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Deficiency Records for The Orchards Post-Acute
A list of the most recent deficiencies for The Orchards Post-Acute. 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 The Orchards Post-Acute. 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 | 2024-09-27 | 2024-10-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-28 | 2024-09-26 | 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 | 2024-08-27 | 2024-09-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-17 | 2024-08-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-19 | 2024-07-15 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-06-19 | 2024-07-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-06-17 | 2024-06-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-06 | 2024-05-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-06 | 2024-05-29 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-28 | 2024-03-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-26 | 2024-03-22 | 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 | 2024-02-26 | 2024-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-02-26 | 2024-03-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-15 | 2024-03-15 | 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 | 2024-02-15 | 2024-03-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-02-15 | 2024-03-15 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-02-15 | 2024-03-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-02-15 | 2024-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-15 | 2024-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-02-15 | 2024-03-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-15 | 2024-03-15 | 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 | 2024-02-15 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-15 | 2024-03-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-15 | 2024-03-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-15 | 2024-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-15 | 2024-03-15 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-02-15 | 2024-03-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-02-15 | 2024-03-15 | 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 | 2024-02-05 | 2024-02-24 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-01-22 | 2024-02-16 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-11-14 | 2023-11-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-06 | 2023-11-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-06 | 2023-10-20 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-10-02 | 2023-10-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-02 | 2023-10-20 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-02 | 2023-10-20 | Y |
| 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 | 2023-10-02 | 2023-10-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-05 | 2023-10-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-28 | 2023-09-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-21 | 2023-09-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-23 | 2023-09-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-07-26 | 2023-08-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-14 | 2023-07-28 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-05-15 | 2023-06-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-08 | 2023-02-27 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-07 | 2023-02-24 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-05 | 2023-01-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-05 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-06 | 2023-01-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-12 | 2023-01-11 | Y |
| 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 | 2022-12-12 | 2023-01-11 | Y |
| 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 | 2022-11-29 | 2022-12-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-19 | 2022-11-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-22 | 2022-10-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-28 | 2022-10-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-24 | 2022-09-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-24 | 2022-09-06 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-07-12 | 2022-08-01 | Y |
| 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 | 2022-07-12 | 2022-08-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-07 | 2022-07-28 | Y |
| 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 | 2022-07-07 | 2022-07-28 | 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 | 2022-07-07 | 2022-07-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-07 | 2022-07-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-14 | 2022-05-23 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-04-14 | 2022-05-23 | 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 | 2022-04-14 | 2022-05-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-14 | 2022-05-23 | 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 | 2022-04-14 | 2022-05-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-14 | 2022-05-23 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-14 | 2022-05-23 | 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 | 2022-04-14 | 2022-05-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-14 | 2022-05-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-14 | 2022-05-23 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-04-14 | 2022-05-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-23 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-04-14 | 2022-05-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-14 | 2022-05-23 | N |
| Keep all essential equipment working safely. | Health | 2022-04-14 | 2022-05-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-14 | 2022-05-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-20 | 2022-05-09 | 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 | 2022-04-20 | 2022-05-09 | 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 | 2022-04-20 | 2022-05-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-20 | 2022-05-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-07 | 2022-04-26 | Y |
| 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 | 2022-03-28 | 2022-04-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-28 | 2022-04-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-29 | 2022-04-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-24 | 2022-02-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-23 | 2022-01-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-23 | 2022-01-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-16 | 2022-01-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-16 | 2022-01-04 | Y |
| 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 | 2021-11-01 | 2021-11-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-01 | 2021-11-24 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-05 | 2020-02-25 | 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 | 2020-02-05 | 2020-02-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2020-02-05 | 2020-02-25 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-12 | 2020-02-05 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-12-12 | 2020-02-05 | 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 | 2019-12-12 | 2020-02-05 | 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 | 2019-12-12 | 2020-02-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-12 | 2020-02-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-12 | 2020-02-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-12-12 | 2020-02-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-02-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-12 | 2020-02-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-12-12 | 2020-02-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-12 | 2020-02-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-12-12 | 2020-02-05 | 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 | 2019-12-12 | 2020-02-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-12 | 2020-02-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-12 | 2020-02-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-02-05 | N |
| Keep all essential equipment working safely. | Health | 2019-12-12 | 2020-02-05 | N |
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