Orchards At Tulare

F-F807)

During an interview on 05/06/25 at 03:57 p.m. with Director of Nursing (DON), DON stated the CNAs see how much fluid residents are drinking and they chart that into PCC (software used for resident's electronic health record) so in IDT meetings ADON (Assistant Director of Nursing) should access those monitoring fluid intake logs and discuss with IDT.

During an interview on 05/06/25 at 04:06 p.m. with ADON, ADON stated, yes, daily monitoring of the fluid intake from meals log to identify potential concerns before outcome becomes worse would be ideal, I do not routinely monitor the fluid intake documented by the CNAs.

During a concurrent observation and interview on 5/7/25 at 11:58 a.m. with Resident 68 in Resident 68's room, Resident 68 was lying in bed, lips were observed to be cracked and dry, and eyes appeared to have dark circles around them. Resident 68 stated facility staff had not asked her what her beverage preferences were or beverages she would drink if she were home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During a review of Resident 68's Nutrition Status Care Plan Report (IDT nutrition care plan/IDTNCP), dated 5/6/2025, the IDTNCP indicated, Interventions, lacked notation to indicate Resident 68 had been ordered an Level of Harm - Minimal harm or HN shake 4 oz with meals [TRUNCATED] potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services.

Level of Harm - Minimal harm or 45654 potential for actual harm Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) Residents Affected - Few titled, Pain Management, for one of one sampled resident (Resident 77) when Resident 77's pain was not controlled consistently. This failure had the potential for Resident 77's pain not to be correctly managed.

Findings:

During an interview on 5/7/25 at 1:50 p.m. with Resident 77, Resident 77 stated two weeks ago the nurse told her she needed to take a different medication and not her regular pain medication. Resident 77 stated

she felt horrible for hours going without her pain medication.

During a review of Resident 77's Physician Order (PO) dated 4/21/25, the PO indicated, Oxycodone HCL [narcotic medication for acute pain 0- no pain, 1-3 mild pain, 4-6 moderate pain interfering with daily activities, 7-9 severe pain, difficult to tolerate or manage, 10 worst pain possible]oral tablet 5 mg [milligram], give 1 tablet by mouth every 4 hours as needed for moderate pain 4-6.

During a review of Resident 77's PO, dated 4/21/25, the PO indicated, Acetaminophen Tablet 325 mg give 2 tablets by mouth every 4 hours as needed for Mild pain 1-3 Not to exceed 3 grams Acetaminophen in 24 hours.

During a concurrent interview and record review on 5/8/25 at 10:25 a.m. with Assistant Director of Nursing (ADON), Resident 77's Medication Administration Record (MAR) dated April 2025 was reviewed. The MAR indicated the following:

On 4/21/25 at 5:00 p.m. Oxycodone HCL 5 mg.

On 4/21/25 at 10:54 p.m. Oxycodone HCL 5 mg.

On 4/22/25 at 10:34 a.m. Oxycodone HCL 5 mg.

On 4/22/25 at 4:16 p.m. Oxycodone HCL 5 mg.

On 4/22/25 at 10:50 p.m. Oxycodone HCL 5 mg.

On 4/23/25 at 6:17 a.m. Oxycodone HCL 5 mg.

On 4/23/25 at 11:38 a.m. Oxycodone HCL 5 mg.

On 4/23/25 at 4:48 p.m. Oxycodone HCL 5 mg.

On 4/23/25 at 11:37 p.m. Oxycodone HCL 5 mg.

On 4/24/25 at 10:00 a.m. Oxycodone HCL 5 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 On 4/24/25 at 3: 00 p.m. Oxycodone HCL 5 mg.

Level of Harm - Minimal harm or On 4/25/25 at 4:54 a.m. Oxycodone HCL 5 mg. potential for actual harm

On 4/25/25 at 11:00 a.m. Oxycodone HCL 5 mg. Residents Affected - Few

On 4/26/25 at 6:30 a.m. Oxycodone HCL 5 mg.

On 4/27/25 at 5:13 p.m. Acetaminophen 325 mg.

On 4/28/25 at 3:19 a.m. Acetaminophen 325 mg.

On 4/26/25 at 11:16 a.m. Oxycodone HCL 5 mg.

On 4/29/25 at 11:00 a.m. Oxycodone HCL 5 mg.

On 4/29/25 at 9:30 a.m. Oxycodone HCL 5 mg.

ADON stated Resident 77 was a chronic pain management resident. ADON did not provide an answer for Resident 77 receiving Acetaminophen medication on 4/27/25 and 4/28/25.

During a review of the facility's P&P titled, Pain Management, dated 10/2022, the P&P indicated, Pain Management and Treatment, 1. Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professional and the resident and/or the resident's representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain at admission.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 52221

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

Findings:

During an observation on 5/7/25 at 8:38 a.m. in the Director of Nursing (DON) office, there was a locked cabinet used to store medications to be destroyed.

During a concurrent interview and record review on 5/7/25 at 8:38 a.m. with the Assistant Director of Nursing (ADON), The facility Controlled Medication Destruction Log (MDL), dated 03/25 and 04/25 were reviewed.

The MDL indicated, entries had not been dated and signed without a pharmacist involvement. ADON stated

she was unable to clarify the following entries: had been dated and signed without pharmacist involvement.

The MDL indicated the following:

On 3/6/25 RX # Resident R817831 Oxycodone [Oxycodone is a prescription opioid pain medication used to relieve moderate to severe pain (generally falls within a range of 5-10 on a 0-10 pain scale)]. 10 mg.

On 3/7/25 RX # 752758 Lorazepam [providing short-term relief from anxiety symptoms and is often prescribed for various anxiety disorders, including generalized anxiety disorder and panic disorder]. 0.5 mg.

On 3/7/25 RX # 752006 Morphine 15 mg. [pain medication used to relieve severe pain (generally falls within

a range of 7-10 on a 0-10 pain scale)].

On 3/7/25 RX # 831375 Hydrocodone [a semi-synthetic opioid that is used to treat moderate to severe pain and as a cough suppressant (generally falls within a range of 5-6 on a 0-10 pain scale)]. 5-325 mg.

On 3/7/25 RX # C8809092 Lorazepam 0.5 mg.

On 3/7/25 RX # C0874708 Lorazepam 30 ml.

On 3/7/25 RX # 824460 Morphine 15 mg.

On 5/5/25 RX # 831375 Hydrocodone 10-325 mg.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview on 5/7/25 at 9:08 a.m. with Pharmacy Consultant (PC), PC stated she had not participated in the destruction of the medications in question. PC stated the nurse had incorrectly Level of Harm - Minimal harm or documented the destruction of narcotics without proper verification. PC stated no concurrent destruction had potential for actual harm occurred for those entries and the documentation errors did not reflect actual disposal events.

Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated 4/2019, the P&P indicated, Policy Statement: Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances .3b. the receiving pharmacist and a registered nurse employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned .6c. Disposal of controlled subtances must take place immediately (no longer than three days) after discontinue of use by

the resident .7d. Document the disposal on the medication disposition record. 7e. Include the signature(s) of at least two witnesses .11. The medication disposition record will contain the following information: a. The resident's name; b. Date medication disposed; c. the name and strength of the medication; d. The name of

the dispensing pharmacy; e. the quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 52221 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure three of twenty eight Residents Affected - Few opportunities for medication administration were performed without error, resulting in an 11% medication error rate. These failures had the potential for:

1. Resident 46, ineffective medication delivery.

2. Resident 46, omissions are inconsistent with manufacturer instructions for use.

3. Resident 34, to rotate injection sites as required.

Findings:

1. During a review of the manufacturer's instructions for Combivent Respimat(inhaler for breathing difficulties) indicated, The patient should exhale fully, place lips around the mouthpiece, then inhale slowly and deeply while pressing the inhaler button. After inhalation, the patient should hold their breath for 10 seconds or as long as comfortable.

During an observation on 5/6/25 at 9 a.m. in Resident 46's room during a medication pass, a Respiratory Therapist (RT) was observed administering Combivent Respimat to Resident 46. Resident 46 was not instructed to exhale fully prior to inhalation and hold their breath following the dose.

During an interview on 5/6/25 at 9:15 a.m. with RT, RT stated, I just forgot to tell him to exhale and hold his breath. I know I'm supposed to, but I was moving quickly.

2. During a review of the manufacturer's instructions for Ellipta (inhaler for breathing difficulties) indicated: Instruct the patient to exhale fully before inhaling the dose. After inhaling, the patient should hold their breath for about 3-4 seconds, or as long as comfortably possible.

During a cocurrent observation and interview on 5/6/25 at 9 a.m. in Resident 46's room, the RT was administering Ellipta to Resident 46. Resident 46 was not instructed to exhale prior to inhalation and was not told to hold their breath after receiving the dose. At 9:15 a.m., the RT stated, I just forgot to do it-I'll make sure to go slower next time.

3. During a review of the manufacturer's instructions for Humalog (used to treat low blood sugars) indicated, Injection sites should be rotated within the same region to reduce the risk of lipodystrophy [how the body breaks down fat].

During a concurrent observation and interview on 5/6/25 at 9:10 a.m. in Resident 34's room, Licensed Vocation Nurse (LVN) 2 was administering Humalog insulin to Resident 34 in the left lower abdomen. At 9:20 a.m., with LVN 2 stated, I gave it in the same spot as before because I forgot to rotate. I'll try to do better next time.

During a review of Resident 34's Medication Administration Record, (MAR) dated 5/1/25, the MAR indicated,

the left lower abdomen was also the last documented injection site.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27157

Residents Affected - Few 51540

Based on observation, interview, and record review the facility failed to:

1. Follow the planned menu for finger foods diet for one of one sample resident (Resident 18) during lunch trayline (a system of food preparation).

2. Ensure the allotted fluid from dietary was followed as ordered pertaining to a fluid restriction for one of one sample resident (Resident 32).

These failures had the potential for Resident 18 to have loss of independence and dignity, and Resident 32 to not have adequate hydration.

Findings:

1. During an observation on 5/6/25 at 12:03 p.m. in the kitchen during lunch trayline observation, Resident 18's meal tray card indicated finger foods. A whole piece of chocolate cake was served onto Resident 18's lunch meal tray and placed on the meal delivery cart for distribution. Per the therapeutic diet spreadsheet Chocolate cake cut into smaller pieces was the planned menu for finger foods.

During an interview on 05/06/25 at 12:03 p.m. with Registered Dietitian (RD), RD was asked to check if the planned menu for finger foods was followed. RD stated the cake was not cut into pieces as written on the therapeutic menu extension, it was just a smaller piece.

During an observation on 5/6/25 at 12:09 p.m. in the kitchen, observed RD giving the chocolate cake to staff and asked them to cut into smaller pieces as indicated on Resident 18's meal tray ticket and on the menu. RD stated she did not like that because it might fall into pieces when picked up.

During a review of Resident 18's Diet Order (DO), dated 5/1/23, the DO indicated, Regular diet: regular texture, thin liquids consistency, finger foods.

During a review of Resident 18's Meal Tray Ticket (MTT), the MTT indicated, Resident 18 was on a finger food diet.

During a review of Resident 18's Care plan-nutrition status (CP), dated 7/27/23, the CP indicated, Resident 18 is at risk for weight loss, dehydration, skin breakdown, and altered nutritional status.interventions: Diet as orders: finger food, fortified, regular diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 During an interview on 5/6/25 at 12:13 p.m. with RD in the kitchen, RD stated she approved the menus, including the planned menu for finger foods. RD stated she was aware it was the facility's RD responsibility Level of Harm - Minimal harm or to review and approve the menus and she had not identified concerns with the finger foods menu in advance potential for actual harm in order to provide instruction to dietary staff on modification to the menu to address concerns that it may impede a resident's dignity while eating amongst others, or potential with difficulty getting the food into the Residents Affected - Few mouth, if the food might be falling between the fingers.

During an interview on 05/08/25 at 10:18 a.m. with the Dietary Supervisor (DS), DS stated the RD did sign

the current menu cycle that included cutting up the cake into smaller pieces for the finger foods planned menu. DS stated she expects the dietary aid (DA) who prepared and placed the whole cake onto Resident 18's lunch meal tray to have had the skill set to follow the planned menu as indicated on the therapeutic spreadsheet for finger foods.

During a review of the facility's job description (JD) titled Dietitian, dated 2023, the JD indicated, Major Duties and Responsibilities: Reviews menu changes to ensure compliance with the facility's policy and procedures and state and federal guidelines. Updates diet orders and menu changes as required. Conducts audits of relevant nutritional care on a routine basis.

During a review of the facility's policy and procedure (P&P) titled Menus and Adequate Nutrition, dated 2/2025, the P&P indicated, The facility's dietician or other clinically qualified nutrition professionals will review all menus for nutritional adequacy and approve the menus.

During a review of the facility's diet manual (DM), dated 2023, the DM indicated, Regular Diet-Finger Foods (RDFF), dated 2023, the RDFF indicated the finger foods diet is a regular diet that provides food in appropriate size and shape to be eaten without utensils, but rather with fingers. This allows residents to maintain independence, dignity and quality of life.cut food to size per the diet order. If no size is indicated, cut food in bite-size pieces (approximately 1).

During a review of the facility's P&P titled Tray Identification, dated 4/2007, the P&P indicated, Appropriate identification/coding shall be used to identify various diets. 1. To assist in setting up and serving the correct food trays/diets to residents, the food services department will use appropriate identification to identify the various diets. 2. The food service manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas.

During review of the Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025,

the NCM defined finger foods as finger foods can be easily picked up with the hands without falling apart. Indication: Using fingers to pick up foods enables self-feeding, independence, and diet adequacy.

2. During a review of Resident 32's facesheet, the facesheet indicated Resident 32 was admitted on [DATE REDACTED] with diagnosis of end stage renal disease.

During a review of Resident 32's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/5/25, the MDS section C indicated Resident 32's Brief Interview for Mental Status (BIMS-an assessment tool used by facilities to screen an identify memory, orientation, and judgement status of the resident) was a score of 15 (able to understand and verbalize thoughts and needs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 During a review of Resident 32's DO, dated 11/14/24, the DO indicated Resident 32 was on a fluid restriction.

Level of Harm - Minimal harm or During a review of Resident 32's CP dated 8/29/23, the CP indicated Resident 32 is at risk for weight loss, potential for actual harm dehydration, skin breakdown, and altered nutritional status r/t [related to] medical condition/dx [diagnosis] ESRD [end stage renal [kidney] disease] w/[with] dialysis tx [treatment]. Interventions: diet as ordered.Fluid Residents Affected - Few restriction: 1500 ml [milliliters-a measurement of volume]/ [per] day; Dietary: 1080 ml; Nursing: 420 ml.

During a review of Academy of Nutrition and Dietetics Nutrition Care Manual (NCM), dated 2025, the NCM indicated to determine how to distribute total fluids throughout the day.

During a concurrent interview and record review on 05/08/25 at 10:13 a.m. with DS, Resident 32's meal tray card (MTC) indicated 1080 ml fluid restriction. DS reviewed Resident 32's MTC that listed the following: 4 fl oz [fluid ounces- a measurement of liquid] fruit juice and 8 fl oz Soy Milk. For lunch 8 fl oz Soy Milk and 4 fl oz Water. For dinner 4 fl oz of Soy Milk and 4 fl oz Water. DS stated, 4 oz is missing and she [Resident 32] has been stating she is thirsty too. DS stated the facility's expectation was for the total allotted amount of 1080 fl oz per 24 hours to be served by dietary, not more and not less.

During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet Orders, the P&P indicated

The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Level of Harm - Minimal harm or potential for actual harm 27157

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

Findings:

During a concurrent observation and interview on 5/7/25 at 11:58 a.m. with Resident 68 in Resident 68's room, Resident 68 stated when she was at home she liked to drink Pepsi, Kool-Aid, and pineapple juice. Resident 68 stated in here they only give her the liquids they have in the kitchen that day. Resident 68 stated no one has come to ask her preferences for liquids.

During a review of Resident 68's RD [Registered Dietitian]/IDT [interdisciplinary team] Weight [wt] Variance Meeting [mtg] (Wt Mtg), dated 12/31/24, the Wt Mtg indicated, Wt: 85# (pounds). Wt Change: -23# (21. 3%[percent]) x [for] 3 months, po [by mouth] intake: 0-50% [of total meals], Diet: fortified [increased calories], double protein diet, Supplements: HN [house nourishment/HN shake] 4 oz [ounce] with meals, ferrous sulfate [a compound containing iron], Vit [vitamin] C, Prostat [supplement to increase protein and calories], MVM [multivitamin with minerals], Skin: Stage 4 [pressure injury with full-thickness skin and tissue loss] to sacrum [bone in the lower portion of the spine], unstageable [pressure injury with obscured full-thickness skin and tissue loss] to R [right] leg, trauma wound to R leg, skin tear to R forearm, Resident sent to acute [hospital] (12/14/2024) for syncope [fainting] and readmitted [to skilled nursing facility on 12/16/2024] s/p [status post] IV [intravenous] hydration. Resident with decreased appetite, new wound, and s/p antibiotic tx [therapy] for R leg trauma wound. CDM [Certified Dietary Manager/DS-Dietary Supervisor] met with resident to update food preferences. Residents likes and dislikes updated, resident desires to take a break from HN [house nourishment shake to increase calories and protein] and instead add ice cream and chocolate pudding [Note: both items turn to liquid at room temperature and therefore are considered alternative sources of liquids] w[with]/L [lunch] & D [dinner],

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 During a concurrent interview and record review on 05/08/25 at 10:11 a.m. with DS, DS stated she obtained Resident 68's food preferences frequently. DS was asked if she obtained Resident 68's beverage and/or Level of Harm - Minimal harm or liquid preferences. DS stated, yes, she offers the beverages they have such as milk (soy or almond and potential for actual harm regular), punch, iced tea, water, fruit juice (100%-pineapple, orange, grape, apple, and cranberry juice) as

these juices are always in stock. DS stated these preferences are documented on Resident 68's meal tray Residents Affected - Few card. DS reviewed Resident 68's meal tray card that indicated for breakfast 4 fl [fluid] oz Fruit Juice [flavor unspecified], 8 fl oz Milk Whole, for lunch 4 oz ice cream, 4 fl oz Milk Whole, 8 fl oz SF [sugar free] Beverage [flavor unspecified] and for dinner 4 oz ice cream, 8 fl oz Iced Tea, and 4 fl oz Milk Whole. DS stated the liquids listed on Resident 68's meal tray card were standing orders, meaning they consisted of the routine beverages facility maintained in stock. It was shared with DS that Resident 68 stated she had to drink what was given to her on the meal trays but if she were home one of her beverages she liked to drink was pineapple juice. DS showed a carton of pineapple juice that was readily available in the kitchen. DS stated if

she knew she liked pineapple juice she would have offered it. DS was asked if there were any other facility policies and procedures (P&P) that guided staff to obtain beverage preferences as the P&P titled Food Preferences, dated 2023, indicated, Food preferences will be obtained as soon as possible.Updating of food preferences will be done as the resident's needs change and/or during the quarterly review, and lacked specific guidance directing staff to obtain liquids preferences. DS stated that was the only P&P the facility had related to preferences whether food or beverage.

During a review of Resident 68's Nutrition Status Care Plan Report (IDT nutrition care plan/IDTNCP), dated 5/6/2025, the IDTNCP indicated, Goal: Will not exhibit s/s [signs/symptoms] of dehydration, there were no beverage preferences listed and/or resident's goals related to person centered care to direct acceptable interventions in accordance with Resident 68's preferences on how to achieve the goal of preventing dehydration.

During a review of the facility's P&P titled, Hydration, dated 2022, the P&P indicated, Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Compliance Guidelines: The facility will utilize a systematic approach to optimize the resident's hydration status: Developing and consistently implementing pertinent approaches. Identification/assessment: The dietary manager or designee shall obtain the resident's beverage preferences upon admission, significant change in condition, and periodically throughout his or her stay.Care plan implementation: The resident's goals and preferences regarding hydration will be reflected in

the resident's plan of care. Interventions will be individualized to address the specific needs of the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 51540

Residents Affected - Many Based on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen when:

1. A brown colored substance and a dead bug were observed between a reach-in freezer and reach-in refrigerator.

2. The ice machine was not sanitized in accordance with manufacturers' guidelines.

3. Baseboards were observed to be peeling away from the wall under a sink leaving a potential entry for pests.

These failures placed the residents at an increased risk for foodborne illness.

Findings:

1. During a concurrent observation and interview on 05/05/25 at 10:04 a.m. with Dietary Supervisor (DS) in

the kitchen, a brown colored substance on the floor behind a white pest control trap located between a reach-in refrigerator and a reach-in freezer was observed. DS was asked what the brown colored debris/substance was, and DS stated, I don't know. DS stated the floor between the freezer and refrigerator was dirty with debris and the external side stainless steel walls of both units that faced each other had a buildup of dust.

During an interview on 05/05/25 at 10:04 a.m. with DS, DS stated she had not seen any pests in the kitchen.

During a concurrent observation and interview on 05/05/25 at 10:29 a.m. with Maintenance Supervisor (MS)

in the kitchen, MS observed the round brown colored item on the floor behind a white pest control trap located between a reach-in refrigerator and a reach-in freezer. MS stated that was a bug, and it looked like a water bug which he stated was a type of cockroach. MS stated the floor between the two units was dirty with debris and a dead waterbug/cockroach, as well as a buildup of dust alongside the external surfaces of the two units that faced each other. MS observed behind the two units in which there was another white pest control trap and dirty flooring. MS stated the white pest control traps were placed there by outside pest control company.

During a review of the FDA Food Code (FDAFC), dated 2022, FDAFC indicated, Non-food contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

During a review of FDAFCA, dated 2022, FDAFCA indicated, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic [capable of causing disease] microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 2. During an interview on 05/05/25 at 10:13 a.m. with MS, MS stated he was responsible for cleaning the ice machine. MS stated the facility did not have an outside vendor to clean the ice machine. MS stated once a Level of Harm - Minimal harm or month he deep cleaned the ice machine located in the kitchen, which was the facility's only ice machine. MS potential for actual harm stated the only product that was circulated through the ice machine was Nickel Safe Ice Machine Cleaner (NSIMC) and he showed the bottle of NSIMC. MS was asked how he sanitized the ice-machine and MS Residents Affected - Many stated with Nickel Safe Ice Machine Cleaner, it does both.

During a review of the manufacturer's guidelines (MGs) for the Koolaire Ice Machine located in the kitchen,

the MGs indicated, Cleaning/Sanitizing Procedure: This procedure must be performed at a minimum of once every six months.Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime.Wait until the trough refills, then add the proper amount of Manitowoc Ice Machine Sanitizer to the water trough.

During a review of the facility's policy & procedure (P&P) titled Ice Machine Cleaning Procedures (IMCP), dated 2023, the IMCP indicated, The ice machine needs to be cleaned and sanitized monthly. Information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and/or in the directional panel on the inside of the machine. 3. Clean inside of ice machine with

a sanitizing agent per the manufacturer's instructions.

3. During a concurrent observation and interview on 05/05/25 at 10:08 a.m. with DS in the kitchen, the baseboards underneath the sink were separating from the floor showing an open crevice. DS stated the open crevice between the floor and baseboard was identified via audit of the kitchen by the Registered Dietitian and MS was aware. DS did not know when the repair was to be made.

During a concurrent observation and interview on 05/05/25 at 10:32 a.m. with MS in the kitchen, MS observed the baseboard separating from the floor alongside the wall in which the dirty side of the dish machine was located. MS stated that it could be an entry for pests and stated he was aware. MS stated the facility started talking about the need to fix that and had been talking about replacing the flooring. MS was asked if there were any action plans put into place that he could provide for review, and MS stated no.

During a review of Food & Nutrition-Monthly Inspection Checklist (FNMIC), dated 03/25/25, the FNMIC indicated old tile needs repair and also baseboards.

During a review of FNMIC, dated 04/15/25, the FNMIC indicated old tile, baseboards repair.

During a review of the facility's P&P titled Sanitation Inspection, the P&P indicated it is the policy of this facility as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations.

According to the FDA (Food and Drug Administration) Food Code 2013, Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. (Cleanability 6-201.11 Floors, Walls, and Ceilings. 6-201.12 Floors, Walls, and Ceilings, Utility Lines)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 27157

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

This deficient practice had the potential for residents to not receive the ordered nutrition intervention and/or services to support their highest practicable well-being.

Findings:

During a review of Resident 57's Order Summary (OS), dated 6/11/2024, the OS indicated add 4 oz house nourishment with breakfast.

During a review of Posted Meal Times (PMT), located in front of the dining room, the PMT indicated breakfast was served at 7 a.m., lunch at 12 p.m., and dinner at 5 p.m.

During a concurrent observation and interview on 05/06/25 at 11:03 a.m. with CNA 1 in rooms 25-29 hallway, CNA 1 stated she assisted Resident 57 with eating her breakfast earlier in the morning. CNA 1 was observed entering 40 ml (milliliter: a unit used in the metric system for measuring capacity) onto an electronic device attached to the wall in the hallway. CNA 1 stated 40 ml was the total consumption of fluids from all fluids located on Resident 57's breakfast meal tray that consisted of milk, apple juice, and a little tiny bit of HN shake.

During a review of Resident 57's Document Fluid Intake Ml's (DFI) log, dated 5/6/2025, the DFI indicated 11:03 (11:03 a.m.) with 40 documented to the right of 11:03 under a column titled Amount. The other two meal time's listed for 5/6/25 on the DFI indicated 14:44 (2:44 p.m.) and 18:00 (6:00 p.m.). No where on the DFI log nor on the Medication Administration Record was documentation to show the order of 4 oz House Nourishment with breakfast was implemented.

During an interview on 5/6/25 at 3:20 p.m. with RD, RD was asked how much of the 4 oz HN shake with meals Resident 68 consumed in the past month, after it was initiated a month prior as an intervention to prevent further weight loss. RD stated she would not be able to estimate how many calories and protein she consumed during the past month from the HN shake to determine whether the intervention was adequate to meet Resident 68's nutritional needs because CNAs included the HN shake with the overall fluid intake of any beverages consumed with the meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During an interview on 05/07/25 at 09:51 a.m. with Director of Staff Development (DSD), DSD stated he was responsible for training CNAs on how to document resident consumption of solid food intake and of fluids Level of Harm - Minimal harm or from meals provided. DSD showed his power point training on how he instructed CNAs to document quantity potential for actual harm of total ml of fluids consumed from a meal tray to include oral nutrition supplements (ONS) such as HN shake on the ADL (Activities of Daily Living) flow sheet (ie.DFI log). DSD stated the facility's policy and Residents Affected - Few procedure (P&P) did not provide specific details on how and where to document ONS but that was how he trained CNAs to do it. DSD stated the closest P&P to this subject matter was titled Serving a Meal.

During a review of the facility's P&P titled, Serving a Meal, dated 1/2025, the P&P indicated, Remove the tray when the resident has finished and record the percentage of food consumed as 25%, 50%, 75% or 100%.

During a review of the facility's P&P titled, Nutritional Management, dated 1/2025, the P&P indicated, Policy:

The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status.Compliance Guidelines: A comprehensive nutritional assessment will be completed by a dietitian.Components of the assessment may include, but are not limited to:.Food and fluid intake, Monitoring/revision:.Examples of monitoring include: Evaluating the care plan to determine if current interventions are being implemented and are effective.

During a review of the facility's P&P titled, Documentation in Medical Record, dated 2022, the P&P indicated, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of

the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or response to care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 38 056261 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056261 B. Wing 05/08/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Orchards at Tulare 604 E. Merritt Ave. Tulare, CA 93274

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 52221 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure staff followed infection control Residents Affected - Few practices for one of one sampled residents (Resident 34) during the administration of an injectable medication. This failure had the potential to increase the risk of exposure to blood-borne pathogens.

Findings:

During a concurrent observation and interview in Resident 34's room on 5/6/25 at 11:09 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 was administering Humalog insulin quick pen (used to treat low blood sugar) to Resident 34 in the left lower abdomen. LVN 2 used her ungloved hand, to uncap and dispose of the contaminated needle tip. LVN 2 stated, I'm not going to lie, I just grabbed it without thinking and threw it out.

During a review of the facility's policy and procedure (P&P) titled, Medication Administration -Subcutaneous Insulin, dated 1/2023, the P&P indicated, Put on gloves, engage safety device, and discard syringe and needle in appropriate syringe disposal container.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 38 056261

F-F842)

3. Effectively monitor, evaluate and identify, inadequate fluid intake during which time Resident 68 had increased fluid needs due to multiple pressure injuries, including Stage 4 (Full-thickness skin and tissue loss) and apply relevant approaches such as obtaining Resident 68's beverage preferences to help Resident 68 improve fluid intake. (Cross Refer