The Orchards at Samaritan

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices and general maintenance of foodservice equipment resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/22/2026 at 7:56 AM observed the ice machine door gasket cracked and worn in the green unit nourishment room. Further observation found spots of corrosion on the surface of the interior metal shield. An interview with Dietary Manager (DM) C at this time found the ice machines are cleaned by an outside company, and they are unsure frequency of cleaning. On 04/22/2026 at 7:59 AM observed an ice scoop holder with a pool of water and debris at the bottom of the holder in the green unit nourishment room. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically submit complete accurate and timely direct care staffing information for the Payroll Based Journal (PBJ) entry to the Centers of Medicare and Medicaid Services (CMS) for the first financial quarter (October 1st-December 31) for 2026.

Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Based on observation, staff interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with infection control standards, including failure to post required EBP signage and failure to ensure staff utilized appropriate personal protective equipment (PPE) during resident care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 04/22/2026 at 7:54 AM observed brown and black residue beneath the sink in the green unit nourishment room. On 04/22/2026 at 8:18 AM observed a brown stained white towel under the hand sink in the blue unit nourishment room. A brown streak was observed on the wall, extending from the drain line exit point in the wall to the base of the cabinet floor. Black splatter marks were observed near the bottom portion of the wall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that five of five sampled Certified Nurse Aides (CNAs R, S, T, U, and V) completed the required 12 hours of annual training to ensure adequate resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two residents (R97 and R117) out of two residents reviewed for accommodation of needs and preferences.

Inspectors wroteThis citation pertains to intake 2959471. Based on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property by an employee for one (R115) out of two residents reviewed for abuse resulting in an employee using R115's debit card.

Inspectors wroteThis citation pertains to intake 2959471. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of an injury of unknown origin to the State Agency (SA) for one (R115) of two residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for two (R2 and R13) of 21 residents reviewed for care plans resulting in inadequate care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the correct size incontinence brief was provided for one bariatric resident (R2) out of two residents reviewed, resulting in the resident verbalizing frustration and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper anchoring/securing of an indwelling urinary catheter for two (R36 and R13) out of three residents reviewed for urinary catheters.

Inspectors wroteBased on interview and record review the facility failed to administer medications according to physician orders for one (R703) of four reviewed for medications.

Inspectors wroteThis citation pertains to intakes 2687870 and 2692032. Based on observation, interview, and record review, the facility failed to protect the resident's (R701) right to be free from physical abuse by Certified Nursing Assistant (CNA) B resulting in hospitalization for a dislocated shoulder.

Inspectors wroteThis citation pertains to intakes 2687870 and 2692032. Based on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of physical abuse for one (R701) in accordance with section 1150B of the Act, resulting in acts of physical abuse going unreported in a timely manner and further placing residents in harm's way.

Inspectors wroteThis citation pertains to intakes MI00152529 and MI00153381. Based on interview and record review the facility failed to prevent verbal abuse for two residents (R901 and R909) out of five residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours each day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to employee sufficient dietary staff and ensure operational consultation was provided to supervisory staff, resulting in inadequate sanitation in the kitchen. This deficient practice had the potential to affected 99 of the 104 residents that consumed meals from the kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and sanitary kitchen for food storage, preparation and service, resulting in the potential for food borne illnesses. This deficient practice affected 99 of the 104 residents within the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted for one medication cart (400 Hall Cart) of four medication carts observed for medication storage and cleanliness.

Inspectors wroteBased on observation, interview, and record review the facility failed to repair the floor of one resident (R95) of three reviewed for a homelike environment resulting in frustration and a potential hazard.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store an oxygen tank for one (R33) out of two residents reviewed for oxygen therapy, resulting in the potential for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to date/label oxygen tubing for two residents (R9 and R33) and failed to ensure a physician order regarding oxygen use for one resident (R33) of three residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review the facility failed to address Medication Regimen Review (MRR) recommendations timely for one resident (R4) of five residents reviewed for medication regimen review, resulting in the continuance of unnecessary medications and a lack of communication of recommended medication changes between pharmacist and physician.

Inspectors wroteBased on interview and record review the facility failed to ensure two residents (R4 and R5) of five sampled residents reviewed for medications, did not receive unnecessary medications in the form of the prolonged use of a cough syrup and an antacid, resulting in the potential for increased risk of adverse drug effects.

Inspectors wroteThis citation has two deficient practices. Deficient Practice Statement #1. Based on observation, interview and record review the facility failed to maintain the physical environment in the kitchen in a safe and sanitary manner, repair and replace broken equipment, properly clean steam tables in three dining rooms and replace stained, soiled ceiling tiles. This deficient practice created an environment that lacked cleanliness and increased the potential for food contamination for 99 of 104 residents within the facility.

Inspectors wroteThis citation pertains to intakes MI00145596 and MI00145720. Based on interview and record review the facility failed to ensure scheduled and as needed pain medications were administered per the physician's orders for one (R103) of three residents reviewed for pain management resulting in uncontrolled pain, frustration, anger, and feelings of helplessness.

Inspectors wroteThis citation pertains to intakes MI145596 and MI145720. Based on interview and record review the facility failed to report an allegation of employee to resident abuse to the State Agency for one resident (R103) of three residents reviewed for abuse, resulting in the potential for feelings of not being protected or safe within the facility, and for abuse to continue without being reported.

Inspectors wroteThis citation pertains to intake MI00147722 and MI00146334. Based on observation, interview and record review, the facility failed to address changes in laboratory findings in a timely manner for R101 of two residents reviewed for a change in condition, resulting in significant critical laboratory values, delay in treatment, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure the proper storage of a narcotic for one (R103) of three residents reviewed for medication administration potentially resulting in a missed dose, medication waste, and misappropriation.

Inspectors wroteThis citation pertains to intake MI00145863. Based on interview and record review the facility failed to provide adequate supervision for one (R102) of three residents reviewed for elopement, resulting in R102 exiting the facility without staff knowledge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was administered properly and per physician's orders for four residents (R45, R61, R71, and R84) of eight residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken or administered properly.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications accurately for two residents (R71 and R84) out of six residents during medication pass, resulting in a medication error rate of 17.86 %.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident (R102) was assessed for self-administration of a medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a hospice care plan for one resident (R12) out of two residents reviewed for hospice care, resulting in not having goals and interventions to meet R12's hospice care needs.

Inspectors wroteThis citation pertains to intake number MI00114339. Based on observation, interview and record review, the facility failed to provide timely incontinence care for one resident (R53) of ten residents reviewed for Activities of Daily Living (ADL), resulting in the potential for skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed properly store nebulizer (used for breathing treatment) tubing between resident use, for one resident (R258) out of two residents reviewed for respiratory care, resulting in the potential for contamination of respiratory devices and the spread of infection.