse to the State Survey Agency. This failure put Resident 28's safety at risk, possibly other residents, as well as family and staff members in the facility. 2. Resident 244 was found on the floor by her bed, deceased and the facility did not report this unusual occurrence to the resident's responsible party (RP- a family member of designated person who is the point of contact for the nursing home staff. They can be kept informed about the resident's condition, receive updates, and ask questions) nor the State Survey Agency. This failure placed all residents' well-being and safety at risk residing in the facility due to lack of knowledge of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of five sampled residents (Resident 21) when Resident 21's deep tissue injury (DTI-localized area of discolored, intact skin, often purple or maroon, or a blood-filled blister due to damage to the underlying tissues) was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 21's care needs not met and the potential for DTI to worsen. Findings: During a concurrent observation and interview on 5/13/25 at 9:40 a.m. during initial tour in Resident 21's room, Resident 21 was lying in bed. Resident 21 observed not able to move left upper extremity and lower extremities, and limited movement of right upper extremity. During a review of Resident 21's admission Record (AR- a document with personal identifiable and medical information)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to follow-up with a positive Preadmission screening and Resident Review (PASARR-a federal requirement to ensure residents with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level I screening for one of three sampled residents (Resident 52) when Resident 52's PASARR level I screening required PASARR Level II mental health evaluation on 9/24/24 and was not completed. This failure had the potential for Resident 52 to not receive the appropriate services related to her mental disorder. Findings: During a review of Resident 52's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 52 was admitted to the facility on [DATE] with diagnoses which included: unspecified psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), major depressive disorder (persistent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan (a plan that provides direction for individualized care of the resident) within 48 hours of resident's admission for one of two sampled residents (Resident 79) when Resident 79's care plans was not created for the oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy per physician's order. This failure had the potential for Resident 79 to not receive oxygen therapy as prescribed by the physician which had the potential to result in hypoxia (a condition where tissues and organs don't receive enough oxygen) and respiratory failure (a condition where the lungs are unable to adequately provide oxygen to the blood or remove carbon dioxide). Findings: During an observation on 5/13/25 at 1:23 p.m. with Resident 79 during the tour in Resident 79's room, Resident 79 was lying in bed with the head of the bed elevated wearing a nasal cannula (NC- thin plastic tube that delivers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure services were provided that met professional standards of quality for one of four sampled Residents (Resident 1), when Licensed Nurses did not document Resident 1 's change of condition for an episode of hypoglycemia (low blood sugar) on 12/16/24 in accordance with facility's policy and procedure on nursing documentation and change of condition. This failure resulted in an incomplete documentation and assessment for Resident 1 and had the potential for delay in care. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for type 2 diabetes mellitus (condition when the body doesn ' t use insulin properly, resulting in high blood sugar). During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure services provided meet professional standard of practice for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 and LVN 2 did not administer insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) per physician's order. This failure had the potential to cause Resident 1 to experience episodes of unstable blood sugar levels such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that could have a serious outcome affecting resident ' s health and wellness. Finding: During a review of Resident 1's admission Record (a document containing demographic information), dated, 11/20/2024 the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 had the following diagnosis . Partial Traumatic Amputation (loss of a body part) of Left Shoulder and upper Arm .Absence of Right Upper Limb…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow professional standards of quality for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility on [DATE] and was re-admitted on [DATE] and 10/28/24 and no inventory of personal belongings was completed, and the facility did not follow their policy and procedure (P&P) titled Personal Property. These failures resulted in Resident 1's personal belongings not being inventoried and the risk for Residents 1's wallet, checkbook and bankcard getting lost. Findings: During a concurrent observation and interview on 11/5/24 at 12:47 p.m. in Resident 1's room, Resident 1 was lying down in bed awake. Resident 1 stated, he was admitted to the facility about three months ago. Resident 1 stated, when he was admitted , he came to the facility with his checkbook, wallet and bank card. Resident 1 stated, he believed his checkbook, wallet and bankcard was in his bedside cabinet. During a review of Resident 1's Face Sheet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for five of 15 sampled residents (Resident 19, Resident 24, Resident 38, Resident 40 and Resident 337) when: 1. Resident 40 was administered 2.5L/min (two point five liter- unit of measurement)/min (minute) oxygen via nasal cannula (NC- plastic device used to deliver supplemental oxygen) instead of 3L/min of oxygen per physician's order. This failure resulted in Resident 40's oxygen needs going unmet and caused Resident 40 received oxygen at different rate. 2. Resident 38 was started on antibiotic (medicines that fight bacterial infections in people) without obtaining a wound (an injury to the skin) culture (a test to find germs such as bacteria, a virus, or a fungus). This failure had the potential to result in Resident 38 receiving unnecessary antibiotic and had the potential for placing Resident 38 at risk for adverse effects (an undesired harmful effect resulting from a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored and/or prepared in accordance with professional standards for food services safety for 91 of 96 residents when: 1. A plastic container of dry bran cereal was uncovered in the dry food storage. 2. An uncovered Styrofoam cup with brown liquid was left on top of an ice chest in the dry food storage. 3. No air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the sink where food was being prepared. 4. The food thermometer (a tool to measure temperature), was not calibrated (verifying the capability and performance of an item of measuring and test equipment by comparison to traceable measurement standards), prior to use during lunch service. 5. The thermometer was not sanitized prior to being placed in a metal container of freshly cooked broccoli during lunch service. 6. The temperature of the soup was not measured prior to serving to residents. 7. The cook touched multiple surfaces with gloves on and then continued to serve food during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to follow their policy and procedure Food-Related Garbage and Refuse Disposal for one of three outside trash bins, when one of the trash bins was uncovered, and a large amount of plastic and debris was noted on the ground behind the trash bin. This failure had the potential to attracts animals, insects and pests which could lead to infestations, unsanitary conditions, and the spread of disease. Findings: During an observation on 7/22/24 at 2:24 p.m. behind the facility in the trash bin storage area, a trash bin was observed with the lid open and large amounts of thin clear plastic and other debris was noted behind the trash bins along the fence. During an interview on 7/23/24 at 2:30 p.m. with the Certified Dietary Manager (CDM), the CDM stated, the trash bins should be closed at all times and there should not be trash on the ground or around the trash bins. The CDM stated, the open trash bin and trash on the ground around the trash bins could attract rats and bugs. During an interview on 7/23/24 at 2:45 p.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for two of three sampled residents (Resident 14 and Resident 67) when: 1. Licensed Vocational Nurse (LVN) 2 did not address Resident 14 by her name. This failure had the potential for Resident 14 to feel disrespected. 2. Resident 67' foley catheter (an indwelling urinary catheter (a thin tube placed in the bladder to drain urine into a bag) drainage bag was without a dignity cover (a cover used to cover and hold the catheter drainage bag so it is not visible). This failure violated Resident 67's right to dignity and privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 67. Findings: 1. During an observation on 7/24/24 at 8:57 a.m. in Resident 14's room, LVN 2 addressed Resident 14 by calling her mama and honey while obtaining Resident 14's blood pressure (the pressure of blood on the walls of your arteries as your heart pumps blood around…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 59) when Resident 59's functional limitation in range of motion was inaccurately coded on the quarterly MDS assessment dated [DATE] and 5/23/24. This failure had the potential to result in Resident 59's care needs not met. Findings: During observation on 7/22/24 at 8:25 a.m. in Resident 59's room, Resident 59 was lying in bed and was assisted by Certified Nursing Assistant (CNA) 8 with breakfast. CNA 8 was spoon-feeding Resident 59. During a concurrent observation and interview on 7/24/24 at 12:35 p.m. in the dining room, Resident 59 was seated on her wheelchair, left hand holding a rolled towel and right hand was observed with weakness. CNA 8 was sitting next to Resident 59 and spoon-feeding her lunch. CNA 8 stated Resident 59 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan (CP -a detailed approach to care customized to an individual resident's needs) for five of six residents (Residents 25, 31, 58, 67, and 74) when Residents 25, 31, 58, 67 and 74 did not have a baseline care plan for the monitoring of anti-platelet medication (medication that prevents blood clots from forming). These failures placed Residents 25, 31, 58, 67, and 74 at risk for complications resulting from not having care needs planned by licensed nurses to determine if nursing interventions needed to be added, changed, or completed. These failures placed Residents 25, 31, 58, 67, and 74 at risk for bleeding and signs of bleeding to go unidentified. Findings: a. During a concurrent observation and interview on 7/22/24 at 11:14 a.m. with Resident 25 in Resident 25's room, Resident 25 was observed dressed sitting in a chair in her room. Resident 25 stated she had been in the facility for four months.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for three of 22 sampled residents (Resident 55, 47, and 387 ) when: 1. Resident 55 did not have a care plan for diagnosis of psychosis (mental disorder characterized by a disconnection from reality). This failure placed Resident 55 at a potential risk for not monitoring behavior which could lead to psychotic breakdown. 2. Resident 47's use of hearing aids was not care planned. This failure had the potential to cause staff to be unaware of Resident 47's need for the usage of hearing aids and resulted in Resident 47 not wearing her hearing aids. 3. Resident 387 did not have a care plan for communication for a foreign language. This failure had the potential for Resident 387's needs to go unmet. Findings: 1. During a review of Resident 55's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program when: 1. Licensed nurses did not maintain one of one medication rooms in a sanitary manner in accordance with the standards referenced by the Centers for Disease Control and Prevention (CDC) and facility policy. This failure resulted in the potential harm of cross contamination. 2. Powder was observed on the surface areas around four of four pill crushers and Licensed Vocational Nurses (LVN's) did not use appropriate cleaning disinfectant as per manufacturer guidelines. This failure resulted in the potential harm of cross contamination. 3. A certified nursing assistant (CNA) did not perform hand hygiene after handling a bag with feces. This failure had the potential to cross contaminate (the process in which harmful germs transfer from one surface to another) other surfaces and get residents sick. 4. LVN 5 did not remove her gloves or perform hand hygiene (a general term referring to any action of hand cleansing) after obtaining a fingerstick (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure physician obtained informed consents (a process in which residents are given important information of the possible risk and benefits of the use of medications) for the use of psychotropic medication (medication capable of affecting mind, emotions, and behavior) and antipsychotic medication (a medication used to treat certain types of mental health problems) were completed for one of six sampled residents (Resident 31) when Resident 31 received Citalopram hydrobromide (an antidepressant medication used to treat a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and Resident 31 received Quetiapine (an antipsychotic medication that can treat several mental health conditions such as bipolar disorder [a disorder associated with episodes of mood swings ranging from depressive lows to manic highs]) without a signed informed consent. These failures resulted in Resident 31 to receive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for one of five sampled residents (Resident 59) when Certified Nursing Assistant (CNA) 8 stood over Resident 59 while spoon feeding her breakfast while lying in bed. This failure resulted in Resident 59 not being provided a respectful and dignified dining experience which could further enhance resident's quality of life. Findings: During an observation on 7/22/24 at 8:25 a.m. in Resident 59's room, Resident 59 was lying in bed with head of the bed elevated and bed was in the highest position. Bedside table on the side of the bed and CNA 8 was standing on the side of Resident 59's bed while spoon feeding her breakfast. During a review of Resident 59's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information) dated 7/25/24, the AR indicated, Resident 59 was admitted to the facility with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide a homelike environment for three of eight sampled residents (Residents 19, 44 and 137) when meals were served on plastic trays. This failure did not enhance or promote the rights of the residents to live and experience dining in a manner or environment that was homelike. Findings: During a concurrent observation and interview on 7/22/24 at 12:01 p.m. in the dining room, staff served Residents 19, 44 and 137 their meals on a plastic trays. Staff placed the entire tray in front of each resident, but did not remove the food plates, beverage glass, utensils, and napkins from the plastic tray. Residents 19, 44 and 137 did not answer any questions asked. During a review of Resident 19's admission Record dated 7/25/24, the AR indicated, Resident 19 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body). During a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to meet the required timelines for encoding, completion and transmission of Minimum Data Set (MDS) assessments (evaluation of cognition, care needs and functional abilities) for one of five sampled residents (Resident 55) when the Minimum Data Set Nurse (MDSN) did not complete or transmit discharge and readmit MDS tracking assessment for Resident 55. This deficient practice resulted in the potential harm of residents' needs upon discharge going unmet. Findings: During a concurrent observation and intervention on 7/22/24 at 8:45 a.m. in Resident 55's room, Resident 55 was sitting up in bed eating breakfast. Resident 55 refused to answer question stated, .Why are you picking on me . During a review of Resident 55's admission Record (AR), dated 7/25/24, the AR indicated, Resident 55 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar) and psychosis (mental disorder characterized by a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to revise and implement a person centered comprehensive care plan for one of four sampled residents (Resident 34) when Resident 34 had a decrease in meal intake and care plan interventions were not revised. This failure had the potential for Resident 34's nutritional needs to go unmet. Findings: During a review of Resident 34's admission Record (AR-document containing resident demographic information and medical diagnosis) undated, the AR indicated Resident 34 was admitted to the facility on [DATE]. Resident 34's diagnosis included unspecified cerebrovascular disease (a condition that affects blood flow to the brain), type two diabetes mellitus (condition in the way body regulates and uses sugar as a fuel) hypertension (high blood pressure), heart failure (when the heart is failing and cannot supply enough blood to the body) gastroesophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to accommodate resident meal preferences and provide an appropriate alternative for one of 18 sampled residents (Resident 35) when Resident 35 received a sandwich on white bread instead of wheat bread. This failure resulted in Resident 35 refusing to eat lunch and missing out on the nutritional value of the meal and had the potential to cause Resident 35 to experience weight loss as a result of not eating. Findings: During an observation on 7/22/2024 at 12:28 P.M. in Resident 35's room, Resident 35 received a sandwich on white bread instead of wheat bread. Resident 35's meal tray ticket indicated wheat bread under preferences. Resident 35's meal ticket indicated his sandwich should have been on wheat bread. During an interview on 7/22/2024 at 12:28 P.M. with Resident 35, Resident 35 stated he did not like white bread, and he would not eat his lunch. Resident 35 stated he had told staff about his preference, and wheat bread was listed on his meal ticket under preferences. During a concurrent observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain complete and accurately documented records for one of 18 sampled residents (Resident 47) when, Resident 47's hearing aids were not documented on her inventory sheet. This failure resulted in Resident 47 not wearing her hearing aids and staff being unaware of where they were located causing Resident 47 to think they went missing. Findings: During a review of Resident 47's admission Record (AR- a document which provides resident contact details, a brief medical history level of functioning, preferences, and wishes), dated 12/20/23, the AR indicated, Resident 4's admitting diagnoses included: encephalopathy (term for any brain disease that alters brain function), muscle weakness, chronic obstructive pulmonary disease(a common lung disease causing restricted airflow and breathing problems), and epilepsy (condition which causes recurrent involuntary movements of the muscles). During a review of Resident 47's Minimum Data Set (MDS-…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of ten sampled residents (Resident 1) when Registered Nurse (RN) 1 left Resident 1's three medications (2 tablets and 1 capsule) in a plastic cup on top of the medication cart unattended. This failure had the potential for other residents to take and administer Resident 1's medications which could result in undesired effects and harm. Findings: During a concurrent observation and interview on 8/17/23, at 8:06 a.m. with RN 1 outside of Resident 1's room, RN 1 was preparing Resident 1's medications for administration. RN 1 placed Resident 1's buspirone (a medication that treat anxiety [a mental health condition characterized by feeling unease or fear]) 5 MG tab, Donepezil (a medication used to treat Dementia [progressive or persistent loss of brain functioning]) 5 MG and Ramipril (a medication use to treat high blood pressure [the force of blood pushing against the walls…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide a complete and accurate discharge notice to ensure a safe discharge for one of three sampled residents (Resident 1) when a written 30-day notice of proposed discharge did not indicate the location to which Resident 1 would be discharged to. This failure resulted in Resident 1 not knowing where she would be residing after the 30 days, causing Resident 1 distress and anxiety. Findings: During a review of Resident 1 ' s admission Record (AR) the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses of . Parkinson ' s Disease . (a progressive disease of the nervous system) .Bipolar disorder .(characterized by both manic and depressive episodes) .Epilepsy .(A disorder in which nerve cell activity in the brain is disturbed) . During a review of Resident 1 ' s Minimum Data Set [MDS- a resident assessment tool used to identify cognitive (mental processes)] and physical functional level assessment dated [DATE], the MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure a home like environment for four of 43 sampled residents (Residents 49, 76, 77, and 93) when, the laundry department did not have towels and linens readily available for resident care, and personal clothes were misplaced in the laundry and delayed in getting back to residents. This failure resulted in not meeting residents' basic needs and prefrence by not providing clean linen, towel and personal clothes. Findings: During an interview, on 1/18/22, at 1:47 p.m., with Resident 76, Resident 76 stated the laundry department was a problem. Resident 76 stated there were occasions when she would request linen for her bed, and there would not be any upon request. Resident 76 stated she had clothes and quilts misplaced in the laundry room. Resident 76 stated items were found weeks later after finding them in the donation bin (items donated by either residents or family no longer in the facility) in the laundry storage room. Resident 76 stated the laundry department manager told her they would fix the laundry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. During an observation on 1/18/21, at 10:57 a.m., in Resident 59's room, Resident 59 was lying in bed asleep with oxygen at 2 Liters Per Minute (LPM- unit of volume flow measurement) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help). During a review of Resident 59's Order Summary Report, dated 11/29/21, the Order Summary Report indicated, .Oxygen (O2) at 2 Liters Per Minute (LPM) via Nasal Cannula prn (as needed) per concentrator (a medical device that concentrates oxygen from ambient air) every shift . During a review of Resident 59's Minimum Data Set (MDS-assessment of healthcare and functional needs) assessment dated [DATE], indicated, .Section C . Cognitive Patterns. Section C0500 . Brief Interview for Mental Status (BIMS-assessment of cognitive status) Summary Score 11 of 15 points which indicated Resident 59 had moderate cognitive impairment . During a concurrent interview and record review, on 1/19/22, at 8:55 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure two of three sampled Residents (Resident 11 and 79) received the necessary care and respiratory services, consistent with professional standards of practice when: 1. Resident 11's nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) and humidifier (to humidify the air you breathe) did not have dates to indicate when it was changed. 2. Resident 79's suction catheter (oral suctioning tool made with firm plastic tip used to suction oral secretions to prevent aspiration) connected to the suction machine at bedside did not have date when it was changed and the suction catheter tip was unprotected. These failures had the potential to put Residents 11 and 79 at risk for developing respiratory infection. Findings: 1. During a review of Resident 11's clinical record titled, admission Record (document containing resident personal information) dated 1/18/22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food served met the daily nutritional needs for seven of 77 residents (Residents 4, 14, 45, 65, 77, 78 and 83) when: 1. Residents on large portion diets (Residents 4, 14, 45, 65, 77 and 78) were served more than the required portion size of the mashed potatoes based on the facility's menu. This failure had the potential to result in Residents 4, 14, 45, 65, 77 and 78 to receive more than the recommended daily calorie intake based on the Medical Doctor's order and Registered Dietitian's (RD) assessment of residents' nutritional dietary needs and the potential for unintended weight gain. 2. Resident 83 did not receive a fortified (foods with nutrients added to help boost nutritional value and benefit health) diet as ordered by the physician. This failure had the potential to result in Resident 83 to not receive the additional calories recommended based on resident nutritional dietary needs. Findings: 1. During a review of facility document titled, Order Listing Report, dated 1/19/22, the order listing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of quality for one of eight sampled residents (Resident 89) when Humalog Lispro Insulin (is a fast-acting insulin that controls blood sugar around mealtimes for both type 1 and type 2 diabetes) was given without food per professional standard of practice. This failure placed Resident 89 at risk for a low sugar event with the potential to develop symptoms of hypoglycemia (low blood sugar) including dizziness, headache, feeling weak, shaking, fast heartbeat, confusion, hunger, sweating or change of consciousness. Findings: During a medication administration observation on 1/19/22, at 11:34 a.m. in resident hallway 1, Registered Nurse (RN) 1 checked Resident 89's blood sugar by fingerstick (a procedure to check blood sugar), and the result was 127. During a medication administration observation on 1/19/22, at 11:43 a.m. in Resident 89's room, RN 1 gave 18 units of Humalog Lispro Insulin subcutaneous injection (injection given in the fatty tissue) in Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were free of accidents for one of three sampled residents (Resident 83) when Resident 83, who was assessed to require two-person assist for transfers, was transferred by one Certified Nursing Assistant (CNA) on 12/18/21 and did not follow the facility policy and procedure. This failure resulted in Resident 83's fall on 12/18/21 and the potential injury from the fall. Findings: Review of Resident 83's clinical record titled, admission record (document containing resident personal information) dated 12/28/21, indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included: .Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), other lack of coordination, Age-related osteoporosis without current pathological fracture (is a broken bone that's caused by a disease, rather than an injury), abnormal posture and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement non-pharmacological interventions (individualized approaches to care other than by administering medications, including supportive physical and psychosocial methods) for two of seven sampled residents (Resident 69 and 295) when Resident 69 and 295 had no documented evidence non-pharmacological interventions were tried or attempted first before starting antipsychotic medications (class of medications to treat severe mental disorder in which thought, and emotions are so weak that contact is lost with external reality). These failures put the residents 69 and 295 at risk for experiencing adverse medication side effects and receiving unnecessary psychotropic medications without the appropriate indication. Findings: a. During a review of Resident 69's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/21/22, the AR indicated, .Original admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

During an observation, interview, and record review, the facility failed to prepare and serve food in accordance with professional standards for food safety when Dietary [NAME] (DC) did not wear a hairnet while inside the kitchen preparation area per facility's policy and procedure (P&P). This failure had the potential to cause cross contamination (physical movement or transfer of harmful bacteria from one person, object or place to another) and foodborne illness (caused by consuming contaminated foods or beverages) to 74 of 77 sampled residents who consumed food from the kitchen. Findings: During initial tour on 1/18/2022, at 9:20 a.m., in the kitchen with the Registered Dietitian (RD) and Dietary Manager (DM), the DC was observed standing in the food preparation area next to the stove and was not wearing a hairnet. During an interview on 1/18/2022, at 9:30 a.m., with the DM, the DM stated the DC should have been wearing a hairnet. The DM stated, Everyone entering the kitchen to the food preparation area were expected to wear a hairnet. During an interview on 1/19/2022, at 8:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.