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Deficiency Records for New Orange Hills
A list of the most recent deficiencies for New Orange Hills. 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 New Orange Hills. 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? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-08-01 | 2024-08-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-30 | 2024-06-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-21 | 2024-04-13 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-03-21 | 2024-04-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-21 | 2024-04-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-12 | 2024-03-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-24 | 2024-02-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-24 | 2024-02-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-24 | 2024-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-13 | 2023-12-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-13 | 2023-12-29 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-11-17 | 2023-12-05 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-23 | 2023-11-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-30 | 2023-09-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-30 | 2023-09-12 | Y |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-08-30 | 2023-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-05-16 | Y |
| 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 | 2023-05-16 | 2023-05-16 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-16 | 2023-05-16 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-05-16 | 2023-05-16 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-04 | 2023-05-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-04 | 2023-05-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-26 | 2023-02-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-26 | 2023-02-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-26 | 2023-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-24 | 2023-02-22 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-24 | 2023-02-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-24 | 2023-02-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-11-23 | 2022-12-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2022-12-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-11 | 2022-09-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-11 | 2022-09-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-22 | 2022-09-08 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-16 | 2022-06-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-16 | 2022-06-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-05-16 | 2022-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-16 | 2022-06-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-16 | 2022-06-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-16 | 2022-06-16 | 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 | 2022-05-16 | 2022-06-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-16 | 2022-06-16 | 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 | 2022-05-16 | 2022-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-16 | 2022-06-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-05-16 | 2022-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-16 | 2022-06-16 | N |
| Keep all essential equipment working safely. | Health | 2022-05-16 | 2022-06-16 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Develop a communication plan. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Use approved construction type or materials. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-17 | 2022-06-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-06 | 2022-06-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-06 | 2022-05-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-01 | 2022-03-02 | 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 | 2022-02-01 | 2022-03-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-10 | 2022-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-18 | 2021-11-18 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-18 | 2021-11-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-10-18 | 2021-11-18 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-07-22 | 2020-08-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-26 | 2020-03-26 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-02-26 | 2020-03-26 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-02-26 | 2020-03-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide appropriate foot care. | Health | 2020-02-26 | 2020-03-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-26 | 2020-03-26 | 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 | 2020-02-26 | 2020-03-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-02-26 | 2020-03-26 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-26 | 2020-03-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-02-26 | 2020-03-26 | 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 | 2020-02-26 | 2020-03-26 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-02-26 | 2020-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-26 | 2020-03-26 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-26 | 2020-03-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-26 | 2020-03-26 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2020-02-26 | 2020-03-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-03-20 | 2019-04-08 | 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 | 2019-03-20 | 2019-04-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-20 | 2019-04-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-15 | 2019-02-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-01-15 | 2019-02-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-01-15 | 2019-02-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-01-15 | 2019-02-15 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-01-15 | 2019-02-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-01-15 | 2019-02-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-01-15 | 2019-02-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-01-15 | 2019-02-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-01-15 | 2019-02-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-15 | 2019-02-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-15 | 2019-02-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-15 | 2019-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-15 | 2019-02-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-15 | 2019-02-15 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-01-15 | 2019-02-15 | N |
| Post nurse staffing information every day. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-15 | 2019-02-15 | 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 | 2019-01-15 | 2019-02-15 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-15 | 2019-02-15 | 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 | 2019-01-15 | 2019-02-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-15 | 2019-02-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-15 | 2019-02-15 | 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 | 2019-01-15 | 2019-02-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-15 | 2019-02-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-15 | 2019-02-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-01-15 | 2019-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-15 | 2019-02-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-15 | 2019-02-15 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2019-01-15 | 2019-02-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-01-15 | 2019-02-15 | N |
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