Orchard Health And Rehabilitation
ORCHARD HEALTH AND REHABILITATION in PULASKI, GA — inspection on April 3, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the signature page revealed there was no signature to indicate that the Activities Director or the Assistant Activity Director were in attendance.
Review of a Resident List revealed 22 residents identified with sexually inappropriate behaviors were discussed, and documented two referrals were made for {Named} Behavioral Health services on 3/31/2025 and seen on 4/1/2025. confirmed attendance of the QAPI meeting held on Monday, 3/31/2025; LPN GG, LPN HH, Senior Director of Clinical Standards, Assistant Activities Director.
All corrective actions were completed on 3/31/2025.
The facility alleges IJ removal 4/1/2025.
115522 04/03/2025
Orchard Health and Rehabilitation 1321 Pulaski School Road Pulaski, GA 30451
Review of the signature page revealed there was no signature to safety indicate that the Activities Director (AD) or the Assistant Activity Director were in attendance.
discussed, and documented two referrals were made for [named] behavioral health services on 3/31/2025 and seen on 4/1/2025.
Interview on 4/3/2025 at 1:30 pm with the Assistant Activities Director revealed the AD was out on Monday, March 31, 2025, the day the QAPI meeting was held, and confirmed she attended the QAPI meeting in the AD's place.
She revealed they discussed residents with sexual behaviors, reviewed a list of residents, and discussed their behaviors and the policy for Behavioral Health.
Interview on 4/3/2025 at 1:55 pm with the Senior Director of Clinical Standards confirmed they reviewed the Behavioral Health policy and revealed they did not make any changes to the policy.
Further interview confirmed all steps in the plan of correction had been initiated and further audits were scheduled as indicated.
Interview on 4/3/2025 at 2:06 pm with LPN HH confirmed attendance of the QAPI meeting held on Monday, 3/31/2025, and verified attendance and her name on the sign-in page.
Further interview confirmed they discussed the Behavioral Health policy and confirmed the list of residents on the form titled Resident List was reviewed related to sexual behaviors.
She revealed how they came up with the names on the list.
They were not all current or new residents, but also included residents who had sexual behaviors in the past.
She confirmed all the residents (22) on the list were reviewed/discussed for sexually inappropriate behaviors, documented if they had behavior monitoring in place or not, two new referrals were made on 3/31/2025, and revealed both were seen by the [named] behavioral health NP on Tuesday, 4/1/2025.
Interview on 4/3/2025 at 2:10 pm with LPN GG confirmed attendance of the QAPI meeting held on Monday 3/31/2025 and verified attendance and her name on the sign-in page.
She also confirmed they reviewed the Behavioral Health policy, discussed all the residents on the list, and two new referrals were made 3/31/2025.
Both residents were seen 4/1/2025 by [named] behavioral health service NP.
All corrective actions will be completed on 3/31/2025.
The immediate jeopardy will be removed on 4/1/2025.
Cross-reference F-F600
115522 04/03/2025
Orchard Health and Rehabilitation 1321 Pulaski School Road Pulaski, GA 30451
include adhering to the Abuse policy.
She confirmed that QAPI education was also provided to the
jeopardy to resident health or inappropriate behavior.
She confirmed that education had been completed with staff on abuse, safety including intervening to protect a patient from further abuse.
She also confirmed that in March 31, 2025, a review was completed to ensure that audits were completed for F-F600, F-F867, and F-F740,
interventions for inappropriate sexual behavior.
She confirmed that audits will continue until the removal of IJ. On 4/3/2025 verified by record review of an audit titled, Quality Improvement DATA Collection Grid.
Indicators: 1.
Any noted sexually inappropriate behavior. 2. If so, were non-pharmalogical interventions implemented 3.
Care Plan updated. 4.
Was change in conditions completed? This tool will indicate whether the indicator was met, three residents were identified no to all indicators and was implemented on 4/3/2025, 4/2/2025, and 4/1/2025. On 4/3/2025 verified by interview with DON that audits will be continued until QAPI committee deems to no longer need audits. DON also confirmed that audits are implemented daily and reported to Administrator Assistance.
She explained that the IJ tags are audited based on expectations of monitoring for tracking of residents with inappropriate behavior.
All corrective actions were completed on 3/31/2025.
The facility alleges that the IJ was removed on 4/1/2025.
115522 04/03/2025
Orchard Health and Rehabilitation 1321 Pulaski School Road Pulaski, GA 30451
dated 3/31/2025, presented by Senior Director of Clinical Standards. On 4/3/2025 at 2:08 pm
jeopardy to resident health or will be conducted as the {Named} Behavioral Health enters and exits the facility. In further interview safety she revealed that they will identify residents that are acute episode and routine visits.
The communication between {Named} Behavioral Health and nursing staff will increase to ensure that
behaviors or behaviors. On 4/3/2025 at 2:27 pm LPN HH confirmed that she attended QAPI meeting and she was educated on 3/31/2025 titled, Behavior Health Process presented by Senior Director of Clinical. In further interviews she revealed that this audit has been conducted since 4/1/2025 the indicators: 1.Were there any self-reportable for sexually inappropriately behaviors submitted? 2. If so, was there an RCA completed to identify trends? LPN GG revealed that no reports were reported to nursing leadership on 4/1/2025, 4/2/2025, or 4/3/2025. A record review conducted on 4/3/2025 at 2:47 pm of the Quality improvement Data Collection Grid was implemented by nursing staff submitting information to assistant Administrator and reviewed by Senior Director for 4/1/2025, 4/2/2025 and 4/3/2025.The results self-reportable for sexually inappropriate behaviors were submitted no reports.
On 4/3/2025 Certified Nursing Assistant (CNA) BB revealed that she is aware that they must report any sexual abuse behaviors for all residents she works on the memory unit. An observation was conducted on 4/3/2025 at 3:33 pm on memory unit residents were singing and calm in TV room no sexual behaviors were seen or heard.
Staff were involved with residents and CNAs and Nursing staff are monitoring residents.
Residents were observed in TV room CNAs were in room observing residents. On Hall C residents were seen in halls chatting with one another no sexual abuse seen or heard on halls.
Residents are communicating with each other no issues found.
Nursing staff are visible and monitoring and interacting with residents. On 4/3/2025 at 3:53 pm an audit of reportable in the last 30 days has been identified on 3/31/2025 of 6 residents that were identified with the date of incident and nature of incident.
All corrective actions were completed on 3/31/2025.
The Facility alleges IJ Removal 4/1/2025.
F-F600 the policy for abuse education was reviewed to include response to sexual abuse, Non-Pharmacological Interventions to manage behaviors, Patient interviews completed on 3/31/2025 by social service director to interviewIO residents to ensure they feel safe and IO associates interviews to ensure they know process for reporting and can identify abuse to include sexual and physical aggression.
Audit will continued until IJ removed.
F-F740, ensuring that patients were safe and that staff understood the education on non pharmacological interventions for inappropriate sexual/physical behavior, and QAPI review completed as indicate on reportable for trends.
Any noncompliance noted will be addressed through written education by the Divisional [NAME] President.
The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows:
1. On 4/3/2025 at 12:55 pm verified by record review of a 5-way tool was used during QAPI meeting that held on
115522
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 115522 B.
Wing 04/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Orchard Health and Rehabilitation 1321 Pulaski School Road Pulaski, GA 30451
F-F835 a daily review for oversight will be completed by the Divisional [NAME] president and/or Senior Director of Clinical Standards to ensure that audits were completed for
F-F867 - QAPI education was provided to include trending RCA to analyze resources needed to decrease or prevent reoccurrence.
Communication tool was developed and implemented on 3/31/2025 by DON to improve the communication between the behavior provider and center to provide notification of any recommendations timely.
The behavior provider will meet with the DON, ADON, and/or nurse supervisor upon entrance and exit to make aware of any new recommendation and to receive report of new adverse events.
Nurse Managers will update the patient care plan with any non-pharmacological interventions to the patient care plan.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.