Orchard Park Assisted Living

Failed to ensure staff received TB screening within three days of employment for 1 of 3 sampled staff.

Failed to ensure safe medication systems were in place for 4 residents, leading to missed documentation and missed medications.

Multiple staff members lacked valid or current CPR and first aid certification: Staff B (no cert), Staff C (no cert), Staff D (expired 04/30/2025), and Staff E (expired 04/30/2025). The office manager admitted they were behind on training.

Failed to complete self-medication assessments for 2 residents to determine if they could safely self-administer medications.

Staff E and Staff F failed to complete the required 12 hours of continuing education (CE) credits within their respective birthdate-to-birthdate periods. The administrator acknowledged the lack of a system for tracking CE completion.

Failed to obtain written plans for family members providing medication assistance for 2 residents.

Failed to obtain physician-prescribed medications in a timely manner for 2 residents, resulting in missed doses and medical risk.

Failed to ensure 5 of 6 sampled staff met long-term care worker training requirements.

Failed to ensure national fingerprint background checks were completed within 120 days of hire for 2 of 6 sampled staff.

Extension cords used as permanent wiring in rooms 315, 317, 2nd floor activities, maintenance office, and nurses station.

Facility unable to provide documentation of hydrostatic testing of fire department connection.

Fire-rated cross corridor doors near room 313 and to the dining room failed to close and latch.

Unable to provide documentation for annual servicing of emergency generator.

Open junction box in the maintenance office.

Missing documentation for 3-year dry system test, annual forward flow test, quarterly inspections; storage blocking sprinkler head; missing hydraulic calculation plate.

Oxygen cylinders in 3rd floor storage room not secured.

Power strip plugged into another power strip in the nurses station/office.

Smoke detectors near 316 and 333 installed within 36 inches of air supply/return; standalone smoke alarms older than 10 years.

Facility failed to correct one Fire and Life Safety violation during the third annual inspection regarding IFC 912.7 2021 (failure to provide documentation of hydrostatic testing for the Fire Department Connection).

Power strip plugged into another power strip in nurses station.

Facility unable to provide documentation for annual servicing of emergency generator.

Facility unable to provide documentation for 3-year dry system full flow test, annual forward flow test, and quarterly inspections. Storage blocking sprinkler head. Missing hydraulic calculation plates.

Extension cords used as permanent wiring in multiple locations.

Oxygen cylinders in 3rd floor storage room #5 not secured.

Facility unable to provide documentation for hydrostatic testing. Update: The hydrostatic test has failed; working with vendor/city for pipe lining.

Cross corridor door near room 313 and dining room door would not close and latch.

Open junction box in maintenance office.

Smoke detector heads installed within 36 inches of air supply/return diffusers; standalone smoke alarms older than 10 years.

Facility failed to follow respiratory protection program and ensure 3 of 3 staff were fit-tested for N95 respirators during a Covid-19 outbreak.

The facility failed to provide care as agreed in the negotiated service agreement for one resident, who was not checked for 11 hours, resulting in the resident being found unresponsive and deceased.

The facility failed to implement their policy to respond to residents' call lights within 15 minutes. Residents experienced wait times of up to 2 hours and 17 minutes.

The facility failed to administer a medication (Warfarin) to a resident as prescribed by their physician after a clinic visit, resulting in a missed dose.