The Orchards at Armada

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 19, 2023

  This citation pertains to Intake M100141494. Based on interview, and record review, the facility failed to prevent an elopement for one resident (R701) who had severe cognitive impairment, a high risk for falls, a known elopement risk, and demonstrated multiple attempts to exit the facility shortly before the elopement occurred. R701 eloped from the facility on 11/06/23 between 7:30 PM and 8 PM through the South exit door, without triggering the door alarm and unwitnessed by staff. In response to R701's repeated attempts to exit the South exit door, a staff member (Certified Nurse Assistant -CNA C) placed a geri-chair in front of the door to discourage R701 from approaching the door. […]

• Immediate jeopardy, isolatedF689Mar 3, 2021

  This citation pertains to intake: MI 945. Based on observation, interview, and record review the facility failed to provide adequate monitoring and supervision to prevent elopement from the facility for one sampled Resident (R27) who had a known history of elopement attempts (the prior day) and was severely cognitively impaired with the [DIAGNOSES REDACTED]. R27 eloped out of the malfunctioning alarmed don the Dementia Unit (that did not alarm) on 2/22/21 for an unknown amount of time. It was documented on 2/21/21, R27 set off the door alarm five times throughout the night to look for (R27's) son. Re-assurance was provided, drinks, snacks, TV offered with short term effectiveness noted. On 2/22/21, R27 left out of the locked Dementia Unit at approximately 8:30 AM. […]

• Actual harm, isolatedF740Jan 19, 2021

  This citation pertains to intake 8. Based on interview and record review, the facility failed to provide ongoing behavioral health services and follow-up after mental status change/decline for one sampled resident (R900), who was suspected to have resolving [MEDICAL CONDITION] upon admission to the facility, resulting in the resident experiencing cognitive decline, hallucinations, and ongoing distress without psychiatric assessment/treatment prior to discharge. Findings include: On 1/14/2021 at 11:00 AM, Confidential Witness A was interviewed regarding R900's care while in the facility. Witness A stated, (R900) came home in worse condition than when they went into that facility. (R900) was no longer able to hold (their) head up, was crying and in pain. […]

• No harm, potential for more than minimal, widespreadF812May 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure opened food items were dated and discarded when expired, and failed to maintain the filter for the ice machine. This deficient practice had the potential to affect all residents that consume food. Findings include: On [DATE] between 8:30 AM-9:00 AM, during a tour of the kitchen with Dietary Manager (DM) L, the following items were observed: In the Blue Air reach-in cooler, there was an opened package of deli turkey dated ,d+[DATE], and an opened, undated package of salami. DM L stated both items would be discarded. In the Traulsen reach-in cooler, there was an opened 1 gallon container of Caesar dressing dated ,d+[DATE], and an opened container of Enchilada sauce dated ,d+[DATE]. […]

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure food items were dated when opened and discarded after the use by date, and failed to maintain the ice machine filters and the flooring around the ice machine in a sanitary manner, resulting in the increased potential for foodborne illness and cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/5/22 between 9:00 AM-9:45 AM, during an initial tour of the kitchen with Certified Dietary Manager (CDM) A, the following items were observed: In the Blue Air reach-in refrigerator, there was an opened package of deli ham dated 3/23-4/23. […]