Orchard Valley Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 21, 2024

  Based on record review and staff, Law Enforcement Corporal, and Medical Doctor (MD) interviews, the facility failed to protect a [AGE] year old female resident with severe cognitive impairment (Resident #2) from sexual abuse by a [AGE] year old male resident with moderate impairment in cognition (Resident #1) for 1 of 4 residents reviewed for abuse. Resident #1 was observed with his shorts/boxers pulled down lying in bed next to and behind Resident #2, whose gown was pulled up exposing her breasts and her brief pulled down between her legs, with the perceived intention of engaging in sexual activity. […]

• Immediate jeopardy, isolatedF689Oct 20, 2022

  Based on observations, record review, review of manufacturer's instructions, and Medical Doctor, Nurse Practitioner (NP, Psychiatric NP and staff interviews, the facility: 1) failed to prevent a resident, who had been deemed incompetent by the North Carolina Clerk of Superior Court and had a history of wandering and exit seeking behaviors, from exiting the facility unsupervised and without staff knowledge (Resident #1). Resident #1 was located by the police department at a 2-lane highway intersection approximately 8 miles from the facility; and 2) failed to ensure securement was according to manufacturer recommendations for providing a safe facility van transport when a resident slid partially out of the wheelchair, underneath the lap belt, causing her knees to hit the floor of the van… […]

• Immediate jeopardy, isolatedF689Jan 31, 2022

  Based on observations, record review and physician and staff interviews, the facility failed to conduct a thorough search in response to an alarm alerting staff that an exit door was opened and failed to determine if a resident had exited the building unsupervised. This affected 1 of 3 residents reviewed for accidents (Resident #3). On 09/13/21 between the hours of 6:30 AM and 6:50 AM, Resident #3, who had severe cognitive impairment, exited the building through the emergency exit doors located at the end of the resident hall and remained outside the building unsupervised. When the alarm at the nurses' station sounded, staff checked all the exit doors but did not search outside the building or conduct a head count to confirm all residents were accounted for. […]

• Immediate jeopardy, isolatedF925Aug 13, 2021

  Based on observations, record reviews, staff, Resident, Respiratory Therapist, Nurse Practitioner and Physicians interviews the facility failed to implement an effective pest control program to control the presence of flies in the rooms of 1 of 3 sampled residents (Resident #2) reviewed for pest control. Resident #2 had live maggots develop in his [CONDITION(S)] site and was transferred to the Emergency Department for removal of 3 maggots from his [CONDITION(S)] site which resulted in bacterial tracheitis and was treated with intravenous antibiotics. Immediate Jeopardy (IJ) began on 08/03/21 when Resident #2 was found to have live maggots in his [CONDITION(S)] site. […]

• No harm, potential for more than minimal, widespreadF803Dec 6, 2024

  Based on observations of the meal service tray line, record review, and dietary staff, Registered Dietician (RD), and the Regional Director of Operations (RDO) interviews, the facility failed to provide all food items as specified by the approved menu and failed ensure residents received the correct portion sizes based on the approved menu. These practices had the potential to affect 77 residents receiving a regular diet, 18 residents receiving a mechanical soft diet (consisting of foods that are easy to swallow), and 8 residents receiving a puree diet (consisting of foods with a pudding-like texture). Findings included: 1. […]