Inspection Reports for Orchard Park Senior Living

An unannounced complaint investigation visit was conducted due to an allegation that staff do not ensure the facility is kept in good repair.

The investigation found a large spot of discoloration on the ceiling caused by water damage, which was substantiated as a violation of Title 22 regulations requiring the facility to be kept clean, safe, sanitary, and in good repair.

The complaint alleging that staff do not ensure the facility is kept in good repair was substantiated based on observation and interviews during the unannounced visit.

An unannounced complaint investigation visit was conducted in response to allegations that staff utilized bed rails for residents without a written physician's order and that staff were not properly safeguarding medications.

The investigation found that one resident had a physician's written order for bed rails and that two residents were capable of self-administering medications despite medications being accessible. There was insufficient evidence to substantiate the allegations, and no deficiencies were issued.

The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-06-02 regarding multiple allegations about staff conduct and resident care at the facility.

The investigation included interviews with staff, review of records, and observation of the facility. Although the allegations may have occurred, there was insufficient evidence to substantiate the claims. No deficiencies were issued and the complaint was determined to be unsubstantiated.

The complaint included allegations that staff did not provide requested records to a resident’s representative, prevented residents from receiving private phone calls, failed to meet residents' toileting needs, improperly stored personal hygiene items, improperly disposed of soiled briefs, did not treat residents with dignity or respect, and overcharged residents for services. The investigation found no preponderance of evidence to prove these violations.

The inspection was an unannounced annual inspection conducted by Licensing Program Analyst J. Leffall to evaluate compliance with licensing requirements at the facility.

The facility was found to be clean, well-furnished, and safe with no passageway obstructions or fire hazards. Resident rooms and common areas were adequately furnished and maintained. Food storage and temperatures were appropriate, and medications were securely stored. No deficiencies were issued during this inspection.

The visit was a case management follow-up to confirm details of an incident report regarding a medication error where a resident's medication was not given but signed off.

The inspection confirmed the medication error incident, noted that medication training was completed by staff, and a citation and civil penalty were issued related to the medication error.

A case management visit was conducted to follow up and confirm details of an incident report regarding a medication error that occurred on 2025-05-15.

The inspection confirmed that a resident was given incorrect medication. Medication training and corrective actions were planned for involved staff. A citation and civil penalty were issued related to the medication error.

The visit was complaint-related, triggered by an incident report of a medication error involving resident R1 on 2025-05-15. The complaint was substantiated as corrective actions and penalties were issued.

The inspection was a Plan of Correction (POC) case management visit to obtain details for a repeat citation 87303(a) – Maintenance and Operations issued on 2025-04-11.

The facility has 9 sandbags placed to mitigate immediate rain and is adding additional weather stripping to a door. An independent agency was contacted for repairs, with details on assessment, quote, and repair timeline to be provided as part of the POC. A civil penalty form was completed and provided to the administrator.

The visit was a follow-up on a complaint regarding the food, but during interviews it was revealed that the dining room floor floods whenever it rains, posing a potential health, safety, or personal rights risk to residents.

The facility was found to have a deficiency related to maintenance and operation, specifically that the dining area flooring is wet from leaks through the double doors during heavy rains, which poses a potential risk to residents. A Plan of Correction is required.

The visit was triggered by a complaint regarding the food, but the complaint interview revealed an issue with flooding in the dining room floor during rain.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-04-02 regarding personal rights allegations at the facility.

The investigation found no preponderance of evidence to substantiate the alleged violations; therefore, the complaint was unsubstantiated and no deficiencies were issued.

The complaint involved allegations related to personal rights. The investigation was unsubstantiated as there was insufficient evidence to prove the alleged violation occurred.

An unannounced complaint investigation visit was conducted to investigate allegations that staff do not ensure food meals are adequately cooked and do not provide adequate food service.

The investigation included interviews with staff, residents, and the facility administrator, a review of records, a tour of the facility, and observation of food supply and meal service. Residents reported no issues with the food, and an adequate supply of food was observed. The allegation was found to be unsubstantiated and no deficiencies were issued.

The complaint was unsubstantiated based on the investigation findings; there was no preponderance of evidence to prove the alleged violations occurred.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2025-03-19 alleging staff did not ensure the facility was free of hazards and were not following residents' care plans.

The investigation included interviews with the General Manager and Health Services Director, a facility tour, and records review. The allegations were found to be unsubstantiated due to lack of preponderance of evidence, and no deficiencies were issued.

The complaint was unsubstantiated after investigation. Allegations included hazards in the facility and non-compliance with residents' care plans, but no evidence was found to prove violations.

An unannounced complaint investigation was conducted in response to allegations received on 2025-03-13 regarding staff not preventing facility flooding and ensuring facility flooring is in good repair.

The allegation that staff does not prevent facility flooding was substantiated due to observed gaps and missing weather stripping allowing water intrusion during heavy rains. The allegation that staff does not ensure facility flooring is in good repair was unsubstantiated as the flooring was found to be in good repair despite flooding.

The complaint was substantiated regarding failure to prevent flooding due to door gaps and missing weather stripping. The complaint regarding flooring repair was unsubstantiated. The investigation was conducted by Licensing Program Analyst Sarah Hurt with interviews including Administrator Shelly Ramos and Maintenance staff Eric Farley.

The inspection was an unannounced complaint investigation visit conducted in response to allegations that facility staff did not ensure the facility was odorless at all times and that the facility carpet was not in good clean condition.

The investigation found no visible stains on the carpet and no abnormal odors. The General Manager confirmed that any stains were from a resident's incontinent dog, which has since moved out. Maintenance staff cleaned the spots promptly, and a housekeeping schedule was submitted. The allegations were unsubstantiated and no deficiencies were issued.

The complaint was unsubstantiated as there was not a preponderance of evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-09-26 regarding questionable death and other allegations at the facility.

The investigation found that the allegations were substantiated. Facility staff failed to seek timely medical care for a resident, did not report resident incidents to responsible parties, did not safeguard resident's personal belongings, and failed to ensure the resident was properly dressed. The facility is subject to citations and potential civil penalties.

The complaint investigation was triggered by allegations including questionable death, failure to seek timely medical care, failure to report incidents to appropriate parties, failure to safeguard personal belongings, and failure to ensure proper dressing of a resident. The investigation substantiated these allegations based on interviews and record reviews.

An unannounced complaint investigation visit was conducted in response to an allegation that staff yelled at a resident.

The investigation included record reviews and interviews with staff, residents, and the administrator. The allegation was found to be unsubstantiated due to lack of preponderance of evidence, and no deficiencies were issued.

The complaint alleged that staff yelled at a resident. After investigation, the allegation was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-12-05 regarding resident care concerns including soiled diapers, call bell response, unmet resident needs, and inadequate food service.

After reviewing records and conducting interviews with staff, residents, and the facility administrator, no preponderance of evidence was found to substantiate the allegations. Residents reported their needs were met, staff responded to call pendants, and no concerns were found with food service. No deficiencies were issued.

The complaint investigation was unsubstantiated based on the evidence reviewed and interviews conducted. Allegations included residents left in soiled diapers, untimely call bell response, unmet resident needs, and inadequate food service, none of which were substantiated.

An unannounced complaint investigation visit was conducted to investigate the allegation that the facility elevator is in disrepair.

The Department reviewed records, interviewed the General Manager, toured the facility, and checked the elevator status. The elevator repair service date was anticipated to be 2025-02-14. Residents used stairwells and evacuation chairs assisted by staff. The allegation was unsubstantiated and no deficiencies were issued.

The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.

An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff do not treat residents with dignity or respect.

Based on records review and interviews with staff, residents, and the Administrator, all staff completed training on residents' personal rights and there was no preponderance of evidence to substantiate the allegation. The complaint was determined to be unsubstantiated and no deficiencies were issued.

The complaint alleged that staff do not treat residents with dignity or respect. The investigation found no evidence to support this allegation, resulting in an unsubstantiated finding.

A case management visit was conducted to follow up and confirm details of an incident report regarding a resident (R1) being given medications after their expiration dates multiple times.

The investigation found that R1 was given expired medications for 3 days, posing an immediate health and safety risk. The facility completed medication training with staff and submitted a completion sheet to the licensing department. A citation was issued related to this medication violation.

The visit was complaint-related, triggered by an incident report received by the Department concerning expired medications given to resident R1. The citation was issued based on substantiated findings.

The visit was conducted to return a resident's file that was obtained on 9/30/24 and to meet with the facility administrator for this purpose.

The Licensing Program Analyst returned the resident's file to the administrator and conducted an exit interview. No deficiencies or violations were noted in the report.

During a complaint visit, a Case Management Health & Safety check was conducted by Licensing Program Analyst K. McClurg with assistance from Administrator Pamela Mazon.

The facility was toured and found to have a comfortable temperature, sufficient furnishings, adequate lighting, and was clean with no unpleasant odors. Passageways were clear, fire extinguishers and detectors were present and operational, and residents appeared groomed and appropriately dressed. No health and safety concerns were observed during the visit.

Complaint visit with a Case Management Health & Safety check conducted; no health and safety concerns observed.

The visit was an unannounced annual inspection conducted by Licensing Program Analysts to evaluate compliance with regulations at the facility.

The facility was generally clean, well-furnished, and maintained at a comfortable temperature with no fire hazards observed. However, deficiencies were cited related to medication administration not following physician directions, unlocked medications accessible to residents, and unlocked tools and knives accessible to residents, all posing immediate health and safety risks.

The inspection was an unannounced complaint investigation visit triggered by complaints received on 2023-10-09 regarding staff not ensuring residents' rooms are free of malodors, overcharging residents for services not provided, and failure to remove soiled linens from residents' rooms.

The investigation found the allegations of malodors and overcharging to be unfounded, with evidence showing proper notification of rate changes and no malodors except during incontinence. The allegation regarding removal of soiled linens was unsubstantiated due to insufficient evidence.

The complaint investigation was conducted by Licensing Program Analyst Les Xiong. The allegations included staff not ensuring residents' rooms are free of malodors, overcharging residents for services not provided, and failure to remove soiled linens. The first two allegations were found to be unfounded, and the third was unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced required annual inspection conducted by the Licensing Program Analyst to assess compliance with regulatory standards.

The facility was generally clean, well-maintained, and properly stocked with food and PPE supplies. However, multiple cleaning chemicals and knives were observed stored unlocked in areas accessible to residents, posing an immediate health and safety risk.

This was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-22 regarding multiple allegations about the facility's care and operations.

The investigation found all allegations unsubstantiated based on interviews, observations, and record reviews conducted on 2023-03-29. No citations were issued during this visit.

The complaint included allegations that staff do not ensure residents' needs are met, facility food services are inadequate, staff do not keep residents' rooms clean, and the licensee did not provide a notice of fee increase with a general description of additional costs. All allegations were found unsubstantiated due to lack of preponderance of evidence.

The inspection visit was an unannounced complaint investigation conducted in response to an allegation of neglect or lack of care and/or supervision resulting in injury to a resident.

The investigation found that it could not be proven or disproven that the facility's lack of care or neglect of supervision resulted in injury to the resident. The allegation was determined to be unsubstantiated and no deficiencies were issued.

The complaint was unsubstantiated due to lack of preponderance of evidence to prove the alleged violation occurred.

The visit was an unannounced annual inspection focused on infection control conducted by the Licensing Program Analyst.

The facility was observed to maintain proper infection control measures including facial coverings, social distancing, and adequate PPE supplies. No deficiencies were issued during this inspection.

The inspection was an unannounced complaint investigation visit triggered by allegations that the facility failed to seek timely medical attention for a resident resulting in serious injury and failed to report a change in resident condition to the responsible party.

The investigation found that it could not be proven or disproven that the facility failed to seek medical attention or notify the responsible party regarding the resident's condition change. Staff did seek immediate medical attention and notified the responsible party when a strong odor in the resident's urine was observed. The allegations were unsubstantiated and no deficiencies were issued.

The complaint was unsubstantiated based on interviews and medical record reviews. There was no preponderance of evidence to prove or disprove the alleged violations.

An unannounced complaint investigation was conducted due to an allegation that a resident sustained a fall while in care.

The investigation found that the resident fell but did not report it to facility staff, and there were no reported falls in October 2021. The resident was admitted to the hospital for cellulitis unrelated to a fall. The complaint was determined to be unfounded and dismissed.

Complaint was regarding a resident sustaining a fall while in care. The complaint was found to be unfounded after investigation including interviews and record review.

An Annual Inspection was conducted as a required 1-year unannounced visit to evaluate the facility's compliance and conditions.

The facility was found clean with no obstructions or fire clearance issues. COVID-19 guidelines were observed, including visitor screening and mask use. Medication, food, cleaning, and PPE supplies were adequate. Ten percent of bedrooms and staff records were reviewed. No deficiencies were observed, but technical advisory notes were provided regarding COVID-19 precautions.

An Annual Inspection was conducted as a required 1-year unannounced visit to evaluate compliance with licensing regulations and COVID-19 guidelines.

The facility was found clean with no obstructions or fire clearance issues. Infection control measures including mask use, social distancing, and hand hygiene were observed. No deficiencies were noted during the inspection, though technical advisory notes were provided regarding COVID-19 precautions and N95 respirator fit testing.

The visit was conducted as a Case Management follow-up on an incident report submitted regarding a theft of money from a resident's apartment by facility staff.

No deficiencies were issued during this unannounced telephone visit. The Licensing Program Analyst requested submission of resident records and video evidence related to the incident.

The visit was triggered by a complaint of money stolen from resident R1's apartment by facility staff on 03/24/2021.