Inspection Reports for
The Orchards Post-Acute

The facility failed to ensure that one of five residents' restrooms had linoleum floor covering in good repair, with the floor torn and lifted causing an uneven surface that posed a tripping hazard.

The complaint alleged that a contractor phlebotomist was using needles on residents, cleaning them with alcohol wipes, and reusing the same needles at other facilities and a hospital. The investigation found the phlebotomist entered the facility after the administrator was informed but was unaware of the entry until after the fact.

The facility failed to follow its policy on Abuse, Neglect, Exploitation or Misappropriation reporting and investigating by allowing the alleged perpetrator to enter the facility after the administrator was informed of the allegation. This failure potentially exposed all residents to harm and infection.

The facility was found deficient in multiple areas including failure to ensure effective communication with residents, incomplete informed consents for psychotropic medications, unsanitary bathroom conditions, failure to notify ombudsman of resident discharges, incomplete smoking assessments, failure to implement fall precautions, inadequate medication administration practices, catheter care deficiencies, oxygen administration issues, incomplete staffing records, lack of annual performance evaluations for some CNAs, failure to follow up on resident eyeglasses, medication availability issues, incomplete medication regimen reviews, improper medication storage and handling, infection prevention lapses, nonfunctional call light system for a resident, and maintenance issues in resident rooms.

The complaint investigation found that Resident 1 was not readmitted after hospitalization despite being ready for discharge. The facility refused readmission due to the resident's low functioning, violating the resident's rights. The complaint was substantiated based on interviews and record reviews.

The facility failed to readmit Resident 1 after hospitalization despite the resident being ready for discharge back to the facility. The facility refused readmission citing 'too low functioning,' which was against their policy prioritizing readmission of discharged residents.

The complaint investigation substantiated failures in medication administration, treatment order compliance, gastrostomy tube care, and staff competency. Resident 1 suffered actual harm with aspiration pneumonia due to delayed reporting and improper care. Residents 2 and 3 were affected by failures in medication and treatment administration.

The facility failed to administer medications and treatments according to physician orders for sampled residents, resulting in potential worsening of infections and wounds. Additionally, the facility failed to properly monitor and report complications related to gastrostomy tube feeding, leading to a resident's transfer to an acute hospital with aspiration pneumonia. Staff competency deficiencies were also identified in caring for residents with gastrostomy tubes.

The facility failed to implement follow-up monitoring for one resident involved in the altercation, as required by their own investigation report and smoking policy. The Director of Nursing confirmed lack of documentation regarding monitoring of the resident's smoking privileges.

The facility failed to provide wound treatment as ordered by the physician for Resident 1 on two consecutive days, which had the potential to delay wound healing. Interviews and record reviews confirmed that wound treatments were not administered on 8/5/24 and 8/6/24, despite physician orders and facility policy.

The complaint investigation found that Resident 1 experienced abdominal pain for approximately seven hours due to lack of catheter assessment. The complaint was substantiated by observations, interviews, and record reviews including the Emergency Documentation indicating a urinary tract infection and emergency medical intervention.

The facility failed to assess Resident 1's foley catheter for approximately seven hours, causing significant abdominal pain and eventual emergency intervention. The medication for pain was administered only after seven hours, and there was no documentation of pain reassessment.

The complaint involved Resident 2 throwing a tray lid and a glass plate at Resident 1, causing fear and anxiety. The facility did not report the incident to CDPH nor complete an investigation, as confirmed by interviews with the Social Services Assistant and Director of Nursing.

The facility failed to report the alleged abuse to the California Department of Public Health and did not complete an investigation. Resident 1 expressed feeling unsafe and fearful due to Resident 2's aggressive actions.

The facility failed to maintain a clean and sanitary kitchen environment, with debris and pests observed, and did not implement an effective pest control program, resulting in the presence of cockroaches in resident rooms and the kitchen. These deficiencies posed potential risks for contamination and spread of infectious diseases.

The facility failed to provide nail care and hand hygiene for one of the five sampled residents (Resident 1), which had the potential to result in skin breakdown and spread of infection. Observations and interviews confirmed Resident 1's fingernails were long with debris and brown stains on his hand, and staff did not provide appropriate nail care as required by the care plan.

The complaint investigation found that the facility failed to notify the physician timely after a resident fall and failed to administer prescribed medication to another resident. The physician notification delay was substantiated by interviews and record reviews. Medication administration failure was confirmed by MAR and progress notes review.

The facility failed to ensure timely physician notification after a resident fall, resulting in delayed medical evaluation, and failed to administer prescribed medication to another resident, resulting in missed doses.

The complaint investigation found that Resident 1 did not receive showers on multiple dates in February 2024 despite care plan requirements. The issue was substantiated with documentation review and interviews.

The facility failed to provide showers to Resident 1 as required by the care plan, with missing documentation for multiple shower dates in February 2024. The resident required partial to moderate assistance with showering, and the failure posed minimal harm or potential for actual harm.

The facility was found deficient in multiple areas including call light accessibility, cleanliness, timely completion of assessments, care planning, medication management, infection control, food safety, and maintenance of a safe environment. Several residents' care plans and assessments were incomplete or not updated, and infection prevention practices were inconsistently followed.

The facility failed to provide warm water and adequate water pressure for showers and bathing for four sampled residents, which could cause discomfort, pain, infection risk, and feelings of worthlessness. Observations and interviews confirmed low water pressure and water temperatures below the facility's policy standards.

The facility failed to ensure that one of three sampled residents had completely covered window blinds for privacy, potentially allowing the resident to be seen from outside when changing clothes. The Environmental Services Manager was unaware of the issue, and no maintenance records indicated communication about the problem.

Complaint investigation found substantiated issues with staff disrespectful behavior, including use of personal communication devices during resident care.

The facility failed to ensure three of four sampled residents were treated with respect and dignity, with staff observed using cell phones and earbuds during resident care, which had the potential to negatively affect residents' self-esteem and self-worth. Facility policies prohibit personal communication device use during work time in patient care areas unless authorized.

Resident 1's daughter made a complaint that RN 1 attempted to give medications by mouth despite Resident 1 having a G-tube and being NPO. The complaint was substantiated based on interviews and record review.

The facility failed to implement its medication administration policy for one of three sampled residents, resulting in a potential medication error when a nurse attempted to administer medications orally instead of via the prescribed G-tube route.

The facility failed to administer prescribed pain medication (Norco) to Resident 1 for two days (8/12/23 and 8/13/23) due to the medication not being placed in the narcotics drawer, resulting in ineffective pain management. The Licensed Vocational Nurse did not notify the physician about the missed doses and administered Tylenol as an alternative.

The facility failed to ensure timely medication administration for one resident, adequate nursing staff to respond to call lights, proper accommodation of food allergies and preferences for two residents, and sufficient supplies such as adult briefs, wipes, and towels for resident care. These deficiencies posed potential or minimal harm to residents.

The complaint involved an allegation by Resident 1 that Maintenance Staff 1 borrowed $200 and did not return it. The facility did not report this allegation to the California Department of Public Health and did not document an investigation. The allegation was not substantiated due to lack of reporting and investigation.

The facility failed to follow its policy on Abuse Investigation and Reporting by not thoroughly investigating or reporting the allegation of financial abuse involving Resident 1. The allegation that Maintenance Staff 1 borrowed and did not return $200 was not reported to the California Department of Public Health, and no documentation of the investigation was found.

The complaint investigation found that Resident 1, diagnosed with dementia and under conservatorship, physically assaulted Resident 2 during an altercation on 8/6/23, causing a fracture to Resident 2's left shoulder. The incident was witnessed by a family member and documented in multiple facility records.

The facility failed to provide adequate supervision for two residents, resulting in Resident 2 sustaining a non-displaced left humeral head fracture from an altercation initiated by Resident 1. The investigation included interviews, record reviews, and policy assessments confirming the incident and subsequent injury.

The facility failed to follow its policy and procedure on administering medications for one of three sampled residents when a cup of medication was left on the resident's table and not administered, posing a potential medication error and risk of adverse health outcomes.

The facility failed to implement the planned intervention of providing Resident 1 with a call bell to minimize fall risk, resulting in potential harm. Resident 1 had fallen twice in the prior two months without use of a call bell, which was only provided during the inspection day after staff instruction.

The complaint investigation found that the facility did not report alleged abuse incidents involving two residents within the required 24 hours, reporting instead three days later. The incidents involved aggressive behavior and improper medication administration by a Licensed Vocational Nurse. The complaint was substantiated by interviews and record reviews.

The facility failed to implement its policy on Abuse Investigation and Reporting by not reporting alleged abuse incidents within the required 24-hour timeframe, resulting in a delay of three days before reporting to the state agency. The incidents involved aggressive behavior by a Licensed Vocational Nurse towards two residents and improper medication administration.

The complaint investigation was substantiated by the finding that the facility did not report the abuse allegation to CDPH as required. The Bakersfield Police Department investigated the allegation but the facility's Director of Nursing did not report it to CDPH, mistakenly believing it was unnecessary after police found no evidence of abuse.

The facility failed to report an allegation of abuse within 24 hours to the CDPH for one of three sampled residents, resulting in delayed investigation and potential for continued abuse. The allegation involved Resident 1, who had bruising from a recent car accident and cognitive impairment. The Director of Nursing (DON) did not report the abuse allegation to CDPH despite the police investigation.

The facility failed to ensure that wound treatment was completed and properly documented for Resident 1, which had the potential to worsen the resident's wounds. The Director of Nursing confirmed the lack of documentation for wound treatments on several days and was unable to provide mitigating information.

The facility failed to ensure that one of three sampled residents received the prescribed double protein serving at lunch, potentially leading to decreased caloric and nutrient intake. Interviews and record reviews confirmed the diet order was not followed as required.

The investigation was complaint-related, focusing on substantiated failures to administer and document enteral feedings and flushes for Residents 1 and 2.

The facility failed to ensure that Residents 1 and 2 received enteral feedings and flushes as ordered, with multiple instances of no documentation of feedings or flushes administered. The Director of Nursing confirmed these findings and stated the expectation for proper documentation.

The complaint investigation found that the facility failed to carry out a physician's order in a timely manner for Resident 1. The authorization for the CT scan was delayed due to failure in communication and processing, with the Case Manager first informed on 8/18/22, despite the order being dated 8/12/22. The Director of Nursing confirmed the nurse should have informed the Case Manager earlier.

The facility failed to timely carry out a physician's order for a CT scan for Resident 1 following an unwitnessed fall resulting in a rib fracture. Authorization for the CT scan was delayed, not submitted to insurance until 8/18/22, and approved on 8/26/22, causing a delay in care.

The facility was found deficient in multiple areas including failure to maintain resident dignity and self-determination, inadequate advance directive documentation, failure to notify responsible parties of significant weight loss, unsafe and unsanitary environmental conditions, inaccurate resident assessments, lack of coordinated hospice care, inadequate bowel and bladder care, poor documentation and monitoring of nutritional supplements, failure to reconcile narcotics each shift, failure to provide special adaptive equipment as ordered, unsafe food handling and sanitation practices in the kitchen, improper storage of food brought in from outside, incomplete antibiotic stewardship documentation, unsafe wheelchair maintenance, and unsafe environmental conditions such as missing door thresholds.