Focused Care at Orange

In the surveyor’s words

From the most serious findings on record at Focused Care at Orange, in the surveyor’s own words.

• Immediate jeopardy, patternF700Apr 25, 2025

  Based on observation interview, and record review, the facility failed to ensure correct installation, use, and maintenance of bed rails, for 3 of 7 residents (Residents #70, #87, and #102) reviewed for bed rails. The facility did not have the manufacturers' recommendations and specifications to follow for installing and maintaining the bed rails to prevent large gap in Resident #70's bed rail. The facility failed to develop care plans to address the risk of entrapment and interventions to prevent entrapment due to the use of bed rails for the residents who had histories of falling out of the bed for Residents #70, #87, and #102 The facility did not follow their Bed Mobility Assessments indicating the bed rails were not recommended for use for Residents #70, #87, and #102. […]

• Immediate jeopardy, isolatedF760Apr 16, 2025

  Based on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. 1. The facility failed to administer Resident #1 the appropriate dose of morphine. Resident #1 was administered 1ml (20mg) of morphine every 3 minutes from 11:15 a.m. to 11:39 a.m. (180mg) instead of 1ml (20mg) every 30 minutes. 2. The facility failed to ensure Resident #1's morphine order was properly transcribed. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. […]

• Immediate jeopardy, isolatedF656Jan 24, 2025

  Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 17 residents (Resident #5) reviewed for care plans. The facility failed to ensure Resident #5's care plan ADL interventions were implemented on 09/22/24 resulting in serious injury. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. […]

• Immediate jeopardy, isolatedF689Jan 24, 2025

  Based on observation , interview and record review the facility failed to provide supervision and assistance devices to prevent accident for 1 of 17 (Resident #5) residents reviewed for accidents/supervision. The facility failed to ensure CNA C provided ADL care with 2 person assistance. Resident #5 fell out of her bed and sustained a fractured left femur during care on 09/22/24. An Immediate Jeopardy (IJ) situation was identified on 01/23/25 at 3:23 p.m. While the IJ was removed on 01/24/25 at 6:37 p.m., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents and injuries. […]

• No harm, potential for more than minimal, widespreadF802Mar 6, 2024

  Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 1 of 12 dietary staff (DA J) reviewed for food and nutrition services. The facility failed to ensure DA J had a current Food Handler's Certificate while working in the facility's kitchen. This failure could place residents who consumed food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff. Findings included: Record review of 12 dietary staff food handlers' certificates indicated DA J's certificate had an expiration date of [DATE]. […]