A list of the most recent deficiencies for The Orchard - Post Acute Care. 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? |
|---|---|---|---|---|
| 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 | 2023-08-18 | 2023-10-26 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-09-28 | 2023-10-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-18 | 2023-09-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-18 | 2023-09-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-09 | 2023-04-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-20 | 2023-01-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-06 | 2023-01-25 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-13 | 2022-10-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-16 | 2022-09-22 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-19 | 2022-07-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-26 | 2022-02-16 | Y |
| 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 | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide activities to meet all resident's needs. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-09 | 2022-01-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-09 | 2022-01-19 | 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 | 2021-12-09 | 2022-01-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-19 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-12-09 | 2022-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2022-01-19 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-09 | 2022-01-19 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-06-02 | 2021-07-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-11 | 2021-04-14 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-11 | 2021-04-14 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-08 | 2020-01-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-08 | 2020-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-08 | 2020-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-10 | 2020-01-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-01-10 | 2020-01-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-10 | 2020-01-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-10 | 2020-01-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-01-10 | 2020-01-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-10 | 2020-01-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-01-10 | 2020-01-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-10 | 2020-01-30 | 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 | 2020-01-10 | 2020-01-30 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2020-01-10 | 2020-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-10 | 2020-01-30 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-01-10 | 2020-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-10 | 2020-01-30 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-10 | 2020-01-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-10 | 2020-01-30 | 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 | 2018-12-20 | 2019-01-23 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-12-20 | 2019-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-20 | 2019-01-23 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-12-21 | 2019-01-22 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2018-12-21 | 2019-01-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-21 | 2019-01-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-21 | 2019-01-22 | 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 | 2018-12-21 | 2019-01-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-21 | 2019-01-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-21 | 2019-01-22 | 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 | 2018-12-21 | 2019-01-22 | 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 | 2018-12-21 | 2019-01-22 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2018-12-21 | 2019-01-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-21 | 2019-01-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-12-21 | 2019-01-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-12-21 | 2019-01-22 | N |
