The Orchards at Warren

In the surveyor’s words

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

• Actual harm, isolatedF686Aug 2, 2023

  This citation pertains to Intake MI00138416. Based on observation, interview and record review, the facility failed to ensure interventions were implemented to prevent development of a pressure sore for one resident (R68) of three reviewed for pressure sore, resulting in the development and or worsening of an unstageable pressure sore to the right medial heel. Findings include: On 07/31/23 at 11:33 AM, a wound was observed with the family of R68. The wound was located on the medial aspect of the right heel. The tissue over the wound appeared moist, mostly gray with areas of black. This was non viable tissue slough and eschar. The dressing appeared with a brown and black drainage. The wound was more oval than circular and around a half dollar in size. […]

• Actual harm, isolatedF692Aug 2, 2023

  Based on observation, interview, and record review, the facility failed to appropriately monitor and timely address a significant weight loss for one sampled resident (R74) of one resident reviewed for nutrition resulting in, undetected significant weight loss, and the potential for further weight loss and decline in nutritional status. Findings include: On 7/31/23 at 2:20 PM, R74 was observed in bed asleep, appearing small in stature. Attempts to arouse R74 were made to no avail. A review of R74's medical record revealed that the resident was initially admitted into the facility on [DATE], hospitalized from 5/29/23, and readmitted on [DATE]. R74's diagnoses include Cerebral Infarction, Dysphagia, Cognitive Communication Disorder, and Legal Blindness. […]

• Actual harm, isolatedF684May 19, 2022

  This citation pertains to intake MI 096 Based on observation, interview, and record review, the facility failed to 1) Implement interventions in a timely manner after a change in condition for one sampled resident (R281) out of one reviewed for a change in condition and 2) Provide [CONDITION(S)] medication as ordered for one sampled resident (R330) resulting in hospitalization and death and the potential for increased [CONDITION(S)] activity. Findings include: Resident 281 (R281) A review of intake MI 096 noted the following, Complainant states on 2/16/22 [Family Member] received a call and was told the resident was not eating and they suspected that [R281] may have a [CONDITION(S)] (Urinary Tract Infection). […]

• Actual harm, isolatedF684Apr 21, 2021

  This citation pertains to intake MI 329. Based on observation, interview, and record review, the facility failed to administer ordered medication for constipation when indicated and failed to conduct follow-up assessments after a known alteration in bowel pattern for one sampled resident (R902) of three reviewed for assessment/monitoring, resulting in a bowel obstruction and hospitalization . Findings include: A review of intake MI 329 revealed: Complainant states [R902] went 1 week without being able to use the restroom and the staff did not document it. Complainant states the resident ended up having a severely impacted bowel which caused [them] to start vomiting feces. […]

• No harm, potential for more than minimal, widespreadF925Dec 3, 2025

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by eliminating harborage conditions. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 12/1/25 at 9:10 AM during an observation of the kitchen, the stainless-steel table holding the coffee maker was observed with a built-in drainage well. The drainage pipe under the table was observed to be propped up by a cardboard box. The box was water damaged, and there were numerous gnats observed on the box and drainage pipe. When queried, Dietary Manager K stated the box was being used to support the pipe. […]