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Deficiency Records for Orchard Gardens
A list of the most recent deficiencies for Orchard Gardens. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Orchard Gardens. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-09 | 2024-05-09 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-08 | 2024-01-30 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-01-30 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-08 | 2024-01-30 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-01-08 | 2024-01-30 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-20 | 2024-01-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-12 | 2023-10-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-09-12 | 2023-10-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-12 | 2023-10-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-09-12 | 2023-10-18 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-12 | 2023-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-12 | 2023-10-18 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-12 | 2023-10-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-12 | 2023-10-18 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-09-12 | 2023-10-18 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-12 | 2023-10-18 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-12 | 2023-10-18 | Y |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-09-12 | 2023-10-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-12 | 2023-10-18 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-12 | 2023-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-12 | 2023-10-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-12 | 2023-10-18 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-14 | 2023-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-09 | 2023-05-09 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-08 | 2023-02-14 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-08 | 2023-02-14 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-08 | 2023-02-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-08 | 2023-01-13 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-12-08 | 2023-01-13 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-12-08 | 2023-01-13 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2021-12-14 | 2022-03-21 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-11-30 | 2021-12-30 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-30 | 2021-12-30 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-30 | 2021-12-30 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-30 | 2021-12-30 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-30 | 2021-12-30 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-11-30 | 2021-12-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-30 | 2021-12-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-30 | 2021-12-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-30 | 2021-12-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-11-30 | 2021-12-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-29 | 2021-12-24 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-13 | 2021-10-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-21 | 2020-02-27 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-01-21 | 2020-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-21 | 2020-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-21 | 2020-02-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-21 | 2020-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-21 | 2020-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-21 | 2020-02-27 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-21 | 2020-02-27 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-01-21 | 2020-02-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-01-21 | 2020-02-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-21 | 2020-02-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-01-21 | 2020-02-27 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-01-21 | 2020-02-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-21 | 2020-02-27 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-01-21 | 2020-02-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-01-21 | 2020-02-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-01-21 | 2020-02-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-21 | 2020-02-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-01-21 | 2020-02-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-05 | 2020-01-03 | N |
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