Orchard View Post Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF600Jul 8, 2022

  Based on policy review, record review, review of the State Survey Agency's Long- Term Care Reporting Portal, and resident and staff interview, it was determined the facility failed to ensure residents were free from sexual abuse. This was true for 4 of 6 residents (#2, #3, #6, and #7) reviewed for abuse. Further, 8 additional instances of abuse to unnamed female residents were referenced in Resident #1's record (the perpetrator). This deficient practice placed the health and safety of Resident #2, #3, #6, and #7 and the other 28 female residents residing in the facility, in immediate jeopardy of serious harm, impairment, or death. […]

• Actual harm, isolatedF689Oct 20, 2023

  Based on policy review, I&A review, record review, and review of the facility's investigation report, it was determined the facility failed to ensure adequate supervision for residents to prevent falls. This was true for 1 of 1 resident (Resident #60) whose record was reviewed for falls. This resulted in harm to Resident #60 when the proper supervision was not provided. Findings include: Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, which can lead to a decrease in bone strength and increase risk of fractures), and dementia. […]

• Actual harm, isolatedF686Aug 3, 2022

  Based on record review, policy review, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing or worsening. This was true for 2 of 6 residents (Resident #9 and Resident #10) whose records were reviewed for wounds. This resulted in harm to Resident #9 and Resident #10 when they had worsening and/or new wounds. […]

• Actual harm, isolatedF610Jul 8, 2022

  Based on record review, policy review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure allegations of sexual abuse were investigated for 4 of 6 residents (#2, #3, #6, and #7) who were reviewed for potential abuse. Further, this was true for 2 additional unnamed residents referenced in Resident #1's record (the perpetrator). This failure caused psychosocial and physical harm to a resident when she was sexually abused. This deficient practice also placed the health and safety of all 31 female residents residing in the facility at risk. […]

• No harm, potential for more than minimal, widespreadF761Oct 11, 2024

  Based on observation, policy review, and staff interview, it was determined the facility failed to ensure medications and medical supplies available for residents were not expired. This was true for 1 of 2 medication storage rooms observed. This failure created the potential for residents to receive expired medications or medical supplies with decreased efficacy. Findings include: The facility's Medication Storage: Storage of Medication policy, initiated January 2023, documented, outdated medications are immediately removed from stock and disposed of according to procedures for medication disposal. On 10/10/24 at 8:35 AM, one of the facility's medication storage rooms was inspected with LPN #1 present. […]