The Orchard - Post Acute Care

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 29, 2025

  Based on interviews and record reviews, the facility failed to provide necessary care and services for one of 4 sampled resident ( Resident 1) who was at risk for developing pressure ulcer (PU- a skin damage or injury due to poor circulation or prolonged unrelieved pressure) and complications from PU, in accordance with the facility ' s policy and procedure, care plan and the physician ' s order by failing to: 1. Ensure the facility ' s licensed staff was referred and followed up on Resident 1 ' s referral and appointment with a vascular physician (a doctor who specializes in the diagnosis, treatment, and prevention of diseases that affect the blood vessels, including arteries and veins), in accordance with Nurse Practitioner (NP) 1 ' s recommendations on 9/24/2024. […]

• Actual harm, isolatedF689Jul 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 143) with history of falls (move downward, typically rapidly and freely without control, from a higher to a lower level) was provided supervision, monitoring and assistance as indicated on the resident's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) of high risk for falls and facility's policy and procedure to prevent falls by failing to: 1. Ensure Resident 143's room was well lit and had adequate lighting and not kept dark, in accordance with the resident's care plan dated 6/8/2024, and 6/14,2024 to prevent hazards, falls and accidents. 2. […]

• Actual harm, isolatedF689Aug 18, 2023

  Based on interview and record review, the facility failed to provide safety measures by assisting, and monitoring to prevent falls and injury for one of five sampled residents (Resident 1) by failing to: 1. Ensure Resident 1, who was assessed at high risk for falls was free from falls and injury when the resident fell hitting her forehead on the floor in her room on [DATE] and on [DATE], when Resident 1 slipped on her feces on the floor and fell . 2. Ensure facility staff immediately assisted Resident 1 when the resident activated the call light (communication system that link facility staff to the needs of residents) on [DATE] as indicated in the facility's policy on Responding to Call lights, and Resident 1's care plan for Risk for Falls and Actual Fall. […]

• No harm, potential for more than minimal, patternF578Jul 31, 2026

  Based on interview and record review, the facility failed to ensure two of thirteen sampled resident (Resident 5 and Resident 48), or their representative were assisted to formulate an Advance Directives (AD-a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) upon admission to the facility and ensure their Acknowledgement of Advance Directive (AAD, a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) form was completed accurately and timely. […]

• No harm, potential for more than minimal, patternF684Jul 31, 2026

  Based on observation, interview, and record review, the facility failed to ensure that one of three sample residents (Resident 141), who was at risk for constipation (a common digestive issue where aa person has fewer than three bowel movements a week, or passes hard, dry, and lumpy stools that are painful or hard to push out) received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and physician's order for effective bowel management by failing to: 1. Assess and monitor the resident's bowel status according to the resident's care plan, physician's order and facility's policy and procedure. […]