Orchard Manor

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 15, 2024

  Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent or heal pressure injuries (PI) for 2 of 2 sampled residents (R9 & R3) reviewed for pressure injuries out of a total sample of 12. R9 was admitted with bilateral heel pressure injuries. The facility did not implement immediate offloading of the bilateral heels and the heels deteriorated. R9's wounds were not measured weekly, and her physician was not updated timely on changes to her wounds. R9 was observed not having her heels offloaded while seated in her recliner. R3 developed a facility acquired PI. The facility failed to measure and assess the PI weekly. R3's PI became infected multiple times requiring antibiotics. […]

• Actual harm, isolatedF580May 17, 2023

  Based on interview and record review, the facility did not ensure that the residents' physician was consulted when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 17 residents (R48). R48 had a change in weight status and the facility did not consult R48's physician per physician orders, resulting in R48 having to go to the emergency room with CHF (Congestive Heart Failure) exacerbation requiring medical intervention and a hospital stay. This is evidenced by: Facility policy entitled, Physician Notification, reviewed 4/6/22, includes, in part: The professional nursing staff will notify the resident's physician when a change in the resident's condition has occurred. […]

• No harm, potential for more than minimal, widespreadF812May 17, 2023

  Based on observation, interview, and record review the facility did not ensure the preparation of food in a clean and sanitary environment with potential to affect all 47 residents residing in the facility. Surveyor observed the facility's downstairs freezer to have liquid dripping from the ceiling into boxes of food that was no longer sealed by the manufacturer. Surveyor observed Cook K wet stacking clean cups. Cook K indicated she was talked to the previous year by Surveyors for not allowing the dishes to air dry completely and knows she should allow them to dry completely before stacking them. […]

• No harm, potential for more than minimal, widespreadF880Feb 24, 2022

  Based on observation, interview and record review, the facility did not ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all 46 residents (R) in the facility. -The facility did not have a system in place to keep up to date on COVID-19 guidance. -The facility did not place residents (R22, R36, and R41) that were unvaccinated in TBP (Transmission Based Precautions) during a COVID-19 outbreak. -Staff were hanging gowns used in a COVID-19 positive room on the outside of the room door. […]

• No harm, potential for more than minimal, patternF687Aug 15, 2024

  Based on interview and record review, the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 2 of 2 sampled residents (R3, R9), and 2 of 2 supplemental residents (R11, R27) reviewed for diabetic foot checks. R11 has no documentation of diabetic foot checks. R27 has documentation of once per month diabetic foot checks. R3's diabetic foot checks are not done daily. R9's diabetic foot checks are not done daily. […]