Inspection Reports for
Orchard View Manor

The complaint investigation was substantiated. The roof was leaking and a large laundry cart and wastebasket were full of dirty water. The leaking water caused damage and safety risks, leading to evacuation of residents and a fire watch due to tampering with the fire panel.

The facility failed to provide a safe, functional, sanitary, and comfortable environment due to active water leaks from the roof penetrating ceiling tiles and electrical fixtures, causing hazardous conditions and necessitating evacuation of 125 residents. The fire panel was tampered with, leading to a fire watch and evacuation orders.

The complaint investigation was substantiated. The complaint involved roof leaks and water damage causing unsafe conditions, confirmed by surveyor observations and staff interviews.

The facility failed to provide a safe, functional, sanitary, and comfortable environment due to active water leaks from the roof penetrating ceiling tiles and electrical fixtures, causing hazardous conditions and compromising life safety systems. This resulted in an emergency evacuation of 125 residents.

The complaint was submitted on 1/22/2026 alleging roof leaks and unsafe water accumulation in resident areas. The complaint was substantiated as the inspection confirmed active leaks, hazardous conditions, and compromised fire safety systems leading to evacuation.

The facility failed to maintain a safe, functional, sanitary, and comfortable environment due to active water leaks from the roof penetrating ceiling tiles and electrical fixtures on the second floor. These conditions caused slippery floors, water pooling in hallways accessible to cognitively impaired residents, and infiltration of the fire alarm panel, resulting in an evacuation directed by the Rhode Island Department of Health.

The complaint investigation was substantiated. The complaint alleged improper storage and disposal of biohazardous waste and garbage blocking exit routes. The facility was found noncompliant with multiple regulatory requirements, including infection control and safety hazards.

The facility was found to have immediate jeopardy related to failure to maintain an effective infection prevention and control program, improper storage and disposal of biohazardous waste and sharps, accumulation of garbage blocking exit routes, and failure to maintain emergency preparedness and fire safety systems. Corrective actions and audits were planned and initiated.

The complaint investigation was initiated based on a community-reported complaint submitted to the Rhode Island Department of Health on 1/7/2026 alleging biohazardous waste and trash blocking exit routes and other safety hazards. The complaint was substantiated with findings of unsecured biohazardous waste, accumulation of garbage blocking exits, and failure of the governing body to ensure proper waste management.

The facility was found to have immediate jeopardy deficiencies related to infection prevention and control, specifically failure to maintain safe storage and disposal of biohazardous waste and sharps, resulting in hazardous conditions on four units. Additional deficiencies included improper disposal and accumulation of garbage blocking exit routes, failure of the governing body to ensure oversight of waste management, and failure to maintain an effective infection prevention and control program. The facility also failed to maintain proper emergency preparedness documentation and fire safety systems.

The complaint alleged that trash and biohazardous waste were blocking the entire back side/entrance of the facility and that biohazardous waste was stored in unlocked and unsecured rooms. The complaint was submitted to the Rhode Island Department of Health on 2026-01-07.

The facility failed to ensure biohazardous waste and sharps were securely stored and properly disposed of, resulting in unsecured, overflowing biohazardous waste and sharps containers accessible to residents on multiple units, including a secured memory care unit. Additionally, garbage accumulated at the back of the facility blocked exit routes, posing immediate hazards to resident safety. These failures were linked to non-payment issues causing suspension of contracted waste removal services.

The complaint investigation was substantiated based on findings that the facility failed to meet quality of care requirements related to a resident fall incident on 09/19/2025, including inadequate assessment, documentation, and notification.

The investigation found that the facility failed to provide appropriate treatment and services for a resident who sustained a fall, including inadequate documentation of the fall, delayed notification to the physician, and failure to complete required assessments and monitoring post-fall.

The complaint investigation was substantiated. The resident fell on 9/19/2025, but the fall was not documented or assessed by staff. The provider was not notified until the resident exhibited severe pain two days later.

The facility failed to document the resident's fall, conduct required assessments including vital signs and neurological checks, monitor the resident for 72 hours post-fall, and notify the provider in a timely manner. The resident sustained a spinal fracture and experienced severe pain two days after the fall.

The complaint investigation was based on intake ID references 2617672 and 2613179. The investigation found that Resident #1 and Resident #3, both diagnosed with CKD and receiving dialysis three times a week, had issues with medication administration and fluid restriction compliance related to Sevelamer Carbonate. The Director of Nursing was unable to provide evidence that fluid restrictions and medication administration orders were consistently followed.

A deficiency was identified related to dialysis care, specifically that the facility failed to ensure residents requiring dialysis received services consistent with professional standards of practice and their care plans. Documentation and medication administration for Sevelamer Carbonate were not consistently followed for two residents.

The facility failed to ensure that residents requiring dialysis received Sevelamer Carbonate as ordered and that their fluid restrictions were followed. Documentation showed multiple missed doses of medication and residents exceeding fluid intake limits.

The visit was triggered by a complaint investigation (intake ID reference numbers 2587830 and 2581543) regarding failure to provide timely diagnostic x-ray services to a resident who sustained a fall and was admitted to the hospital with a hip fracture.

The facility failed to provide timely diagnostic x-ray services for a resident, resulting in delayed diagnosis and treatment. The nursing staff received in-service education on diagnostic services policy, and corrective actions include auditing STAT x-ray orders and ensuring timely completion of orders.

The facility failed to provide or obtain a STAT X-ray in a timely manner for Resident ID #1 after an unwitnessed fall, resulting in prolonged pain and hospitalization. The delay was attributed to issues with the contracted radiology service and lack of timely notification to the provider.

The facility was found not in compliance with life safety code regulations, including issues with self-closing doors and the emergency power supply system generator maintenance and testing. Deficiencies were identified related to fire rated cross corridor doors not closing and latching properly, and failure to document generator load testing to meet required standards.

The facility was found not to be in compliance with all regulations surveyed. Deficiencies included doors with self-closing devices that did not close and latch properly, and failure to maintain the Emergency Power Supply System (EPSS) generator according to required standards.

The investigation was complaint-driven, focusing on medication errors related to methadone administration for Resident ID #330. The complaint was substantiated with findings of actual harm.

The facility failed to ensure that a resident received the correct methadone dosage as ordered, resulting in withdrawal symptoms and increased pain. The methadone order was transcribed incorrectly, and the resident was not monitored for withdrawal symptoms as expected.

Deficiencies were identified related to accident hazards with loose shower safety rails, pain management issues including medication reconciliation and monitoring, food safety violations including unlabeled and undated food items, infection control breaches, life safety code violations including doors with self-closing device failures, unsecured handrails, pest control program deficiencies, and maintenance issues with fire alarm systems and emergency power supply.

The facility was found deficient in multiple areas including unsafe shower safety rails, inadequate pain management and medication errors related to methadone dosing, failure to maintain food safety standards, lapses in infection control practices, overdue kitchen exhaust hood cleaning, unsecured handrails in hallways, and ineffective pest control resulting in presence of ants and cockroaches.

The facility failed to follow a physician's order for daily weights, did not provide a prescribed therapeutic diet, failed to maintain accurate medical records for fluid restriction, and had a cracked glass panel on the facility's entrance door.

The visit was complaint-related with ACTS reference numbers 100196, 100223, 100172, and 100146. The complaint survey identified multiple deficiencies as described in the findings.

Deficiencies were identified related to failure to meet professional standards of quality in comprehensive care plans, failure to provide therapeutic diets and fluid restrictions as ordered by physicians, failure to maintain accurate and complete resident medical records, and failure to maintain a safe, functional environment due to a cracked glass door panel.

The complaint was submitted on 2025-03-24 alleging 23 residents lacked functioning call lights and used hand bells instead. The complaint was substantiated by surveyor observations, record reviews, and staff interviews confirming the ongoing issue.

The facility failed to provide a working call system in residents' rooms and bathing areas, affecting 21 residents across all four units. The call light system has been broken for months, with replacement parts discontinued and no evidence of repair work underway.

The complaint investigation was substantiated, revealing that 23 residents lacked functioning call lights and used hand bells as an alternative. Multiple staff interviews confirmed the ongoing issue and safety concerns.

The facility was found to have inadequate resident call systems, with approximately 30 residents lacking functioning call lights and using hand bells instead. The issue has been ongoing for months, posing safety concerns, and the call light system requires replacement and repair.

The complaint was submitted on 2024-11-27 alleging the resident fell and experienced increased pain and impaired mobility. The complaint was substantiated by findings that the facility did not obtain all ordered x-rays as required.

The facility failed to obtain all ordered x-rays for a resident after a fall, specifically missing the lateral view of the lumbar spine and the thoracic spine views. This failure delayed diagnosis of two new compression fractures in the resident's back.

The complaint alleged that the resident fell, experienced increased pain, and impaired mobility. The investigation found that the resident was admitted to the hospital with new fractures after incomplete x-rays were obtained and inadequate documentation was provided by the facility.

The facility failed to meet professional standards of quality related to comprehensive care plans and ensuring proper x-ray procedures were followed for a resident. Specifically, the facility did not ensure all ordered x-rays were obtained, and documentation was incomplete, leading to inadequate assessment of the resident's condition.

The facility failed to ensure that a newly admitted resident received prescribed antibiotic treatment as ordered by the physician. The physician's order for Keflex 500 mg twice daily for 2 days was not transcribed or administered.

The complaint survey referenced multiple ACTS numbers and was substantiated by findings that the facility did not follow physician's orders for medication administration for Resident ID #1, a new admission with diagnoses including UTI and dementia.

The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice relative to physician's orders for one resident who was a new admission. Specifically, an antibiotic order (Keflex 500 mg) was not transcribed or administered as ordered.

The investigation was initiated due to a community reported complaint submitted to the Rhode Island Department of Health alleging that Resident ID #1 attempted suicide on 2024-09-07 with a belt around their neck and the family was not informed. The complaint was substantiated with findings of failure to provide adequate supervision and notification.

The survey identified Immediate Jeopardy level deficiencies related to failure to provide 1:1 supervision for a resident who attempted suicide, failure to notify appropriate parties including family and physician, failure to send the resident for psychiatric evaluation, and failure to ensure resident safety and adequate supervision. The facility implemented a corrective action plan and completed in-service training on trauma informed consent and suicide attempt/threat policies.

The complaint alleged that Resident ID #1 attempted suicide on 9/7/2024 by tying a belt around their neck and that the family was not informed. The investigation confirmed failures in supervision, notification, and safety measures.

The facility failed to keep a resident free from neglect after a suicide attempt by not placing the resident on one-to-one supervision, not notifying the physician or family, leaving hazardous items accessible, and allowing the resident to leave the facility unsupervised twice on the same day.

The complaint was received from the Rhode Island Department of Health on 6/27/2024 alleging concerns about Resident ID #1's left lateral lower leg wound status while being evaluated in the Emergency Department of an acute care hospital. The complaint was substantiated based on record reviews and interviews.

The facility failed to provide necessary treatment and services to prevent pressure ulcers for Resident ID #1, who developed an actual pressure injury. The wound physician's recommendations were not implemented timely, resulting in untreated pressure wounds for up to 19 days. Interviews confirmed lack of treatment orders until the surveyor brought attention to the wounds.

The complaint was substantiated based on findings that the resident's wound treatments were not implemented as ordered, leading to untreated pressure injuries.

The facility failed to provide necessary treatment and services to promote wound healing and prevent new pressure ulcers for one resident. Specifically, wound treatment orders recommended by the contracted Wound Physician on 2024-06-11 and 2024-06-18 were not implemented for 12 to 19 days until the surveyor brought this to the facility's attention.

The facility was found deficient in multiple areas including failure to post recent survey results, failure to prevent resident-to-resident abuse, incomplete adherence to physician orders for weekly weights, delayed treatment for deep vein thrombosis, inadequate wound care, failure to communicate critical lab values to dialysis center, incomplete nurse aide performance evaluations, delayed pharmacy recommendation implementation, food safety violations, and lapses in infection prevention and control practices.

The complaint investigation found that Resident ID #45 was assaulted by his/her roommate, Resident ID #81, who bit the resident's face. The incident was substantiated with multiple staff statements, progress notes, and a telehealth evaluation confirming the injury and abuse.

The facility failed to keep Resident ID #45 free from physical abuse by Resident ID #81, who bit Resident ID #45's face. The facility did not provide sufficient protection to prevent the abuse despite known behavioral issues of the alleged perpetrator.

Deficiencies were cited in multiple areas including failure to post survey results in a readily accessible area, failure to keep residents free from abuse, failure to meet professional standards for care plans, failure to obtain weekly weights as ordered, failure to provide treatment and care for residents with deep vein thrombosis, failure to ensure dialysis services met professional standards, failure to complete annual performance reviews for nursing assistants, failure to maintain food safety and sanitation standards, failure to conduct required fire drills, and failure to maintain an infection prevention and control program.

The complaint was substantiated. Resident ID #4 eloped twice successfully from the facility and once from a behavioral health appointment. The facility failed to conduct elopement risk assessments or follow AMA discharge procedures after these incidents.

The facility failed to ensure adequate supervision and assessment of Resident ID #4 who eloped multiple times, did not complete required elopement risk assessments, and did not follow policies for discharge Against Medical Advice (AMA). The resident's care plan lacked interventions for elopement risk despite multiple incidents.

The complaint investigation was substantiated. The facility failed to provide adequate supervision and failed to report elopements involving Resident ID #4, resulting in immediate jeopardy findings.

The facility failed to provide adequate supervision to prevent elopements for Resident ID #4, who eloped multiple times resulting in hospital transfers. The facility also failed to assess the resident's elopement risk and implement interventions. Additionally, the facility failed to report elopements to the licensing agency within required timeframes and did not follow their own policies related to elopements and AMA discharges.

The complaint investigation survey reference number 94385 was conducted to assess compliance with baseline care planning and quality of care requirements. Findings substantiated that baseline care plans were not completed timely for residents #1, #2, and #3, and that the facility failed to promptly identify and intervene in a resident's acute condition change related to a fall.

The facility failed to develop and implement baseline care plans within 48 hours of admission for 3 residents reviewed, and failed to promptly identify and intervene during an acute change in a resident's condition related to a fall. Deficiencies were found in comprehensive person-centered care planning and quality of care.

The complaint investigation found substantiated deficiencies related to failure to develop baseline care plans for three residents and failure to promptly identify and intervene during a resident's acute change in condition after a fall.

The facility failed to develop and implement baseline care plans within 48 hours of admission for 3 residents. Additionally, the facility failed to promptly identify and intervene during an acute change in condition related to a mental status change and fall for one resident, resulting in actual harm.

The complaint alleged that nursing staff failed to assist a resident's roommate who had woken up hungry, and staff did not save or wake the resident to eat dinner. The investigation found the resident required extensive assistance with eating, and staff did not provide adequate feeding assistance or document meal intake accurately.

Deficiencies were identified related to Resident Rights and Resident Records. The facility failed to treat a hospice resident with respect and dignity during assistance with eating, and failed to maintain accurate medical records for the resident's breakfast meal intake.

The complaint alleged that nursing staff did not wake a resident who was sleeping when dinner was served and failed to save or assist with the meal. The complaint was substantiated based on surveyor observations, record review, and staff interviews.

The facility failed to assist a hospice resident with eating during meals and did not maintain accurate medical records regarding the resident's meal intake. Staff were observed not providing adequate assistance and documentation was inconsistent with observed facts.

The complaint investigation was substantiated with findings that the facility did not provide adequate supervision and assistance devices to prevent accidents, specifically for Resident ID #1 who fell out of bed on 12/2/2023.

The facility failed to ensure a resident's environment was free of accident hazards, resulting in a resident falling out of bed due to inadequate assistance and mattress air deflation. The resident required assistance of two staff members for bed mobility, but care plans and documentation did not clearly reflect this need.

The complaint investigation was substantiated. The resident fell out of bed on 12/2/2023 while being assisted by a single CNA instead of the required two staff members. Interviews with staff and the Director of Nursing confirmed the resident's need for two-person assistance and acknowledged the failure to provide it.

The facility failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision, resulting in a resident falling out of bed. The resident required extensive assistance for bed mobility, but was assisted by only one staff member, leading to the fall.

The complaint was submitted on 2023-11-05 alleging the resident was not being washed well and certain areas were rarely washed. The complaint was substantiated based on surveyor observations, record reviews, and interviews.

The facility failed to ensure that a resident dependent on staff for bathing received necessary showering and hygiene care, resulting in skin excoriation and unclean appearance. The facility's Quality Assurance plan to audit weekly showers was discontinued without evidence of compliance, and documentation of showers was missing for a month.

The complaint alleged that a resident was not being washed well and certain areas were rarely being washed. The complaint was investigated and deficiencies were cited based on observations, record reviews, and staff interviews.

The survey found deficiencies related to failure to provide necessary ADL care, specifically showers, to a resident unable to carry out activities of daily living. Documentation and evidence showed the resident did not receive showers regularly from 9/28/2023 to 10/28/2023, and staff failed to complete weekly shower audits as required.

The complaint involved an alleged unwitnessed head first fall from bed on 10/26/23 resulting in head laceration, loss of consciousness, and hospitalization. The facility did not report the incident to the Rhode Island Department of Health as required.

The facility failed to report an accident resulting in hospitalization for two residents within the required timeframe. A resident was admitted to the hospital with injuries from a fall that was not reported to the Rhode Island Department of Health as required. The Director of Nursing acknowledged the failure to report the incident.

The facility was found deficient in multiple areas including medication management, resident assessments, professional standards of care, infection control, food safety, and trauma-informed care. Several residents experienced inadequate supervision, improper medication handling, failure to follow physician orders, and unsafe infection control practices.

The survey identified multiple deficiencies including failures in medication self-administration, accuracy of assessments, services provided meeting professional standards, infection control, emergency preparedness, and life safety code compliance. Immediate Jeopardy was identified but removed after corrective actions. The facility failed to ensure proper treatment, care, and documentation in several areas affecting resident safety and quality of care.

The complaint was submitted to the Rhode Island Department of Health on 5/1/2023 alleging improper bed hold notification and resident relocation. The complaint was substantiated by record review and staff interviews.

The facility failed to provide written notice of its bed hold policy to Resident ID #3 or their representative before hospital transfers on 2/2/2023 and 4/18/2023. Staff interviews confirmed lack of awareness and absence of evidence of such notification.

The facility was found deficient in multiple areas including failure to provide appropriate pressure ulcer care, inadequate catheter care leading to urinary tract infections, failure to maintain residents' nutritional status, significant medication administration errors, delays in timely laboratory reporting, and failure to implement infection prevention and control measures for residents on contact precautions.

The complaint was substantiated based on record review and staff interviews indicating that CNAs did not clean residents well and residents did not receive showers as scheduled.

Deficiencies were cited related to failure to provide reasonable accommodation of resident needs and preferences for showers, and failure to develop and implement comprehensive person-centered care plans for residents requiring mechanical lifts and Hoyer lifts. Interviews and record reviews revealed residents did not receive showers as scheduled and care plans did not reflect safe transfer methods using Hoyer lifts.

The complaint was substantiated as the facility failed to ensure a resident received his/her ordered afternoon Clonazepam doses from 10/14/2022 through 11/10/2022, totaling 28 missed doses. The Director of Nursing was unable to provide evidence that the doses were administered as ordered.

Deficiencies were cited related to failure to ensure residents were free from significant medication errors, specifically that one resident did not receive 28 ordered afternoon doses of Clonazepam as documented in medication administration records and hospital discharge orders.

Complaint investigation ACTS Reference Numbers 87195, 87188, 87190, 87194 survey was conducted. State deficiencies were identified.

A state deficiency was identified related to dietetic services where the facility continued to serve resident meals on dinnerware that was not of good quality, specifically using 6-ounce Styrofoam cups and 5-ounce plastic cups instead of durable and aesthetically pleasing materials.

The investigation was conducted following complaint reference numbers 86345 and 86354. The deficiency was substantiated based on observations and staff interviews confirming the use of Styrofoam plates and plastic utensils during meal service.

A state deficiency was identified related to the facility's failure to serve resident meals on dinnerware of good quality, specifically the use of Styrofoam plates and plastic silverware instead of durable and aesthetically pleasing materials. The dietary department was found to be using Styrofoam plates and plastic utensils regularly, substituting them when dinnerware ran out.

Multiple deficiencies were cited related to professional standards of care, accident hazards and supervision, nutrition and hydration maintenance, respiratory care, oxygen administration, food safety, and environmental conditions. The facility failed to meet several regulatory requirements as evidenced by record reviews, staff interviews, and observations.

The investigation was complaint-driven, referenced as ACTS Reference Number 82579. The complaint was substantiated as deficiencies were cited related to treatment and services for mental/psychosocial concerns.

The facility failed to ensure that a resident with mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Deficiencies were cited related to treatment and services for mental/psychosocial concerns.

The facility was determined to not be in compliance with the requirements and deficiencies were identified related to tube feeding management, medication labeling and storage, and infection prevention and control practices including PPE use and hand hygiene.

The facility was found not to be in compliance with 42 CFR §483.80 Infection Control regulations, specifically failing to ensure staff utilized personal protective equipment (PPE) properly and residents practiced social distancing.