Inspection Reports for Orchard View Rehabilitation & Skilled Nursing Center
8414 Whitesville Rd, Columbus, GA 31904, United States, GA, 31904
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 8, 2025, included a routine survey that cited deficiencies related to incomplete Minimum Data Set assessments and missing physician orders for restraint use for two residents. Earlier inspections showed a mixed pattern with prior deficiencies involving resident care issues such as failure to investigate injuries, medication storage, and care plan adherence, as well as fire safety code violations. Complaint investigations were mostly unsubstantiated or substantiated without deficiencies, except for one substantiated complaint in 2021 involving failure to notify a physician of abnormal vital signs that resulted in resident death, which led to immediate jeopardy findings and corrective actions. No fines, license suspensions, or enforcement actions were listed in the available reports. The facility’s recent survey results suggest ongoing challenges with documentation and resident care compliance, though some prior deficiencies have been corrected over time.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
58% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Life Safety
Census: 115
Capacity: 200
Deficiencies: 0
Date: Jun 8, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Report Facts
Certified beds: 200
Census: 115
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 8, 2025
Visit Reason
The visit was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements at Orchard View Rehabilitation & Skilled Nursing Center.
Findings
No State Health deficiencies were cited during the survey conducted from June 6 through June 8, 2025.
Inspection Report
Routine
Census: 115
Deficiencies: 2
Date: Jun 8, 2025
Visit Reason
A standard survey was conducted from June 6, 2025 through June 8, 2025, including investigation of multiple complaint intake numbers, some substantiated without deficiencies and others unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00253451, GA00251942 and GA00254518 were substantiated without deficiencies. Complaint Intake Numbers GA00245386 and GA00253501 were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to failure to complete accurate Minimum Data Set (MDS) assessments indicating use of alarms for two residents and failure to ensure physician orders for restraint use for the same residents.
Deficiencies (2)
Failure to complete an accurate Minimum Data Set (MDS) assessment indicating the use of an alarm for two residents (R2 and R108).
Failure to ensure two residents (R2 and R108) had a physician order for restraint use.
Report Facts
Complaint Intake Numbers investigated: 5
Residents observed with alarm use issues: 2
Census: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Confirmed alarms attached to residents' wheelchairs were to alert staff if the resident falls. |
| BB | Minimum Data Set (MDS) Coordinator | Revealed that alarms should be included in Section P on the MDS indicator and care plans developed accordingly. |
| CC | Minimum Data Set (MDS) Coordinator | Revealed that alarms should be included in Section P on the MDS indicator and care plans developed accordingly. |
| Unknown | Director of Nursing (DON) | Confirmed alarms were used as preventive intervention for falls and that alarms for residents R2 and R108 were not indicated on their MDS assessments. |
| Unknown | Administrator | Stated alarms were used to reduce risk of falls and was not aware residents needed orders for alarms; plans to work on QAPI to eliminate alarms. |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and restraint use, specifically focusing on the accuracy of Minimum Data Set (MDS) assessments and the presence of physician orders for alarms and restraints for residents.
Findings
The facility failed to complete accurate MDS assessments indicating the use of alarms for two residents (R2 and R108). Both residents had alarms attached to their wheelchairs without physician orders documented. The facility also failed to ensure physician orders for restraint use for these residents. Interviews confirmed alarms were used as fall prevention but were not properly documented in the MDS or physician orders.
Deficiencies (2)
Failure to complete an accurate Minimum Data Set (MDS) assessment indicating the use of alarms for two residents.
Failure to ensure two residents had physician orders for restraint use.
Report Facts
Residents affected: 2
BIMS score for R2: 3
BIMS score for R108: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Confirmed alarms on residents' wheelchairs were to alert staff if the resident falls |
| BB | Minimum Data Set (MDS) Coordinator | Revealed that alarms should be included in Section P on the MDS indicator |
| CC | Minimum Data Set (MDS) Coordinator | Revealed that alarms should be included in Section P on the MDS indicator |
| Director of Nursing (DON) | Confirmed alarms were used as preventive intervention for falls and were not indicated on MDS | |
| Administrator | Stated alarms were used to reduce risk of falls and planned to work on a QAPI plan to eliminate alarms |
Inspection Report
Routine
Deficiencies: 2
Date: Jun 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, use of alarms, and restraint orders at Orchard View Rehabilitation & Skilled Nursing Center.
Findings
The facility failed to complete accurate Minimum Data Set (MDS) assessments indicating the use of alarms for two residents (R2 and R108). Both residents had alarms attached to their wheelchairs without physician orders or proper documentation in the MDS. The facility also failed to ensure physician orders for restraint use for these residents. Interviews confirmed alarms were used as fall prevention but were not properly ordered or documented.
Deficiencies (2)
Failure to complete an accurate Minimum Data Set (MDS) assessment indicating the use of alarms for residents R2 and R108.
Failure to ensure physician orders for restraint use for residents R2 and R108.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Confirmed alarms on wheelchairs were to alert staff if residents fall |
| BB | Minimum Data Set (MDS) Coordinator | Revealed alarm use should be included in Section P of MDS |
| CC | Minimum Data Set (MDS) Coordinator | Revealed alarm use should be included in Section P of MDS |
| Director of Nursing (DON) | Confirmed alarms were used as fall prevention and not indicated on MDS | |
| Administrator | Stated alarms were used to reduce fall risk and planned to work on QAPI plan to eliminate alarms |
Inspection Report
Deficiencies: 0
Date: Apr 10, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Orchard View Rehabilitation & Skilled Nursing Center, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 128
Deficiencies: 0
Date: Apr 10, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 15, 2024 Recertification Survey.
Findings
All deficiencies cited in the prior February 15, 2024 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
A Life Safety Code revisit was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags related to Life Safety Code have been corrected.
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 3
Date: Feb 15, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and investigate an injury of unknown origin sustained by Resident 31, as well as concerns about medication storage practices.
Complaint Details
The complaint investigation involved Resident 31 who sustained a fracture to the right distal fibula of unknown origin. The facility did not report the injury as required and failed to conduct an investigation. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed lack of knowledge about how the injury occurred and failure to report or investigate.
Findings
The facility failed to report an injury of unknown origin for Resident 31 to the proper authorities within the required timeframe and did not conduct a thorough investigation into the injury. Additionally, the facility failed to store medications in a locked compartment when unattended for one of five treatment carts.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or injury of unknown origin to proper authorities for one resident.
Failed to investigate an allegation of injury of unknown origin for one resident.
Failed to store medications in a locked compartment when unattended for one of five treatment carts.
Report Facts
Facility census: 128
Sample size: 24
Treatment carts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Occupational Therapist Licensed (OT/L) | Reported being unaware of how Resident 31 received the fracture and documented findings to Therapy Director |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding failure to report injury and investigation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Observed leaving treatment cart unlocked and interviewed about injury and medication storage |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a State Licensure survey to determine compliance with the State Long Term Care Requirements at Orchard View Rehabilitation and Skilled Nursing Center.
Findings
The facility failed to investigate an allegation of injury of unknown origin for one resident (R31), specifically a fracture to the right distal fibula. Interviews with staff confirmed no thorough investigation was conducted regarding the injury.
Deficiencies (1)
Failure to investigate an allegation of injury of unknown origin for one resident (R31) with a fracture to the right distal fibula.
Report Facts
Sample size: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EE | Occupational Therapist Licensed (OT/L) | Reported being unaware of how R31 received the fracture and documented findings to the Therapy Director |
| Director of Nursing (DON) | Interviewed and revealed no thorough investigation was conducted into how R31 received the fracture |
Inspection Report
Routine
Census: 128
Deficiencies: 3
Date: Feb 15, 2024
Visit Reason
A standard survey was conducted from February 13, 2024, through February 15, 2024, including investigation of multiple complaint intake numbers, to assess compliance with Medicare/Medicaid regulations for Orchard View Rehabilitation and Skilled Nursing Center.
Complaint Details
Complaint Intake Numbers GA00232428 and GA00231948 were unsubstantiated. Complaint Intake Numbers GA00241418 and GA00238211 were substantiated with no deficiencies.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to report and investigate an injury of unknown origin for one resident, and failure to store medications securely in a locked compartment when unattended.
Deficiencies (3)
Failure to ensure an injury of unknown origin was reported to proper authorities immediately for one resident.
Failure to investigate an allegation of injury of unknown origin for one resident.
Failure to store medications in a locked compartment when unattended for one of five treatment carts.
Report Facts
Complaint Intake Numbers investigated: 4
Facility census: 128
Sample size: 24
Treatment carts observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported inability to confirm how resident received fracture and confirmed treatment carts should be locked when unattended |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Observed leaving treatment cart unlocked with medications inside and interviewed regarding medication storage |
| Occupational Therapist Licensed EE | Occupational Therapist Licensed (OT/L) | Reported being unaware of how resident received fracture and documented resident's pain |
Inspection Report
Life Safety
Census: 126
Capacity: 200
Deficiencies: 4
Date: Feb 14, 2024
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including failure to protect the fire alarm circuit breaker, lack of sprinkler system coverage at the outdoor loading dock, failure to maintain fire sprinkler system gauges, and use of oversized soiled linen and trash containers exceeding code limits.
Deficiencies (4)
Failed to protect the fire alarm circuit breaker with a lock to prevent power shut off.
Failed to provide sprinkler system coverage for the outdoor loading dock area.
Failed to maintain water pressure gauges to the fire sprinkler system; gauges were outdated beyond their 5-year replacement life.
Failed to maintain proper size trash/soiled linen collection receptacles; containers exceeded the 32-gallon capacity limit.
Report Facts
Census: 126
Total Capacity: 200
Fire sprinkler gauges: 3
Residents affected by sprinkler deficiency: 50
Staff affected by sprinkler deficiency: 10
Trash/linen container capacity: 119
Trash/linen container capacity: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Orchard View Rehabilitation & Skilled Nursing Center following a survey completed on 07/26/2022.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 128
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited during the Recertification Survey concluded on May 26, 2022.
Findings
All deficiencies cited as a result of the Recertification Survey were found to be corrected.
Inspection Report
Life Safety
Census: 122
Capacity: 200
Deficiencies: 0
Date: May 31, 2022
Visit Reason
The visit was conducted as a Life Safety Code Survey to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found to be in substantial compliance with the requirements set forth in 42 CFR § 483.73 and the NFPA 101 Life Safety Code 2012 Edition.
Report Facts
Census: 122
Total Capacity: 200
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 26, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, and facility operations at Orchard View Rehabilitation & Skilled Nursing Center.
Findings
The facility was found deficient in multiple areas including failure to maintain call lights within residents' reach, failure to notify physicians and responsible parties of hypoglycemic events, failure to follow care plans for residents regarding hypoglycemia and oxygen therapy, failure to provide appropriate treatment for a skin tear, failure to provide oxygen according to physician's orders, and failure to provide therapy-recommended adaptive feeding devices to a resident.
Deficiencies (6)
Failed to ensure call light was maintained within reach of resident #47.
Failed to notify physician and responsible party following two hypoglycemic events for resident #33.
Failed to ensure staff followed care plans for residents #33 (hypoglycemia) and #52 (oxygen usage).
Failed to assess and provide treatment for a skin tear for resident #105 according to wound care guidelines.
Failed to provide oxygen according to physician's orders for resident #52 (oxygen set at 5 liters instead of 4 liters).
Failed to provide therapy-recommended right-angled silverware for resident #32 during meals.
Report Facts
Residents sampled: 25
Blood sugar readings: 30
Blood sugar readings: 35
Blood sugar readings: 28
Blood sugar readings: 228
Oxygen liter flow: 4
Oxygen liter flow: 5
BIMS score: 4
BIMS score: 15
BIMS score: 15
BIMS score: 11
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RR | Certified Nursing Assistant (CNA) | Interviewed regarding call light placement for resident #47 |
| HH | Licensed Practical Nurse (LPN) | Interviewed regarding call light placement for resident #47 |
| OO | Restorative Certified Nursing Assistant (CNA) | Interviewed regarding call light placement for resident #47 |
| NN | Unit Manager (UM) | Wrote nurse note on hypoglycemic event for resident #33 and interviewed about notification procedures |
| MMM | Licensed Practical Nurse (LPN) | Wrote nurse note on hypoglycemic event for resident #33 and unavailable for interview |
| JJJ | Certified Nursing Assistant (CNA) Team Leader | Interviewed regarding adaptive feeding equipment for resident #32 |
| FFF | Registered Dietitian (RD) | Interviewed regarding resident #32's feeding and adaptive equipment |
| GGG | Director of Rehabilitation (DOR) | Interviewed regarding occupational therapy and adaptive equipment for resident #32 |
| KK | Licensed Practical Nurse (LPN) | Interviewed regarding skin tear treatment for resident #105 |
| LL | Unit Manager (UM) | Interviewed regarding skin tear treatment procedures |
| PP | Licensed Practical Nurse (LPN) | Interviewed regarding awareness of skin tear for resident #105 |
| Certified Nursing Assistant (CNA) | Interviewed regarding oxygen therapy for resident #52 | |
| MM | Licensed Practical Nurse (LPN) | Interviewed regarding oxygen therapy for resident #52 |
| SS | Respiratory Therapist | Interviewed regarding oxygen therapy for resident #52 |
| EEE | Registered Nurse (RN) Unit Manager | Interviewed regarding notification procedures and adaptive feeding equipment |
| AA | Dietary Manager (DM) | Interviewed regarding adaptive feeding equipment procedures |
| III | Licensed Practical Nurse (LPN) | Interviewed regarding feeding assistance for resident #32 |
| Administrator | Administrator | Interviewed regarding expectations for call light placement, notification procedures, care plan adherence, oxygen therapy, skin tear treatment, and feeding equipment |
| DON | Director of Nursing | Interviewed regarding expectations for notification, care plan adherence, oxygen therapy, skin tear treatment, and feeding equipment |
Inspection Report
Original Licensing
Deficiencies: 2
Date: May 26, 2022
Visit Reason
A State Licensure survey was conducted at Orchard View Rehabilitation & Skilled Nursing from May 23, 2022 through May 26, 2022 to determine compliance with State Long Term Care Requirements.
Findings
The facility failed to ensure staff followed care plans for two of 25 sampled residents, specifically related to hypoglycemic/hyperglycemic episodes for Resident #33 and oxygen usage for Resident #52.
Deficiencies (2)
Failure to follow care plan for Resident #33 related to hypoglycemic/hyperglycemic episodes, including lack of physician or responsible party notification after low blood sugar events.
Failure to follow care plan for Resident #52 related to oxygen usage, with oxygen set higher than ordered.
Report Facts
Sampled residents: 25
Resident #33 blood sugar readings: 30
Resident #33 blood sugar readings: 35
Resident #33 blood sugar readings: 28
Resident #33 blood sugar readings: 228
Resident #33 BIMS score: 15
Resident #52 BIMS score: 15
Oxygen liters ordered: 4
Oxygen liters observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NN | Unit Manager | Wrote nurse's note regarding Resident #33's blood sugar on 04/03/2022 |
| MMM | Licensed Practical Nurse | Wrote nurse's note regarding Resident #33's blood sugar on 05/24/2022 |
| Director of Nursing | Director of Nursing | Interviewed on 05/26/2022 regarding importance of following care plans |
| Administrator | Administrator | Interviewed on 05/26/2022 regarding expectation for staff to follow care plans |
Inspection Report
Routine
Census: 125
Deficiencies: 6
Date: May 26, 2022
Visit Reason
A standard survey was conducted by CertiSurv on behalf of the Georgia Department of Community Health at Orchard View Rehabilitation and Skilled Nursing Center from May 23, 2022 through May 26, 2022 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to maintain call lights within reach of residents, failure to notify physicians and responsible parties of significant changes such as hypoglycemic events, failure to follow care plans for residents related to hypoglycemia and oxygen therapy, inadequate treatment of a skin tear, and failure to provide adaptive feeding utensils as ordered.
Deficiencies (6)
Resident #47's call light was not maintained within reach despite care plan instructions.
Failure to notify physician and responsible party following two hypoglycemic events for Resident #33.
Failure to follow comprehensive care plans for Residents #33 (hypoglycemia) and #52 (oxygen therapy).
Failure to assess and treat a skin tear on Resident #105's hand according to wound care guidelines.
Resident #52 received oxygen at 5 liters per minute contrary to physician's order for 4 liters per minute.
Resident #32 was not provided with therapy-recommended right-angled silverware for self-feeding as ordered.
Report Facts
Resident census: 125
Blood sugar level: 30
Blood sugar level: 35
Blood sugar level: 28
Oxygen liters per minute: 4
Oxygen liters per minute: 5
BIMS score: 4
BIMS score: 15
BIMS score: 15
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician JJ | Physician | Referenced in hypoglycemia notification deficiency for Resident #33 |
| Unit Manager NN | Unit Manager | Documented hypoglycemia events and notification practices for Resident #33 |
| Licensed Practical Nurse MMM | LPN | Documented hypoglycemia event on 05/24/2022 for Resident #33 |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for call light placement, notification, care plans, and oxygen orders |
| Administrator | Administrator | Interviewed regarding expectations for call light placement, notification, care plans, and adaptive equipment |
| Registered Dietitian FFF | Registered Dietitian | Provided dietary notes and interview regarding Resident #32's feeding needs |
| Director of Rehabilitation GGG | Director of Rehabilitation | Provided interview regarding occupational therapy recommendations for Resident #32 |
| Dietary Manager AA | Dietary Manager | Interviewed regarding kitchen procedures for adaptive equipment |
| Certified Nursing Assistant JJJ | CNA Team Leader | Interviewed regarding awareness of adaptive equipment needs for Resident #32 |
Inspection Report
Abbreviated Survey
Census: 121
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints GA00217738, GA00221418, and GA00223085 from April 11, 2022 through April 19, 2022.
Complaint Details
Complaints GA00217738 and GA00221418 were unsubstantiated. Complaint GA00223085 was substantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with 42 CFR §483.80 Infection Control regulations. Complaints GA00217738 and GA00221418 were unsubstantiated. Complaint GA00223085 was substantiated with no deficiencies cited.
Report Facts
Total census: 121
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00216198.
Complaint Details
Complaint #GA00216198 was investigated and found to be unsubstantiated with no regulatory violations.
Findings
The complaint was unsubstantiated with no regulatory violations found during the survey.
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Date: Apr 28, 2021
Visit Reason
A revisit survey was conducted from April 26, 2021 through April 28, 2021 to verify correction of deficiencies cited in the January 22, 2021 COVID-19 Focused Infection Control Survey.
Findings
All deficiencies cited in the January 22, 2021 COVID-19 Focused Infection Control Survey were found to be corrected during the revisit survey.
Inspection Report
Deficiencies: 0
Date: Apr 28, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Orchard View Rehabilitation & Skilled Nursing Center following a survey completed on April 28, 2021.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 119
Deficiencies: 0
Date: Apr 28, 2021
Visit Reason
A revisit survey was conducted from April 26, 2021 through April 28, 2021 to verify correction of deficiencies cited during the March 10, 2021 Complaint Survey.
Complaint Details
The revisit survey was conducted to verify correction of deficiencies from the March 10, 2021 Complaint Survey.
Findings
All deficiencies cited as a result of the March 10, 2021 Complaint Survey were found to be corrected during this revisit survey.
Report Facts
Census: 119
Inspection Report
Abbreviated Survey
Census: 117
Deficiencies: 0
Date: Mar 10, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00211611, GA00211790, and GA00211804, along with a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaints GA00211611 and GA00211790 were substantiated with no deficiencies cited. Complaint GA00211804 was not substantiated.
Findings
Complaints GA00211611 and GA00211790 were substantiated but no deficiencies were cited. Complaint GA00211804 was not substantiated. The facility was found to be in compliance with infection control regulations and COVID-19 recommended practices.
Report Facts
Resident census: 117
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 4
Date: Mar 10, 2021
Visit Reason
An Abbreviated/Partial Extended Survey investigating complaints GA00211611, GA00211790, and GA00211804 was initiated on 2021-02-03 and concluded on 2021-03-10. Complaints GA00211611 and GA00211790 were substantiated but with no deficiencies cited. Complaint GA00211804 was substantiated with deficiencies cited. A COVID-19 Focused Infection Control Survey was also conducted.
Complaint Details
Complaint GA00211804 was substantiated with deficiencies cited related to failure to notify physician of abnormal vital signs and failure to reassess resident R#4, who expired in the facility. Complaints GA00211611 and GA00211790 were substantiated but with no deficiencies cited.
Findings
The facility failed to ensure that resident R#4's physician was notified of abnormal vital signs obtained by therapy and nursing staff, and failed to reassess the resident after abnormal vital signs were obtained. R#4 was found unresponsive and pronounced dead on 2021-01-19. Immediate Jeopardy was identified related to notification of changes, freedom from abuse and neglect, administration, and quality assessment and assurance. The facility implemented a removal plan including staff education, audits, and policy revisions. The QAA committee failed to meet quarterly but resumed meetings in 2021.
Deficiencies (4)
Failure to notify physician of abnormal vital signs and failure to reassess resident after abnormal vital signs were obtained, resulting in resident death.
Failure to ensure resident was free from neglect and abuse related to failure to notify physician and reassess resident.
Failure to administer facility in a manner that ensures effective management and monitoring of abnormal vital signs and changes in condition.
Failure of Quality Assessment and Assurance committee to meet at least quarterly to identify issues and ensure quality improvement.
Report Facts
Resident census: 117
Resident age: 70
Heart rate: 122
Blood pressure: 88
Blood pressure: 64
Respiratory rate: 53
Oxygen saturation: 87
Blood pressure: 92
Blood pressure: 38
Heart rate: 124
Respiratory rate: 52
Heart rate: 48
Heart rate: 49
Heart rate: 105
Respiratory rate: 33
Oxygen saturation: 92
Resident count: 22
Resident count: 116
Resident count: 41
Resident count: 7
Resident count: 15
Resident count: 4
Staff education completion: 100
Staff education completion: 86
Staff education completion: 92
Staff education completion: 75
Staff education completion: 50
Staff education completion: 69
Staff education completion: 91
Staff education completion: 57
Staff education completion: 83
Staff education completion: 50
Staff education completion: 44
Staff education completion: 52
Resident count: 108
Resident count: 78
Resident count: 44
Resident count: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PT BB | Physical Therapist | Reported abnormal vital signs for resident R#4 to nursing staff on multiple occasions |
| LPN GG | Licensed Practical Nurse | Nurse for R#4 who confirmed being informed of abnormal vital signs but did not notify physician |
| RN Unit Manager AA | Registered Nurse Unit Manager | Notified of resident R#4's condition on 1/19/2021 shift change |
| LPN FF | Licensed Practical Nurse | Documented abnormal vital signs for R#4 on 1/19/2021 but did not notify physician |
| SLP II | Speech Therapist | Reported abnormal vital signs for resident R#4 to nursing staff |
| OT Rehab Manager | Occupational Therapist Rehab Manager | Confirmed reporting vital signs to nursing staff for resident R#4 |
| Physician WW | Physician | Expected to be notified of abnormal vital signs and changes in condition for resident R#4 |
| Administrator | Facility Administrator | Re-educated on oversight responsibilities and monitoring of nursing staff |
| DON | Director of Nursing | Re-educated on oversight responsibilities and monitoring of nursing staff |
| ADON | Assistant Director of Nursing | Assessed resident R#4 on 1/13/2021 and documented concerns |
| Social Services Director | Social Services Director | Provided resident rights education to residents and responsible parties |
| RT RRR | Respiratory Therapist | Conducted oxygen usage audits and communicated with nursing staff |
Inspection Report
Routine
Census: 95
Deficiencies: 3
Date: Jan 22, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and CMS/CDC recommended practices for COVID-19 preparedness.
Findings
The facility was found not to be in compliance with infection control regulations, specifically failing to place a resident with known COVID-19 exposure on droplet precautions and staff failing to wear appropriate PPE on multiple units.
Deficiencies (3)
Failure to place a resident with known COVID-19 exposure on droplet precautions per CDC recommendations.
Staff failed to wear Personal Protective Equipment (PPE) appropriately and in accordance with facility practice for residents on droplet precautions on three of five units.
Social Services Assistant observed not wearing a face mask while at her desk in a hallway.
Report Facts
Total census: 95
Number of sampled residents: 17
Number of units with PPE noncompliance: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Interviewed regarding resident exposure and PPE practices |
| Administrator | Provided information on resident exposure protocols and policy updates | |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed about infection control practices and PPE usage |
| Temporary Nurse Assistant BB | Temporary Nurse Assistant | Observed not wearing PPE properly while assisting resident |
| LPN CC | Licensed Practical Nurse | Interviewed about resident droplet precautions |
| LPN BB | Licensed Practical Nurse | Interviewed about resident condition and symptoms |
| Treatment Nurse (TN) | Treatment Nurse | Observed not wearing eye protection while caring for residents on droplet precautions |
| Social Services Assistant (SSA) | Social Services Assistant | Observed not wearing face mask at desk |
Inspection Report
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction for Orchard View Rehabilitation & Skilled Nursing Center following a survey completed on December 30, 2020.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Dec 30, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the complaint survey conducted on 2020-11-09.
Complaint Details
The revisit survey was conducted following a complaint survey on 2020-11-09; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 11/9/2020 complaint survey were found to be corrected.
Report Facts
Census: 143
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 3, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00209937 and GA00209956.
Complaint Details
Complaints #GA00209937 and GA00209956 were investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaints #GA00209937 and GA00209956 were unsubstantiated with no deficiencies found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 10, 2020
Visit Reason
A licensure survey was conducted to investigate three complaint allegations identified as GA00207754, GA00207406, and GA00208616.
Complaint Details
The investigation of complaints GA00207754, GA00207406, and GA00208616 concluded with all three being unsubstantiated.
Findings
All three complaints were unsubstantiated and no state licensure deficiencies were cited during the investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Nov 10, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 11/5/2020 to 11/9/2020 to investigate three complaint allegations (GA00207754, GA00207406, GA00208616). All complaints were unsubstantiated, but deficiencies unrelated to the complaints were cited.
Complaint Details
The survey investigated three complaints (GA00207754, GA00207406, GA00208616). All were unsubstantiated. The cited deficiencies were not related to these complaints but involved failure to timely report and investigate an abuse allegation for one resident.
Findings
The facility failed to report an allegation of abuse in a timely manner and failed to investigate the allegation promptly for one resident. The abuse allegation involved a resident reporting inappropriate touching by a roommate. The facility delayed reporting to the state and police beyond the required two-hour timeframe. Interviews with staff revealed breakdowns in communication and documentation regarding the abuse allegation.
Deficiencies (2)
Failure to report an allegation of abuse immediately, not later than 2 hours after the allegation was made.
Failure to investigate an allegation of abuse in a timely manner and prevent further potential abuse while the investigation was in progress.
Report Facts
Complaint investigations: 3
Mental status score (BIMS): 14
Mood severity score: 4
Date of abuse allegation report: Jul 14, 2020
Date of final investigation completion: Jul 20, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Assessed resident and reported abuse allegation to RN Manager |
| RNM BB | Registered Nurse Manager | Received abuse allegation from LPN, contacted DON but did not document or report timely |
| DON | Director of Nursing | Notified late of abuse allegation, completed state report and police notification, re-educated staff |
| Administrator | Facility Administrator | Made aware of abuse allegation on 7/14/20, initiated investigation and state notification |
Inspection Report
Routine
Census: 135
Deficiencies: 0
Date: Aug 12, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Infection Control Survey were conducted to assess compliance with federal regulations related to emergency preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Routine
Census: 133
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and had implemented the recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 149
Deficiencies: 0
Date: Jun 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services from June 2, 2020 through June 5, 2020 to assess compliance with COVID-19 related regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a prior complaint survey conducted on 6/28/19.
Complaint Details
Complaint intake numbers GA00199060, GA00198667, and GA00198111 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected. Additionally, complaint intake numbers GA00199060, GA00198667, and GA00198111 were investigated and found to be unsubstantiated.
Report Facts
Complaint intake numbers: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 5, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Complaint survey conducted on 6/28/19 and to investigate complaint intake numbers GA00199060, GA00198667, and GA00198111.
Complaint Details
Complaint intake numbers GA00199060, GA00198667, and GA00198111 were investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the Complaint survey conducted on 6/28/19 were found to be corrected. The complaint investigations for intake numbers GA00199060, GA00198667, and GA00198111 were found to be unsubstantiated.
Report Facts
Complaint intake numbers: GA00199060, GA00198667, GA00198111
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 28, 2019
Visit Reason
The inspection was conducted due to complaints regarding failure to notify physicians or responsible parties of significant changes in residents' health status and concerns about infection control practices related to oxygen tubing and equipment.
Complaint Details
The complaint investigation revealed substantiated failures to notify the physician and responsible party of significant changes in condition for Resident #5 and Resident #16. The Medical Director and facility staff confirmed these were significant changes that required notification but were not made.
Findings
The facility failed to notify the physician and/or responsible party for two residents after significant changes in their medical conditions. Additionally, the facility failed to maintain proper infection control practices by allowing oxygen tubing to lie on the floor, tubing and humidifiers were undated and unlabeled, potentially exposing residents to infection risks.
Deficiencies (2)
Failure to notify physician and/or responsible party of significant changes in residents' health status for Resident #5 and Resident #16.
Failure to maintain infection prevention and control program by allowing oxygen tubing to be on the floor and tubing and humidifiers being undated and unlabeled for multiple residents.
Report Facts
Date of survey completion: Jun 28, 2019
Resident #5 vital signs: 84
Resident #5 vital signs: 150
Resident #16 BIMS score: 8
Oxygen tubing observations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT HH | Respiratory Therapist | Noted low oxygen saturation and high heart rate for Resident #5 and notified nurse |
| PT GG | Physical Therapist | Provided physical therapy to Resident #5 and noted concerning vital signs |
| ADON | Assistant Director of Nursing | Responded to Resident #5's emergency and called 911 |
| LPN II | Licensed Practical Nurse | Nurse for Resident #5 on 6/6/19 who did not notify physician or responsible party |
| RN JJ | Registered Nurse, Unit Manager | Reviewed records and confirmed failure to notify physician for Resident #5 |
| MD | Medical Director and Resident #5's Physician | Confirmed he was not notified of Resident #5's significant change in condition |
| LPN PP | Licensed Practical Nurse | Recalled Resident #16 having bloody stools but did not recall notifying anyone |
| DON | Director of Nursing | Interviewed multiple times confirming failures to notify and infection control issues |
| Administrator | Facility Administrator | Interviewed and stated expectation that facility policy be followed at all times |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 28, 2019
Visit Reason
A complaint survey was conducted from 6/24/19 through 6/28/19 to investigate complaints GA00196436, GA00196849, GA00197384 to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00197384 was substantiated with deficiencies related to failure to notify physician or Responsible Party of significant changes in condition for two residents and infection control issues with oxygen tubing.
Findings
The facility failed to notify the physician and/or Responsible Party for two residents after significant changes in medical conditions occurred, and failed to maintain an infection prevention and control program by allowing oxygen tubing to be on the floor and tubing being undated and unlabeled for multiple residents.
Deficiencies (2)
Failure to notify physician or Responsible Party of significant change in condition for two residents.
Failure to maintain infection prevention and control program; oxygen tubing on floor, tubing undated and unlabeled for four residents.
Report Facts
Dates of complaint survey: 6/24/19 through 6/28/19
Number of residents affected by notification deficiency: 2
Number of residents affected by infection control deficiency: 4
Oxygen tubing change frequency: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT HH | Respiratory Therapist | Notified nurse of resident #5's low oxygen saturation and concerning vital signs on 6/6/19 |
| PT GG | Physical Therapist | Provided therapy to resident #5 and noted concerning vital signs on 6/6/19 |
| LPN II | Licensed Practical Nurse | Nurse for resident #5 on 6/6/19 who did not notify physician or Responsible Party of significant change |
| RN JJ | Registered Nurse, Unit Manager | Reviewed records and confirmed significant change of condition for resident #5 on 6/6/19 |
| MD | Medical Director and Physician for resident #5 | Stated he was not notified of resident #5's significant change of condition on 6/6/19 |
| ADON | Assistant Director of Nursing | Called 911 for resident #5 on 6/6/19 but did not notify physician after sending resident to hospital |
| LPN PP | Licensed Practical Nurse | Recalled resident #16 having bloody stools but did not recall notifying anyone |
| DON | Director of Nursing | Agreed physician should have been notified of significant changes and infection control issues |
| Administrator | Facility Administrator | Expected facility policy to be followed at all times |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 11, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00195883, GA00196039, and GA00196094.
Complaint Details
The complaints GA00195883, GA00196039, and GA00196094 were investigated and found to be unsubstantiated.
Findings
The complaints investigated during the survey were found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 18, 2019
Visit Reason
A Revisit Survey was conducted to determine if deficiencies cited during the standard survey of 1/17/19 were corrected.
Findings
All deficiencies cited as a result of the standard survey of 1/17/19 were found to be corrected during the revisit survey.
Inspection Report
Routine
Census: 175
Deficiencies: 4
Date: Jan 17, 2019
Visit Reason
A standard survey was conducted at Orchard View Rehabilitation & Skilled Nursing Center from 1/14/19 to 1/17/19, including investigation of a complaint intake which was unsubstantiated.
Complaint Details
Complaint Intake Number GA00193830 was investigated in conjunction with the standard survey and was unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to treat residents with dignity by providing plastic silverware only on the dementia unit, improper use of physical alarms as restraints without assessment or consent, and improper preparation of pureed foods diluting nutritive value and flavor.
Deficiencies (4)
Residents in the dementia unit were provided plastic silverware only, which was a facility rule due to safety concerns, but residents were not individually assessed for safety hazards related to metal utensils.
Four residents were found to have physical alarms used without proper assessment, consent, or documentation, and alarms were not recognized as potential restraints by staff.
Expired medical supplies were found in medication rooms, and there was no facility policy for expired medications or supplies.
Pureed foods for 22 residents were prepared with excessive water and thickener, diluting nutritive value and flavor, and recipes lacked specific instructions on liquid/thickener amounts.
Report Facts
Resident census: 175
Residents on dementia unit: 38
Residents prescribed pureed diets: 22
Expired supplies: 2
Pureed food portions: 36
Thickener added: 128
Thickener added: 32
Residents with alarms: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| WW | Certified Nurse Assistant | Stated plastic silverware was a facility rule in dementia unit |
| ZZ | Licensed Practical Nurse | Explained plastic silverware use due to safety concerns in dementia unit |
| XX | Social Service Staff | Unaware of plastic cutlery use in dementia unit |
| DON | Director of Nursing | Confirmed plastic silverware use and lack of individual safety assessments |
| Administrator | Acknowledged plastic silverware use and potential dignity concerns | |
| Dietary Director | Described pureed food preparation and safety concerns with silverware | |
| ADON | Assistant Director of Nursing | Described alarm use and lack of assessment or consent |
| CNA AAA | Certified Nurse Assistant | Described resident alarm use and behaviors |
| RN UM BB | Registered Nurse Unit Manager | Discussed alarm use and lack of assessment or consent |
| RN UM EE | Registered Nurse Unit Manager | Discussed alarm use and lack of consent |
| RN GG | Registered Nurse Unit Manager | Discussed bed alarm use without physician order |
| LPN KK | Licensed Practical Nurse | Found expired supplies in medication room |
| LPN DD | Licensed Practical Nurse | Found undated opened vial of tuberculin |
| RN AA | Registered Nurse Unit Manager | Described medication room expired supply checks |
| Dietary Cook QQ | Cook | Prepared pureed foods with excessive water and thickener |
| Dietary Aide RR | Dietary Aide | Served pureed foods using three ounce scoops |
| Dietary Aide SS | Dietary Aide | Served pureed foods using three ounce scoops |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 16, 2019
Visit Reason
The inspection was conducted to evaluate compliance with pharmacy management and administration regulations, specifically to ensure expired medications and supplies were not available for resident use.
Findings
The facility failed to ensure expired medications and supplies were removed from two of six medication rooms. Expired items included an enteral feeding tube, a urinary specimen catheter kit, and an open multidose vial without an open date. The facility lacked a policy for expired medications and supplies.
Deficiencies (3)
Expired enteral feeding tube and urinary specimen catheter kit found in South Rehab Unit medication room.
Open multidose vial of Tuberculin Purified Protein Derivative without an open date found in Meadow Terrace unit medication room.
Facility had no policy for expired medications and supplies.
Report Facts
Medication rooms inspected: 6
Medication rooms with expired supplies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| KK | Licensed Practical Nurse | Verified expired supplies in South Rehab Unit medication room |
| DD | Licensed Practical Nurse | Inspected Meadow Terrace unit medication room and received vial without open date |
| AA | Registered Nurse, Unit Manager | Provided information about medication room checks on Meadow Terrace unit |
| Assistant Director of Nursing | Assistant Director of Nursing | Revealed facility had no policy for expired medications and supplies |
| Director of Nursing | Director of Nursing | Revealed facility had no policy for expired medications and supplies |
Inspection Report
Life Safety
Census: 176
Capacity: 200
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found in substantial compliance with the Life Safety Code requirements and the Emergency Preparedness plan was also in substantial compliance.
Report Facts
Stories: 2
Construction Type: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 27, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00193504 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
Complaint #GA00193504 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 12/26/18 through 12/27/18.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 8, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00192595 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00192595 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 30, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00192426 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00192426 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 27, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00190904.
Complaint Details
Complaint GA00190904 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 18, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00189743.
Complaint Details
Complaint GA00189743 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 21, 2018
Visit Reason
A complaint investigation was conducted by a Certified Surveyor at Orchard View Rehabilitation & Skilled Nursing Center from 05/17/2018 to 05/21/2018.
Complaint Details
The complaint was substantiated but no health deficiencies were identified.
Findings
The complaint was found to be substantiated; however, no health deficiencies were cited during the investigation.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 5, 2018
Visit Reason
A revisit survey was conducted from 4/2/18 through 4/5/18 to verify correction of deficiencies cited in the 2/8/18 Standard Survey. Additionally, a complaint investigation (Intake Number GA00186781) was conducted in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00186781 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited in the prior 2/8/18 Standard Survey were found to be corrected. The complaint investigation found the complaint to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 5, 2018
Visit Reason
A revisit survey was conducted from 4/2/18 through 4/5/18 to verify correction of deficiencies cited in the 2/8/18 Standard Survey. Additionally, Complaint Intake Number GA00186781 was investigated in conjunction with this revisit survey.
Complaint Details
Complaint Intake Number GA00186781 was investigated and found to be unsubstantiated.
Findings
All deficiencies cited as a result of the 2/8/18 Standard Survey were found to be corrected. The complaint investigation found the complaint to be unsubstantiated.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 2, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 184
Deficiencies: 4
Date: Feb 8, 2018
Visit Reason
The inspection was conducted to assess compliance with resident care, treatment, and environmental sanitation standards at Orchard View Rehabilitation & Skilled Nursing Center.
Findings
The facility failed to ensure timely meal service to residents, maintain dignity during dining, follow care plans for wound care and psychotropic medication monitoring, provide reasonable accommodation for resident needs, and maintain proper infection control practices including use of gowns and gloves.
Deficiencies (4)
Failure to serve all residents eating at the same table in a timely manner, compromising dignity during meals.
Failure to provide a urinal for a resident as per care plan and maintain dignity.
Failure to follow care plan related to wound treatment and psychotropic drug monitoring for multiple residents.
Failure to prevent contamination of staff uniform, clean linen, and exposure of bare skin during wound care, violating infection control policies.
Report Facts
Facility census: 184
Observation times: 42
Pressure ulcer size: 5
Pressure ulcer size: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant EE | Certified Nursing Assistant | Stated resident #148 was incontinent and urinal was not left at bedside |
| Registered Nurse MM | Unit Manager | Verified lack of behavior monitoring for residents #144 and #128 |
| Licensed Practical Nurse RR | Licensed Practical Nurse | Observed performing wound care incorrectly by not using Dakin's solution |
| Licensed Practical Nurse CC | Licensed Practical Nurse | Observed performing wound care with exposed wrists and improper infection control |
| Certified Nursing Assistant AA | Certified Nursing Assistant | Observed contaminating clean linen with dirty gloves and not wearing gown in MRSA room |
| Registered Nurse DD | Infection Control Nurse | Stated all employees must perform hand hygiene and don gowns and gloves before entering contact precaution rooms |
| Licensed Practical Nurse GG | Unit Nurse | Stated she always follows contact precaution policies and would correct staff not complying |
Inspection Report
Routine
Census: 184
Deficiencies: 10
Date: Feb 8, 2018
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations at Orchard View Rehabilitation & Skilled Nursing Center.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident rights, reasonable accommodations, Medicaid/Medicare coverage notices, freedom from restraints, comprehensive care planning, significant change assessments, psychotropic medication monitoring, infection control, and sufficient nursing staff. Specific deficiencies included delayed meal service to dependent residents, failure to provide a urinal as requested, missing advance beneficiary notices, improper use of bed bolsters as restraints, failure to complete significant change MDS, failure to monitor psychotropic drug effects, improper wound care, insufficient nursing staff during meals, and infection control breaches.
Deficiencies (10)
Residents dependent on assistance with meals were served late, causing dignity issues.
Failure to provide a urinal to a resident as requested, impacting dignity and care.
Failure to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) for residents discharged off Medicare Part A but remaining in the facility.
Use of bed bolsters as restraints without proper assessment and documentation.
Failure to complete a Significant Change Minimum Data Set (MDS) after resident developed an unstageable pressure ulcer and significant weight loss.
Failure to implement care plan related to wound treatment and psychotropic drug monitoring for two residents.
Failure to provide wound care per physician's orders for one resident.
Insufficient nursing staff to meet the needs of dependent residents during meal times, causing extended wait times.
Failure to document monitoring of behaviors and side effects for residents on psychotropic medications.
Infection control breaches including staff contaminating uniform with dirty gloves, contaminating clean linen with dirty gloves, and exposing bare wrists during wound care.
Report Facts
Resident census: 184
Meal wait time: 45
Significant weight loss: 18.4
Psychotropic medication monitoring frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MM | Registered Nurse Unit Manager | Interviewed regarding meal service delays, psychotropic medication monitoring, and care plan implementation |
| ZZ | Certified Nursing Assistant | Interviewed regarding meal service and resident behavior |
| EE | Certified Nursing Assistant | Interviewed regarding resident #148 urinal use and incontinence |
| JJ | Social Worker | Interviewed regarding Skilled Nursing Facility Advance Beneficiary Notice issuance |
| KK | Bookkeeper | Interviewed regarding Skilled Nursing Facility Advance Beneficiary Notice issuance |
| CC | Licensed Practical Nurse Treatment Nurse | Observed and interviewed regarding wound care for resident #144 |
| AA | Certified Nursing Assistant | Observed contaminating clean linen with dirty gloves during bed making |
| DD | Registered Nurse Infection Control Nurse | Interviewed regarding infection control practices |
| GG | Licensed Practical Nurse Unit Nurse | Interviewed regarding infection control practices |
| WW | Certified Nursing Assistant | Interviewed regarding meal service delays |
| SS | Certified Nursing Assistant | Interviewed regarding meal service delays |
| II | Staffing Coordinator | Interviewed regarding staffing changes and agency use |
| FF | Registered Nurse Unit Manager | Interviewed regarding urinal use policy |
| NN | Licensed Practical Nurse | Interviewed regarding psychotropic medication monitoring |
| PP | Licensed Practical Nurse MDS Staff | Interviewed regarding significant change MDS |
| OO | Registered Nurse MDS Staff | Interviewed regarding significant change MDS |
Inspection Report
Life Safety
Census: 186
Capacity: 200
Deficiencies: 2
Date: Feb 6, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code standards.
Findings
The facility was found not in substantial compliance due to failure to maintain doors in hazardous area enclosures and corridor doors to ensure proper latching and resistance to smoke passage, potentially placing residents at risk in the event of fire.
Deficiencies (2)
Failed to maintain doors in a hazardous area enclosure to ensure that the door is properly latched while in the closed position.
Failed to maintain corridor doors to resist the passage of smoke; several corridor room doors had gaps greater than 0.5 inch between the door face and door stop.
Report Facts
Census: 186
Total Capacity: 200
Number of doors with gaps: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Confirmed findings related to door deficiencies during facility tour |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 5, 2017
Visit Reason
The inspection was conducted to investigate complaints #GA00180226 and #GA00180432 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
The survey was complaint-related, investigating two complaints identified by numbers GA00180226 and GA00180432. No deficiencies were found, indicating the complaints were not substantiated.
Findings
No deficiencies were cited during the complaint survey conducted from 10/4/17 through 10/5/17.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 28, 2017
Visit Reason
The visit was conducted as an abbreviated survey to investigate complaints #GA00178778 and #GA00178955 and to determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Complaint Details
The survey was conducted to investigate complaints #GA00178778 and #GA00178955; no deficiencies were found.
Findings
No deficiencies were cited during the abbreviated survey conducted on 8-25-17 and 8-28-17 at Orchard View Rehabilitation and Skilled Nursing Center.
Inspection Report
Follow-Up
Census: 172
Deficiencies: 0
Date: Mar 9, 2017
Visit Reason
A follow-up survey was conducted at Orchard View Rehabilitation and Skilled Nursing Facility from March 8, 2017 through March 9, 2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The follow-up survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Catherine Segelman | RN | Named in the initial comments of the follow-up survey report. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 9, 2017
Visit Reason
A complaint survey was conducted from March 8, 2017 through March 9, 2017 to investigate Complaint GA #171785 and #171415. These complaint investigations were done in conjunction with an Abbreviated Standard Survey Follow Up.
Complaint Details
Complaint GA #171785 and #171415 were investigated and no deficiencies were cited.
Findings
No deficiencies were cited in regards to these complaints.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 8, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Life Safety
Census: 173
Capacity: 200
Deficiencies: 2
Date: Jan 17, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to properly enclose stairways, elevator shafts, and smoke barriers with the required fire resistance ratings, potentially placing 15 residents at risk in the event of a fire.
Deficiencies (2)
Failure to enclose stairways and elevator shafts with construction having a fire resistance rating of at least one hour, including unprotected penetrations in Elevator #2, Elevator #3, and Garden View south stairwell.
Failure to maintain smoke barrier walls with construction having a fire resistance rating of at least one-half hour, including unprotected penetrations in NAT Classroom, Fire Sprinkler riser room, and Meadow Terrace at the Multi-Purpose Office.
Report Facts
Residents at risk: 15
Census: 173
Total licensed beds: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff S | Staff interviewed and confirmed findings during the inspection |
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