The Orchards at Samaritan

In the surveyor’s words

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

• Actual harm, isolatedF600Dec 16, 2025

  This citation pertains to intakes 2687870 and 2692032.Based on observation, interview, and record review, the facility failed to protect the resident's (R701) right to be free from physical abuse by Certified Nursing Assistant (CNA) B resulting in hospitalization for a dislocated shoulder.Findings include: On 12/16/25 at 10:55 a.m. R701 was observed self-propelling in a wheelchair, with a sling applied to the right arm. R701 was asked what happened to the arm. R701 began to laugh and made an unclear statement. R701 was asked if the arm was in pain. R701 looked at the arm, smiled, and rolled away. On 12/15/25 at 11:35 a.m. the Nursing Home Administrator (NHA) provided the facility reported incident regarding an allegation of staff to resident abuse that occurred on 12/1/25 between 9:30 p.m. […]

• Actual harm, isolatedF697Nov 8, 2024

  This citation pertains to intakes MI00145596 and MI00145720. Based on interview and record review the facility failed to ensure scheduled and as needed pain medications were administered per the physician's orders for one (R103) of three residents reviewed for pain management resulting in uncontrolled pain, frustration, anger, and feelings of helplessness. Findings include: On 11/6/24 at 11:57 a.m. the complainant (R103) was contacted and spoken to about the allegations submitted to the state agency complaint hotline on 7/11/24. The complainant said the complaint was made because of multiple daily calls from R103 not getting pain medication ((R103) would literally be in tears begging me to come get him because he was in so much pain. […]

• Actual harm, isolatedF686May 25, 2023

  This citation pertains to intake MI00135781 and MI00135936. Based on observation, interview and record review, the facility failed to implement interventions to prevent the development and worsening of a pressure ulcer for one (R707) of three residents reviewed, resulting in a facility acquired Stage 3 pressure ulcer (Full thickness tissue loss potentially extending into the subcutaneous tissue layer). Findings include: In an observation and interview on 5/24/23 at 8:57 a.m., Wound Nurse (WN) A reported R707 had a Stage 3 facility acquired pressure ulcer on the buttocks. WN A removed a heavily soiled dressing with no date from R707's buttocks. A foul smell was noted when the dressing was removed. R707 had an area the size of a grapefruit with a black center and red edges on the buttocks. […]

• No harm, potential for more than minimal, widespreadF812Apr 24, 2026

  Based on observation, interview, and record review, the facility failed to maintain best practices and general maintenance of foodservice equipment resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/22/2026 at 7:56 AM observed the ice machine door gasket cracked and worn in the green unit nourishment room. Further observation found spots of corrosion on the surface of the interior metal shield. An interview with Dietary Manager (DM) C at this time found the ice machines are cleaned by an outside company, and they are unsure frequency of cleaning. On 04/22/2026 at 7:59 AM observed an ice scoop holder with a pool of water and debris at the bottom of the holder in the green unit nourishment room. […]

• No harm, potential for more than minimal, widespreadF851Apr 24, 2026

  Based on interview and record review, the facility failed to electronically submit complete accurate and timely direct care staffing information for the Payroll Based Journal (PBJ) entry to the Centers of Medicare and Medicaid Services (CMS) for the first financial quarter (October 1st-December 31) for 2026.Findings include:On 4/24/2026 at 10:09 AM, Human Resources Director (HRD) P was interviewed and said she submits the quarterly PBJ data to the regional human resources director. HRD P said the regional human resources director then submits the PBJ information to CMS. The PBJ staffing data report was reviewed with HRD P. […]