Orchard Hill Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 23, 2026

  Based on medical record review, resident and staff interview, and the facility investigation record, it was determined that the facility staff failed to follow the physician's order or the resident's care plan to prevent a resident (Resident #25) from experiencing a fall that resulted in harm. This was evident for 1 (25) of 1 resident.The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 3/6/2026 The findings Include On 4/16/2026 10:50AM, during the initial interview, Resident #25 stated that GNA #41 had dropped me on the floor and broke my ankle. […]

• Actual harm, isolatedF689Oct 22, 2024

  Based on review of facility reported incidents, medical record review, facility documentation review, and staff interviews, it was determined the facility failed to keep residents who required either extensive assistance or total dependence with turning and repositioning in bed free from falling out of bed while providing activities of daily living (ADL) care, resulting in actual harm to Resident #33 and Resident #17. The failure of the facility staff to protect a resident from a fall resulted in a hematoma for Resident #33 and bilateral femur fractures for Resident #17. […]

• No harm, potential for more than minimal, widespreadF812Mar 18, 2025

  Based on observation and interview it was determined the facility failed to: 1) ensure food items were labeled, 2) ensure food items were discarded appropriately, 3) ensure the freezer was maintained free from ice accumulation, 4) ensure the device utilized for dispensing of juice was not stored on the kitchen floor, 5) ensure safe storage of cleaning chemicals and 6) ensure consistent required temperature levels for dishwashing sanitization. These deficient practices have the potential to affect all facility residents. […]

• No harm, potential for more than minimal, widespreadF812Jun 30, 2021

  Based on observations of the facility's kitchen food services, and staff interview it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations. This was identified while observing the facility's dish washing machine in operation. The findings include. Observation of the facility's dish washing machine on 6/22/21 at 2:30 PM revealed that the lunch time dish washing was nearly completed. Observation of the wash temperature gauge revealed that the wash temperature did not go above 141 degrees Fahrenheit (F). The Certified Dietary Manager (staff #11) joined the surveyor and confirmed that the wash cycle water temperature was not at the correct temperature for proper dishware sanitation. […]

• No harm, potential for more than minimal, patternF657Apr 23, 2026

  Based on record review, responsible person interview, and staff interview, it was determined that the facility failed to ensure care plans were reviewed and revised at least quarterly and updated to reflect residents' current needs. This is evident for 6 (Residents #2, #3, #4, #6, #107, and #113) of 9 residents reviewed for care plan review and revision.The findings include: 1.) On 04/17/2026 at 9:11 AM, during review of the electronic medical record, it was revealed that Resident #113's last documented care plan review was on 12/18/2025. At 9:30 AM, review showed that Resident #107's last documented care plan review was on 01/02/2026. At 9:37 AM, review showed that Resident #2's last documented care plan review was on 12/11/2025. […]