Orchard Creek Skilled Nursing

In the surveyor’s words

From the most serious findings on record at Orchard Creek Skilled Nursing, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 4, 2025

  Based on interview and record review, the facility failed to protect the resident's right to be free from neglect by facility staff for one Resident (#4) of one residents reviewed for abuse and neglect. This deficient practice resulted in actual harm when Resident #4 experienced unnecessary pain and persistent feelings of fear and anxiety.Findings include:Resident #4 (R4) Review of R4's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/13/25 with diagnoses including congestive heart failure, difficulty in walking, and pain in right shoulder. Review of R4's most recent Minimum Data Set (MDS) assessment, dated 8/25/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicative of intact cognition. […]

• Actual harm, isolatedF689Oct 25, 2023

  This citation pertains to Intake MI00137609. Based on interview and record review, the facility failed to prevent a fall for one Resident (#18) of one resident reviewed, resulting in Resident #18 falling with staff present and sustaining multiple fractures requiring hospitalization and surgery. Findings include: Resident #18 (R18) Review of a Post Fall/Incident Note dated 4/8/2023 revealed R18 fell in the bathroom while the Certified Nursing Assistant (CNA) was with her. The note revealed [Patient] washed her hand, turned to get towel, and lost balance. fell on left side of face and body. Injuries included laceration on left eyebrow, bleeding around scab on left elbow, and bruising lateral side of left calf. The note revealed R18 was transferred to the hospital. […]

• No harm, potential for more than minimal, widespreadF725Sep 4, 2025

  Based on interview and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being of residents. Findings include: On 9/3/25 at approximately 11:30 a.m. an interview was conducted with Certified Nurse Aides (CNA) J and K in regard to complaints of low staffing numbers. CNAs J and K confirmed that during shift change, residents can wait 30 to 45 minutes after report for staff to come and assist. CNA K stated, Sometimes it can be up to 45 minutes before we are out on the floor and then we have to get people up, get them dressed, toilet, vitals, breakfast, etc. When there are only two of us, it can be a challenge, and they (residents) have to wait a long time. […]

• No harm, potential for more than minimal, widespreadF812Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by:Failing to label, date, and discard expired food in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, and dry storage. Failing to ensure kitchen utensils were stored in a sanitary manner.Failing to ensure the ice cube machine/bin was free from mold accumulation.These deficient practices have the potential to result in food borne illness among any or all of the 17 residents in the facility.Findings include: On 9/2/25 at 11:24 PM, an initial tour of the kitchen was conducted with Dietary Manager (DM) G. […]

• No harm, potential for more than minimal, widespreadF838Sep 4, 2025

  Based on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population.Findings include: Review of the Facility Assessment document provided by the facility revealed the Facility Assessment was last completed, updated, or reviewed on 8/6/24.In an interview on 9/4/25 at approximately 11:30 AM, the Nursing Home Administrator (NHA) confirmed that the Facility Assessment had not been completed, updated, or reviewed since 8/6/24.