Deficiency Records for Orange Healthcare and Wellness Centre, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Orange Healthcare and Wellness Centre, LLC. 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-18 | 2024-02-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-18 | 2024-02-09 | 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 | 2023-10-24 | 2023-11-23 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-24 | 2023-11-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-24 | 2023-11-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-24 | 2023-11-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-24 | 2023-11-10 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-10-24 | 2023-11-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-05 | 2023-02-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-21 | 2022-11-03 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-21 | 2022-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-21 | 2022-11-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-21 | 2022-11-03 | 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 | 2022-09-21 | 2022-11-03 | 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 | 2022-09-21 | 2022-11-03 | 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 | 2022-09-21 | 2022-11-03 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-02-03 | 2022-03-03 | Y |
| 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 | 2022-02-03 | 2022-03-03 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-16 | 2021-12-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-16 | 2021-12-27 | 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 | 2021-11-16 | 2021-12-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-16 | 2021-12-27 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-11-16 | 2021-12-27 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-16 | 2021-12-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-11-16 | 2021-12-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-15 | 2021-12-15 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-15 | 2021-12-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-15 | 2021-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-11-15 | 2021-12-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-15 | 2021-12-15 | 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 | 2021-11-15 | 2021-12-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-15 | 2021-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-15 | 2021-12-15 | 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 | 2021-11-15 | 2021-12-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-15 | 2021-12-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-15 | 2021-12-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-15 | 2021-12-15 | 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 | 2021-11-15 | 2021-12-15 | 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 | 2021-11-15 | 2021-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-15 | 2021-12-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-15 | 2021-12-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-15 | 2021-12-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-12 | 2021-11-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-15 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-15 | 2021-07-15 | Y |
| 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 | 2021-06-15 | 2021-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-15 | 2021-07-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-28 | 2021-05-28 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-14 | 2021-05-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-14 | 2020-04-02 | 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 | 2020-01-14 | 2020-04-02 | 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 | 2020-01-14 | 2020-03-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-14 | 2020-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-14 | 2020-03-03 | 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 | 2020-01-14 | 2020-03-03 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-14 | 2020-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-14 | 2020-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-14 | 2020-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-14 | 2020-03-03 | 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 | 2020-01-14 | 2020-03-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-01-14 | 2020-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-14 | 2020-03-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-14 | 2020-03-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-14 | 2020-03-03 | 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 | 2020-01-14 | 2020-03-03 | 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 | 2020-01-14 | 2020-03-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-01-14 | 2020-03-03 | 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 | 2020-01-14 | 2020-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-14 | 2020-03-03 | 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 | 2020-01-14 | 2020-03-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-01-14 | 2020-02-03 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-21 | 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 | 2019-03-21 | 2019-04-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-03-21 | 2019-04-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-30 | 2019-02-26 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-01-30 | 2019-02-26 | 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 | 2019-01-30 | 2019-02-26 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-01-30 | 2019-02-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-01-30 | 2019-02-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide activities to meet all resident's needs. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-30 | 2019-02-26 | 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 | 2019-01-30 | 2019-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-01-30 | 2019-02-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-30 | 2019-02-26 | 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 | 2019-01-30 | 2019-02-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-30 | 2019-02-26 | 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 | 2019-01-30 | 2019-02-26 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-30 | 2019-02-26 | 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 | 2019-01-30 | 2019-02-26 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-01-30 | 2019-02-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-30 | 2019-02-26 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-01-30 | 2019-02-26 | N |
