Orchards at Tulare

In the surveyor’s words

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

• Actual harm, isolatedF600Nov 15, 2024

  Based on observation, interview, and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 1) was free from physical abuse by facility staff (Certified Nursing Assistant-CNA 1). This failure resulted in Resident 1 sustaining discoloration (bruise) to left inner corner eye, discoloration to right eyebrow, discoloration to bilateral upper extremities (region of the body that includes arm, forearm, and hand), discoloration to the back of left thigh, a bald spot to the back of head, and hospitalization . 2. Ensure one of four sampled residents (Resident 3) was free from verbal abuse by facility staff (Licensed Vocational Nurse-LVN 3). This resulted in staff verbally abused Resident 3 and resulted in Resident 3 feeling angry and frustrated. Findings: 1. […]

• Actual harm, isolatedF656Sep 14, 2023

  Based on observation, interview, and record review, the facility failed to implement one of three sampled residents (Resident 1) Comprehensive Care Plan (a written plan developed by an interdisciplinary team [attending physician, registered nurse, dietician, etc.] and the resident, to help attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being) to prevent a fall incident when Resident 1 was left in the dining room without staff supervision. […]

• Actual harm, isolatedF689Jul 26, 2023

  Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) when Resident 1 was not in staff's line of sight (where staff can observe at all times) while up in her wheelchair. This failure resulted in Resident 1 and Resident 2 having a resident-to-resident altercation and Resident 2 falling to the floor, sustaining a right hip fracture (broken bone) requiring hospitalization and the need for surgical intervention. […]

• Actual harm, isolatedF689Feb 8, 2022

  Based on observation, interview, and record review the facility failed to provide supervision for one of three sampled residents (Resident 1). This resulted in Resident 1 sustaining a right [CONDITION(S)] from an unwitnessed fall in the bathroom. Findings: During an interview on 11/17/21, at 10:15 AM, with Administrator and Director of Nurses (DON), Administrator stated Resident 1 had an unwitnessed fall on 11/8/21. X-ray to right knee and hip was obtained due to complaint of pain. X-ray to right knee and hip indicated no fracture. On 11/10/21, Resident 1 was transferred to the acute hospital due to uncontrolled pain. […]

• Actual harm, isolatedF580Feb 3, 2022

  Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P & P), Change in a Resident's Condition or Status when the facility failed to assess and notify Attending Physician (AP), for one of three sampled residents (Resident 1) that a bruise was identified on 10/19/21 to Resident 1's right hip. This resulted in a delay in treatment, right hip fracture, and potential for pain. Findings: During a concurrent interview and record review on 11/3/21, at 10:30 AM, with Director of Nursing (DON), DON reviewed Resident 1's medical records. DON stated on 10/21/21, a bruise on Resident 1's right hip was identified, an x-ray was obtained on 10/23/21 with a result of a right hip fracture. […]