Orchard Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Orchard Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 3, 2025

  Based on interviews, record reviews, and review of the policy titled, Abuse Prohibition, the facility failed to ensure one cognitively impaired resident (R48) was free from sexual and physical abuse from one resident (R121) who had a history of sexually inappropriate behaviors, and history of being agitated and hostile. The sample size was 36. On 3/31/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, isolatedF740Apr 3, 2025

  Based on resident and staff interviews, record review, and review of the facility's policies titled, Behavior Health, and Abuse Prohibition, the facility failed to ensure one of eight residents (R) (R121) received behavioral health services that promoted psychosocial well-being, met the resident's needs, and included individualized approaches related to nonpharmacological interventions to address worsening sexual behaviors and sexual aggression. The deficit practice provided the opportunity for R121 to sexually and physically abuse R48. On 3/31/2025, a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, isolatedF835Apr 3, 2025

  Based on record review, staff interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Abuse Policy, the facility Administration failed to provide protective oversight to attain the highest practicable physical and psychosocial well-being of the residents. Specifically, the Administration failed to take appropriate action on allegations of resident-to-resident physical and sexual abuse for resident (R) R48 by resident (R) R121; and failed to establish and implement written policies and procedures for feedback, data collection, and monitoring, including adverse event monitoring for Quality Assurance Performance Improvement (QAPI). […]

• Immediate jeopardy, isolatedF867Apr 3, 2025

  Based on staff interview, facility document review, and review of the facility policy titled, Quality Assurance/Performance Improvement, the facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program regarding the facility's Performance Improvement Plan (PIP) for Sexual Abuse. This had the potential to affect all residents of the facility. On 3/31/2025, a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• No harm, potential for more than minimal, isolatedF584Jul 15, 2021

  Based on observations and interviews, the facility failed to ensure the upkeep of one resident's (R) wheelchair related to rust, dirt, and debris (R#19) and failed to ensure a mattress was free of sagging and indentations for one resident (R#56). The facility failed to ensure that bedside rolling table were free of rust in rooms 26A and 27A. In addition, the facility failed to ensure that two residents' bathrooms were free of strong urine odor (23A and 27A). The facility census was 65. Findings include: 1. Observations on 7/12/2021 at 10:30 a.m., 7/13/2021 at 12:00 p.m., 7/14/2021 at 11:00 a.m., and 7/15/2021 at 9:15 a.m. of room 27A revealed three rolling bedside tables heavily covered in rust. In room 26A there was one rolling bedside table heavily covered in rust. 2. […]