Orchards of East Liverpool, The

In the surveyor’s words

From the most serious findings on record at Orchards of East Liverpool, The, in the surveyor’s own words.

• Actual harm, isolatedF686Nov 25, 2022

  Based on record review, facility policy review and interview the facility failed to ensure routine skin assessments were completed for Resident #28 to timely identify the deterioration of a pressure ulcer. Actual Harm occurred on 09/23/22 after the facility failed to complete routine assessments (from 09/02/22 to 09/23/22) and evaluation of treatments for skin impairment resulting in Resident #28's sustaining a deterioration in skin integrity and subsequent Stage III (full thickness skin loss involving damage or premature death of subcutaneous tissue that may extend down to, but not through, underlying connective tissue. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue) pressure ulcer to the right buttocks. […]

• Actual harm, isolatedF689Nov 25, 2022

  Based on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive and individualized fall safety interventions were implemented to prevent a fall with injury for Resident #37, who was identified upon admission at high risk for falls. The facility also failed to ensure adequate assistance using a mechanical (Hoyer) lift was provided to Resident #33 during a transfer to prevent a possible fall/injury. Actual Harm occurred on 11/19/22 when Resident #37 sustained a fall with injury (head injury, nausea, bilateral black eyes and leg laceration) requiring hospitalization without evidence of any type of fall/safety interventions being in place prior to or at the time of the fall. […]

• No harm, potential for more than minimal, patternF761Dec 17, 2025

  Based on observation, review of insulin inserts, interview and review of the facility policy, the facility failed to label and store medication in a manner that enabled staff to know when the medication should be discarded. This affected four (Residents #12, #36, #41, and #60) of five residents who had insulin stored on the [NAME] wing medication cart. The facility census was 45.Findings include:During observations of the medication cart for rooms 21-31 in the long-term care building with Licensed Practical Nurse (LPN) #270 on 12/15/25 at 11:45 A.M., the following medication storage concerns were identified:1. Resident #60 had an open Basaglar insulin (insulin glargine) pen. The pen was not dated with the date it was opened. […]

• No harm, potential for more than minimal, patternF812Dec 17, 2025

  Based on observation and interview, the facility did not ensure chemical sanitation was completed on kitchen dishes in the rehabilitation unit. This had the potential to affect all ten (Residents #9, #19, #20, #23, #32, #40, #42, #44, #45, and #57) residing on the rehabilitation unit. The facility census was 45. Findings include:Initial tour of the kitchen on [DATE] from 9:13 A.M. to 9:20 A.M. with Dietary Manager #310 revealed the kitchen contained a low temperature dish washer that utilized chlorine for chemical sanitation. Observation on [DATE] at 9:13 A.M. of the chemical sanitation of a dishwasher cycle revealed the test strips did not register the chlorine dilution level 50 to 100 parts per million (PPM) as required. […]

• No harm, potential for more than minimal, isolatedF684Dec 17, 2025

  Based on observation, medical record review and interview, the facility failed to ensure comprehensive assessments of skin impairment were documented for one (Resident #32) of two residents reviewed for non-pressure-related skin impairment. 16 residents were screened for non-pressure skin impairment. The facility census was 45. Findings include:Review of Resident #32's medical record revealed diagnoses including necrotizing fasciitis (also known as flesh-eating disease; is a bacterial infection that affects the tissue under your skin called fascia), Methicillin-Resistant Staphylococcus Aureus (MRSA) infection (type of infection that many antibiotics don't work on), osteomyelitis (serious bone infection), displaced trimalleolar fracture (fracture of the lower leg sections that form the… […]