Pearl of Orchard Valley

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 17, 2026

  Based on interview and record review, the facility failed to keep residents free from sexual abuse when R3 sucked on R2's breast. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on February 9, 2026, at 11:30 AM, when R2, a female dementia resident with known inappropriate sexual behaviors was left unsupervised in the dining room with R3, a male dementia resident, and R2 waved R3 over, lifted her shirt, and R3 sucked on R2's breast. This applies to 2 of 4 residents (R2 and R3) reviewed for sexual abuse in the sample of 6. V3 (Assistant Administrator), V17 (Senior Administrator), and V18 (Regional Nurse Consultant) were notified of the Immediate Jeopardy on March 10, 2026, at 11:47 AM. […]

• Immediate jeopardy, isolatedF600Sep 18, 2025

  Based on observations, interviews, and record reviews, the facility failed to ensure the safety and protection of R1, a female resident with severe cognitive impairment, from R2, a male resident with a documented history of wandering and entering other residents' rooms within the secured dementia care unit.This failure resulted in an incident on August 29, 2025, in which R2 entered R1's room without staff awareness. R2 had remained in the room with the door closed for approximately eight minutes. Staff later discovered R2 near R1, with his genitals exposed and near R1's face. […]

• Actual harm, isolatedF689Jul 25, 2026

  Based on observation, interviews, and record review, the facility failed to ensure the use of the appropriate total mechanical lift device and the required two-person assistance when obtaining a resident's weight and performing transfers for one resident (R1) who was totally dependent on staff for transfers. This failure resulted in R1 sustaining a traumatic fracture of the right tibia and fibula after falling during an improper transfer.This applies to 1 of 3 sampled residents (R1) reviewed for falls. The findings include:Review of the Electronic Medical Record (EMR) showed that R1, an [AGE] year-old resident, was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF684Nov 21, 2025

  Based on interview, and record review, the facility failed to assess a resident after an unwitnessed fall. This failure resulted in a delay of treatment for R1 who sustained subdural hematoma after a fall incident. This applies to 1 of 3 residents (R1) reviewed for assessments in the sample of 3. The findings include:R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, delirium due to known physiological condition, unsteadiness on feet, unspecified lack of coordination, unspecified abnormal gait and mobility, muscle weakness, cognitive communicative deficit, and vascular dementia moderate without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. […]

• Actual harm, isolatedF686Mar 21, 2025

  Based on observation, interview, and record review, the facility failed to monitor a resident's skin for breakdown. This failure resulted in a pressure injury not being identified until it was a stage 3, which delayed treatment, and the wound became infected. The facility also failed to implement pressure ulcer care plan interventions. This applies to 1 of 3 residents (R108) reviewed for pressure injury in a sample of 32. The findings include: On 03/18/2025, observations made at 10:18 AM, 11:01 AM, 12:17 PM, 1:04 PM, and 2:35 PM, showed R108 was visible from his doorway and was lying in bed on his back on a regular mattress. R108 appeared frail and lethargic. The sign on R108's door showed he was on contact and droplet isolation precautions. […]