The Orchards Post-Acute

In the surveyor’s words

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

• Immediate jeopardy, patternF812Sep 22, 2022

  Based on observation, interview, and record review, the facility failed to maintain a clean, safe, and sanitary kitchen for 126 out of 133 residents' receiving meals when: 1. One of one live cockroaches (roaches - small insects that cause spread of bacterial infection) and two of two of two dead cockroaches were observed in the kitchen during daylight (11:53 AM) and while the kitchen was being operated. 2. A black and green substance approximately 56 and 1/2 X 42 X 11 and 1/4 inches (length by width by height) was observed in one of one produce refrigerators above the food items ready to be served for residents consumption and empty plates ready to be used to serve residents' food. 3. Resident lunch food temperatures were not taken prior to being served for resident consumption. 4. […]

• Actual harm, isolatedF689Mar 19, 2026

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) safety when:1. Physician's order (any time the doctor writes or gives verbal instruction for nursing staff to follow) for bilateral landing mats (high-density foam cushions placed beside beds to reduce injury from falls) was not followed for one of three sampled residents (Resident 1).2. Care plan (CP- a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) for bilateral landing mats was not implemented for one of three sampled residents (Resident 1).3. […]

• Actual harm, isolatedF693Dec 11, 2024

  Based on interview and record review, the facility failed follow their policy and procedure (P&P) titled, Enteral Feedings (a method of delivering nutrients and fluids to the body for patients who cannot safely chew or swallow) - Safety Precautions, for one of three sampled residents (Resident 1) who was on gastrostomy tube (G- tube- a tube which delivers liquid, nutrition, and medications through a flexible tube that goes directly into the stomach) feeding when G-tube placement was not checked, gastric residual volume (measures the amount of fluid or contents remaining in the stomach after feeding) was not checked, and signs and symptoms of complications were not reported timely to the physician. […]

• Actual harm, isolatedF686Dec 12, 2022

  Based on interview and record review, the facility failed to ensure: 1. Wound (pressure injury) care was provided and weekly wound assessments were completed for one of 33 sampled residents (Resident 4). This failure resulted in Resident 4's pressure injury/ulcer [a wound caused by pressure] to worsen, develop an infection, and caused an increase in wound pain. 2. Wound (pressure injury) care was provided for 11 of 33 sampled residents (Resident 1, Resident 6, Resident 17, Resident 18, Resident 20, Resident 21, Resident 22, Resident 24, Resident 28, Resident 30 and Resident 31). This failure had the potential for residents' wounds/pressure injury to worsen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2025

  Based on observation, interview, and record review, the facility failed to: 1) Ensure three of three sampled clean linen carts were in good repair. 2) Follow the manufacturer's guidelines on how to disinfect the clean linen carts. 3) Ensure the laundry room was clean and sanitary. These failures had the potential for contaminating clean linens and spread of infections to all residents. Findings: 1) During a concurrent observation and interview on 3/12/25 at 7:42 a.m. in the hallway, with Laundry Aide (LA), LA was delivering clean linens to the clean linen closet. The clean linen cart edges were ripped, exposing the metal frames, and had a hole on the side. LA stated, I don't know how old they are, they must be too old. During a concurrent observation and interview on 3/12/25 at 7:55 a.m. […]