Orchard Villa

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 10, 2023

  AMENDED 02/27/23 Based on medical record review, review of in room video camera footage, policy review and staff interview, the facility failed to appropriately transfer a resident from the bed to wheel chair. This resulted in actual harm when Resident #81 was transferred without a mechanical by one staff member and suffered a fracture of the left tibia which required hospitalization and surgery. This affected one resident (#81) of 16 residents that required a mechanical lift transfer. The facility census was 129. Findings include: Review of Resident #81's medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, patternF583Mar 20, 2025

  Based on observation, staff interview, and facility policy the facility failed to ensure residents protected health information was kept confidential. This affected 12 residents (#43, #52, #323, #421, #422, #423, #425, #427, #428, #429, #430, and #431) reviewed for protected health information. The facility census was 117. Findings include: 1. Observation on 03/19/25 at 8:35 A.M. revealed Registered Nurse (RN) #593 was at the medication cart in the hallway and she walked away from her medication cart with the computer screen open and visible. Concurrent observation revealed Resident #52's information for medication administration was displayed on the computer screen. During the observation Resident #101 was seated in her wheelchair next to the medication cart. […]

• No harm, potential for more than minimal, patternF761Dec 11, 2023

  Based on observations, staff interviews, and review of facility policy, the facility failed to date insulin pens after initial use and failed to date a vial of opened and used sterile water. This affected two out of four medication carts observed and had the potential to affect four (#54, #72, #75, and #119) residents with insulin pens that were opened and not dated. The facility census was 125. Findings include: Observation on 12/11/23 at 9:20 A.M. of medication storage for the medication cart on A hall on the skilled unit revealed one vial of sterile water that was opened and undated, one lantus insulin pen opened and undated, and one humalog insulin pen that was opened and undated for Resident #119. […]

• No harm, potential for more than minimal, patternF921Aug 24, 2023

  Based on observation, review of the medical record, resident and staff interviews and review of facility policy, the facility failed to ensure carpet was in good repair. This affected one (Resident #45) and had the potential to affect 23 (Residents 3, #9, #17, #18, #27, #28, #38, #39, #45, #46, #47, #53, #55, #73, #79, #81, #83, #84, #86, #89, #107, #118, and #121) who were indecently mobile and residing on the Bayshore hall. Additionally, the facility failed to ensure a resident's bathroom was kept in a clean and sanitary manner. This affected one (Resident #64) of one resident observed for bathroom cleanliness. The facility census was 124. Findings include: 1. Interview on 08/22/23 at approximately 9:30 A.M. […]

• No harm, potential for more than minimal, patternF925Aug 24, 2023

  Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure an effective pest control program. This had the potential to affect 11 (#1, #9, #17, #40, #46, #53, #83, #86, #89, #107, and #121) residents residing on the Bayshore unit. The facility census was 124. Findings include: Observation on 08/21/23 at 4:36 P.M. of the Bayshore unit dining area revealed multiple gnats flying around the refrigerator. A gnat trap on top of the refrigerator had approximately 15 gnats sitting on the trap. Interview on 08/22/23 at 7:30 A.M. of Resident #86 revealed there were gnats everywhere, including in the halls, resident rooms, and in the dining area. Resident #86 stated she believed they were coming from the drains. […]