The Orchards at Armada

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was kept within reach for one (R15) of four residents reviewed for call light access.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative services were provided timely for one resident (R902) of four reviewed for range of motion (ROM) and mobility.

Inspectors wroteThis citation pertains to Intake 2786506. Based on interview and record review, the facility failed to ensure a wound status condition update to specialist for one resident (R901) of three residents reviewed for wounds. Findings Include:A complaint called into the State Agency indicated, Neither (name of consulting physician) and/or myself or my family members-who were visited daily- were never notified that there was an infection going on with (name of R901's) leg. (Name of consulting physician) sent (name of R901) to emergency immediately .Review of the clinical record revealed R901 was admitted to the facility on [DATE]. R901's diagnoses included Chronic ulcer of the right ankle (open wound right lower leg) and Varicose veins of Right lower extremity (RLE) with ulcer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance in a dignified manner for one (R15) of six residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) line care was performed consistant with professional standards of practice for one resident R42 of one whose Intravenous (IV) medication administration was observed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Peripherally Inserted Central Catheter (PICC) line care infection control measures and hand hygiene during meal assistance was performed for two residents (R42 and R15) of three residents reviewed for infection prevention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened food items were dated and discarded when expired, and failed to maintain the filter for the ice machine. This deficient practice had the potential to affect all residents that consume food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan for one resident (R56) out of one reviewed for care plans. Findings Include: On 5/21/2024 at 9:46 AM, R56 was observed in their bed with a breakfast tray in front of them. R56 was observed attempting to eat some of their applesauce. R56 was noted to have pureed textured food. A review of the tray ticket stated R56 was supposed to be a 1:1 assist with feeding, no one was noted to be in the room. A review of the medical record revealed R56 admitted into the facility on 3/13/2024 with the following diagnoses, Dysphagia following Cerebral Infarction and Aphasia. Further review of the medical record revealed a Brief Interview for Mental Status score of 2/15 indicating an impaired cognition. R56 also required assistance with bed mobility and transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal assistance and positioning were provided for two residents (R53, R56) of five whose care needs and activities of daily living (ADLs) were reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply heel protecters and lids to drinks per physician orders for one resident (R5) out of one reviewed for physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an indwelling catheter (tube inserted into the bladder to drain urine) leg strap/band was in place and tubing positioned to allow for urine to drain for one resident (R367) of one reviewed for catheters.

Inspectors wroteThis citation pertains to Intakes MI00142869 and MI00143155. Based on observation, interview, and record review, the facility failed to provide timely assistance to meet the needs of residents for four residents (R367, R33, R17, R6) of five whose care needs were reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered per manufactures recommendations and per physician order for one resident (R54) of four observed for the medication pass, resulting in a med error rate of 7.89 percent.

Inspectors wroteThis citation pertains to Intake MI00143588. Based on observation, interview, and record review, the facility failed to ensure food items were provided in a puree consistency per the diet order for one resident (R53) of two whose diets were reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear proper personal protective equipment (PPE) for one resident (R24) out of one reviewed for Enhanced Barrier Precautions (EBP). Findings Include: On 5/21/2024 at 9:50 AM, Registered Nurse (RN) E was observed in front of R24's door grabbing gloves. RN E stated they were going into the room to finish performing care on R24. An EBP sign and cart was noted to be in front of the door. On 5/21/2024 at 9:55 AM, RN E was observed coming out of R24's room. RN E was queried as to why R24 was on EBP. RN E stated they thought that they were on EBP because R24 has chronic urinary tract infections. A review of the medical record revealed that R24 admitted into the facility on [DATE] with the following diagnoses, Personal History of Urinary Tract Infections and Muscle Weakness. [...]

Inspectors wroteThis citation pertains to Intake M100141494. Based on interview, and record review, the facility failed to prevent an elopement for one resident (R701) who had severe cognitive impairment, a high risk for falls, a known elopement risk, and demonstrated multiple attempts to exit the facility shortly before the elopement occurred. R701 eloped from the facility on 11/06/23 between 7:30 PM and 8 PM through the South exit door, without triggering the door alarm and unwitnessed by staff. In response to R701's repeated attempts to exit the South exit door, a staff member (Certified Nurse Assistant -CNA C) placed a geri-chair in front of the door to discourage R701 from approaching the door. CNA C exited another resident's room after providing care, and noticed the geri-chair had been moved and did not see R701. [...]