Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple psychiatric diagnoses was sexually and physically abused by another resident with a known history of sexually inappropriate and aggressive behaviors. Despite documented incidents and behavioral health recommendations, the facility did not implement or communicate effective interventions, resulting in the abusive event being witnessed by an LPN and confirmed by hospital and law enforcement reports.
A resident with severe cognitive impairment and a history of sexual aggression did not receive individualized behavioral health services or nonpharmacological interventions, despite documented worsening behaviors and staff awareness of the risks. The care plan lacked specific interventions for sexual aggression, and staff did not implement recommended strategies, resulting in the resident sexually abusing another resident.
Facility administration failed to provide adequate oversight and did not take appropriate action on allegations of resident-to-resident abuse. A resident with a history of sexually aggressive behavior assaulted another resident, and staff were aware of prior threats but did not implement effective monitoring or interventions. The administration also did not update procedures or ensure QAPI plans addressed abuse prevention, and there was no evidence of systematic monitoring or data collection for adverse events.
Facility staff did not maintain an effective QAPI program for sexual abuse prevention, failing to identify or address recurring abuse allegations. Despite multiple reports of inappropriate touching and abuse, the QAPI committee made no procedural changes, and PIP documentation lacked critical data and follow-up. Leadership confirmed that no new interventions or processes were implemented after a resident sexually abused another, with staff only instructed to report incidents to the DON and Administrator.
Failure to Protect Resident from Sexual and Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired resident from sexual and physical abuse by another resident with a known history of sexually inappropriate, agitated, and hostile behaviors. The resident who was abused had diagnoses including schizoaffective disorder, bipolar disorder, Alzheimer's, and major depressive disorder, and was assessed as having moderate cognitive impairment. The perpetrating resident had diagnoses of anxiety disorder, mild intellectual disabilities, and was newly diagnosed with hypersexuality. This resident had a documented history of making sexually inappropriate statements, attempting to enter other residents' rooms, and displaying aggressive behaviors toward both staff and other residents. Despite the perpetrating resident's ongoing behavioral issues, including documented incidents of sexual aggression and physical violence, the facility did not implement adequate interventions or monitoring as outlined in their own policies and behavioral health recommendations. The care plan for the perpetrating resident identified inappropriate sexual behaviors and wandering, but interventions were limited to behavior monitoring without clear evidence of effective preventive strategies. Staff and leadership were aware of the resident's behaviors, including recent threats to staff, but failed to communicate these risks effectively or to update care plans and interventions accordingly. The incident occurred when the perpetrating resident entered the victim's room, physically assaulted her, and committed sexual abuse. The event was witnessed by an LPN, who intervened and separated the residents. The victim was assessed and sent to the hospital, where a sexual assault was confirmed. Law enforcement was notified, and the perpetrating resident was arrested. The facility's failure to implement and communicate appropriate interventions and to follow up on behavioral health recommendations directly contributed to the occurrence of this abuse.
Removal Plan
- R48 was assessed for injury, changes in behavior, trauma, and pain. NP gave orders to send R48 to the Hospital for evaluation and treatment. The patient was sent to the hospital for evaluation and treatment. MD and family were notified. R48 was discharged back to the center from the hospital. Center nurses began observation on the patient to ensure feelings of safety with no noted distress. Patient had a visit with behavioral health for a psychosocial support visit. Patient refused to see the behavioral health NP. Patient did have visit by hospice. Behavior health visit for the patient completed.
- R121 was immediately removed from R48 room by the LPN Charge Nurse and placed on one-on-one observation by a CNA until police arrived at the center to test the patient. Patient R121 was arrested.
- Skin audits were conducted on all residents to evaluate for any signs of abuse by the facility charge nurses and nurse managers. R48 noted with bruising to the thigh. No other adverse findings for other patients were audited.
- Resident with BIMs of 10 and above were interviewed by licensed nursing staff.
- In-service education was initiated for staff and to include abuse prohibition, abuse reporting, burnout, and de-escalation for all staff of the facility. Education was provided by the Administrator, Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director.
- A Resident Council Meeting was held. Abuse & Neglect Prevention to include Residents Rights reviewed by Activities Director. R48 was in attendance at the meeting.
- Interviews were completed on all residents who are interviewable to identify any concerns for abuse by the Social Services Director, Director of Nursing (DON), Activity Director (AD), and Nurse Managers. All denied any type of abuse or neglect.
- R48 was interviewed by the Administrator. Expressed no problems at this time and was happy and planning to attend activities.
- A Root Cause Analysis was completed for the Abuse Prevention. Root Cause identified that the center failed to implement interventions to protect the residents as outlined on the behavior health visit. A communication tool was developed 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. Education of this process has been provided to the nurse leadership, SSD, and behavior provider by the DON.
- Education was provided to all cognitive residents regarding the Elder Justice Act and reporting of abuse by the Social Services Director and the Director of Social Services.
- Education provided to the center leadership team by the Governing Body on abuse prohibition policy to reviewing adverse events during Quality Assurance Performance Improvement (QAPI), recognizing trends to create proactive measures to reduce further reoccurrences, and utilization of non-pharmacological interventions as warranted for patients to promote safety of all patients.
- Re-education was completed for staff and to include abuse prohibition, abuse reporting to include physical and sexual aggression, burnout, and de de-escalation for all staff of the facility. Education was provided by the Director of Nursing (DON) Assistant Director of Nursing (ADON), Nurse Manager, or Social Services Director. All staff have been in serviced which totals 100%. No staff shall work until they have completed in-service education. Contract and newly hired associates will be educated upon hire on abuse prohibition, abuse reporting, burnout, and de-escalation by the Nurse Manager, DON, or ADON.
- Audits started by the social service director to interview residents to ensure they feel safe, and associates' interviews have been completed to ensure they know the process for reporting and can identify abuse, including sexual and physical aggression. Any noncompliance identified will be addressed by the Administrator assistant and/or [NAME] by written education, and incidents identified will be reported following the HFRD reporting protocol.
- The DON, Financial Controller, and Nurse Managers notified all current non-interviewable resident representatives via written notification on Abuse & Neglect Prevention Policy, and the Elder Justice Act and reporting.
- An ADHOC QAPI meeting was held with the Medical Director, center leadership, and Governing Body to notify of the deficiencies cited and the interventions implemented to ensure that the deficient practices do not reoccur. The Abuse Policy was reviewed with no needed revisions needed.
Failure to Provide Behavioral Health Services and Interventions for Sexual Aggression
Penalty
Summary
The facility failed to ensure that a resident with a history of severe cognitive impairment, catatonic schizophrenia, anxiety disorder, and a diagnosis of hypersexuality received necessary behavioral health care and services. Despite documented evidence of worsening sexual behaviors and sexual aggression, there were no physician orders or interventions in place to monitor or address these behaviors. The resident's care plan did not include specific problems, care areas, or interventions related to sexual abuse, sexual aggression, or sexual behaviors, and there was no revision to the care plan after documentation of sexually aggressive behaviors. Staff interviews and record reviews revealed that nonpharmacological interventions for sexual behaviors were not implemented or documented, even though behavioral health services had recommended such interventions. The resident exhibited inappropriate sexual behaviors, including making sexual comments to staff, attempting to kiss a nurse, and stating intentions to commit sexual assault. On one occasion, the resident sexually abused another resident in her room, and staff had to physically intervene to stop the incident. Documentation also showed that staff had been threatened by the resident in the weeks leading up to the incident. Although staff could describe examples of nonpharmacological interventions for managing sexual behaviors, these interventions were not put into practice for the resident in question. The care plan only referenced inappropriate sexual behavior under a general behavior category, without individualized or targeted interventions. The lack of appropriate assessment, care planning, and implementation of nonpharmacological interventions contributed to the opportunity for the resident to sexually and physically abuse another resident.
Removal Plan
- R121 was discharged from the facility and was arrested and did not return to the facility.
- The Assistant Administrator, DON, Division [NAME] President, and the medical director reviewed the facility's policy titled Behavioral Health. No revisions were indicated through review.
- An audit was completed by DN for residents with sexual inappropriate behaviors complete of all patients. A review of the plan of care was completed to ensure that nonpharmacological interventions were captured for residents that exhibited behaviors. A referral was initiated as appropriate by the DON.
- In-service education was initiated for RNs and LPNs and included identifying behavioral health needs, updating the plan of care and implementing interventions in the plan of care as outlined in the facility's Behavioral Health Policy to include nonpharmacological interventions. CNAs provided education on abuse reporting to include sexual inappropriate behaviors. Education was provided by the DON, Assistant Director of Nursing, Nurse Manager, or Social Services Director. All RNs, LPNs, CNAs, and CMAs have been in serviced. No staff shall work until they have completed in-service education. No new hires.
- An audit tool was developed by DON to review patients with inappropriate behaviors to ensure they have a non-pharmacological intervention noted on care plan. Any noncompliance noted will be addressed through written education by assistant administrator and/or DON.
Failure to Protect Residents from Abuse and Inadequate Oversight
Penalty
Summary
Facility administration failed to provide protective oversight to ensure the highest practicable physical and psychosocial well-being of residents. Specifically, administration did not take appropriate action on allegations of resident-to-resident physical and sexual abuse. One resident, who had a history of sexually aggressive behaviors, entered another resident's room and sexually and physically assaulted her. Staff and the DON were aware of prior threatening behaviors by the perpetrator, including threats to staff, but there was no evidence of effective monitoring or intervention to address these behaviors before the incident occurred. The administration did not complete a thorough investigation or implement non-pharmacological interventions for residents with inappropriate behaviors, as required. Behavioral health notes confirmed that the resident with aggressive behaviors was seen by a behavioral consultant, but there was no documentation or evidence that interventions specifically targeting sexual behaviors were put in place. The facility also failed to update or change procedures after multiple abuse allegations, and the QAPI team did not implement new plans or monitoring systems in response to these events. Additionally, the administration did not ensure that concerns related to abuse prevention were identified or that QAPI plans were implemented to address resident-to-resident abuse. The facility's abuse policies were not fully enacted, and there was a lack of systematic feedback, data collection, and monitoring for adverse events. The administrator could not recall details of the incident and did not take further action to revise processes or provide additional staff education following the assault, despite multiple allegations of abuse within the facility.
Removal Plan
- Police was notified by DON regarding the incident for R121 and an arrest was made.
- Ad hoc QAPI and performance improvement plan (PIP) was developed and initiated by the Director of Quality and Regulatory Services (DOQRS). The meeting discussion included plan development and citations issued for F-835, F-867, F-600, and F-740. The Medical Director was made aware by the Director of Nursing. The existing Abuse policies were reviewed and concluded no revisions were needed.
- The Division [NAME] President provided education to the Administrator on job description to include roles, responsibilities, and duties to ensure the safety of all residents. Education provided on the abuse prohibition policy to include reviewing adverse events during QAPI, recognizing trends to create proactive measures to reduce further reduce reoccurrences to ensure the safety of all residents.
- Corrective action for other residents having the potential to be affected by the same deficient practice.
- All residents who reside in the center have the potential to be impacted by the deficient practice.
- Systemic changes were made to ensure that the deficient practice would not recur.
- Oversight was provided by the Divisional Nurses (DN), Program Director of SSD, and Divisional [NAME] President (DVP) to ensure the Administrator and the DON were informed about and adhered to the Abuse policy in their day-to-day operations. The administrator was placed on administrative leave pending investigation, and oversight was provided by the Senior Director of Clinical Services (SRDCS). Oversight was provided by the Senior Director of Clinical Services (SRDCS), Program Director of SSD, and Director of Quality and Regulatory Services (DQRS). Education was provided to Administrator Assistant by DVP to ensure the day to day operations were being followed to include adhering to the Abuse policy, QAPI education was also provided to the leadership team to include monitoring and follow-up for adverse events and being proactive by tracking and trending to identified what resources are needed to be proactive when inappropriate behavior is noted by Director of Quality and Regulatory Services and Sr Director of Clinical Standards. DVP, Sr. DCS, and DORQ confirmed that education had been completed with staff on abuse, including intervening to protect a patient from further abuse. DVP and/or DN completed a review to ensure that audits were completed for F600, F867, and F740, ensuring that patients were safe, and that staff understood the education on non-pharmacological interventions for inappropriate sexual behavior, and QAPI review completed as indicate on reportable for trends. Audits will continue until the removal of IJ.
- Quality Assurance Plans were implemented to monitor facility performance, ensuring that corrections are implemented and remain permanent. An audit tool was developed and initiated by the Assistant Administrator and is being used daily to monitor the implementation of the Plan of Correction. The Assistant Administrator, Director of Nursing, or Assistant Director of Nursing will be responsible for ensuring the completion of this tool. The audits will be validated by the Governing body to include DVP, SrDCS, DOQR, and/or DN. The results of the monitoring completed under this plan of correction will be submitted monthly to the QAPI committee for review and further follow-up. The Audit tool will continue until the QAPI committee deems it is no longer necessary. Any noncompliance noted will be addressed through written education by the Divisional [NAME] President.
Failure to Maintain Effective QAPI Program for Sexual Abuse Prevention
Penalty
Summary
Facility staff failed to maintain an effective Quality Assurance/Performance Improvement (QAPI) program, specifically regarding the Performance Improvement Plan (PIP) for sexual abuse. The QAPI committee did not identify or prioritize problems and opportunities based on performance indicator data, resident and staff input, or other relevant information. Despite multiple allegations of sexual abuse, including a significant incident where one resident sexually abused another in her room, the QAPI team did not implement any changes in procedures or action plans to address these issues. Meeting minutes from several months showed that abuse allegations were discussed, but no procedural changes were made. The facility's PIP documentation for incidents of inappropriate touching and abuse lacked essential elements such as baseline data and identification of barriers, and did not specify which residents were involved. The PIP was marked as ongoing, but no further information or updates were provided to the survey team. The QAPI process, as outlined in the facility's own policy, was not followed, and the committee failed to conduct root cause analyses or implement systematic actions to address the recurring abuse allegations. Interviews with facility leadership confirmed that after months of abuse allegations, the only action taken was to instruct nursing staff to report incidents to the DON and Administrator, with no changes to existing procedures. Staff were required to discuss incidents with leadership before reporting, and no new processes or interventions were introduced following the sexual abuse incident. The facility's approach to handling sexual abuse remained unchanged, limited to notifying authorities and family, without any proactive measures to prevent recurrence or address systemic issues.
Removal Plan
- The QAPI committee reviewed reportable adverse events to determine if any trends were identified, noted that some behaviors were a result of GDRs, and established a communication tool to provide to the behavioral health provider upon entrance and to schedule an exit meeting after the visit to include review of GDRs.
- An ad hoc meeting was held by the Director of Quality and Regulatory to review F-835, F-867, F-740, and F-600, and a performance improvement plan was developed.
- The policy for abuse education was reviewed to include response to sexual abuse and non-pharmacological interventions to manage behaviors.
- Patient interviews were completed by social service director to interview residents to ensure they feel safe and associate interviews to ensure they know process for reporting and can identify abuse to include sexual and physical aggression. Audit will continue until IJ removed.
- QAPI education was provided to include trending RCA to analyze resources needed to decrease or prevent reoccurrence.
- A communication tool was developed and implemented 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.
- An audit tool was developed by DON to review patients with inappropriate behaviors to ensure they have non-pharmacological interventions noted on care plan. Audit will continue until IJ removed.
- Education of this process has been provided to the nurse leadership and behavior provider by the DON.
- Any noncompliance will be brought back through QAPI process and addressed through the PDSA framework to identify RCA through the QAPI committee.
- A daily review for oversight will be completed by the Divisional President and/or Senior Director of Clinical Standards to ensure that audits were completed for F600, F867, and 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 indicated on reportable for trends.
- Any noncompliance noted will be addressed through written education by the Divisional President.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pulaski
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Nursing Center | 5.4 mi | ★★★★★ | 6 | 0 |
| Azalea Health And Rehabilitation | 6.1 mi | ★★★★★ | 8 | 0 |
| Westwood Healthcare And Rehabilitation | 10.6 mi | ★★★★★ | 0 | 0 |
| Eagle Health & Rehabilitation | 10.7 mi | ★★★★★ | 0 | 0 |
| Brown's Health And Rehabilitation | 10.9 mi | ★★★★★ | 4 | 0 |
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