Orchard Park Health Care Center

In the surveyor’s words

From the most serious findings on record at Orchard Park Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 19, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of five residents reviewed for accident hazards received adequate supervision out of 12 sample residents. Resident #1 was admitted to the facility on [DATE] with diagnoses of dementia with agitation, muscle weakness and reduced mobility related to left lower leg fractures sustained prior to admission to the facility. Resident #1 was dependent on two staff members providing maximum physical support/ assistance to complete positioning and transfer activities of daily living (ADL). Resident #1 had severe cognitive impairments, per staff interview, and was unable to understand the operation of the bed controls safely or appropriately (see staff interviews below). […]

• No harm, potential for more than minimal, patternF761May 14, 2026

  Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of seven medication carts and two of three medication storage rooms. Specifically, the facility failed to: -Ensure ophthalmic solutions were labeled with the date when the medications were opened;-Ensure there were no loose pills in the bottom of the medication cart drawers; and,-Ensure that lorazepam and insulin vials were labeled with the dates the medications were opened.Findings include:I. […]

• No harm, potential for more than minimal, patternF812May 14, 2026

  Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to ensure food was held at the correct temperature. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 5/18/26. It revealed in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control time/temperature control for safety food shall be maintained at 135 degrees Fahrenheit (F) or above and 41 degrees F or less. (3-501.16) II. […]

• No harm, potential for more than minimal, patternF804May 9, 2024

  Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, temperature and texture. Findings include: I. Resident interviews Resident #108 was interviewed on 5/6/24 at 1:37 a.m. Resident #108 said his meal trays were often missing an ordered item. He said he was served a hamburger for lunch with no lettuce and tomatoes and sugar and creamer and no tea. The resident said warm food was usually cold when it was delivered. Resident #215 was interviewed on 5/6/24 at 2:02 p.m. Resident #215 said the food in the facility was not good. […]

• No harm, potential for more than minimal, patternF676Jan 26, 2023

  Based on observation, record review and interviews, the facility failed to ensure two (#5 and #23) of two residents reviewed for communication out of 50 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #5 and Resident #23, who spoke a language other than English. Findings include: I. Facility policy and procedure The Auxiliary Aide and Services Assessment policy and procedure, revised 2019, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:02 p.m. […]