A list of the most recent deficiencies for Orchard 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? |
|---|---|---|---|---|
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-14 | 2023-08-25 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-01-24 | 2023-02-03 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2022-01-27 | 2022-02-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-27 | 2022-02-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-27 | 2022-02-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-27 | 2022-02-22 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-27 | 2022-02-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-01-27 | 2022-02-22 | 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 | 2022-01-21 | 2022-02-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-21 | 2022-02-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-21 | 2022-02-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-21 | 2022-02-17 | 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 | 2022-01-21 | 2022-02-17 | 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 | 2022-01-21 | 2022-02-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-21 | 2022-02-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-21 | 2022-02-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-03-20 | 2019-06-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-03-20 | 2019-06-07 | 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 | 2019-03-20 | 2019-06-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-03-20 | 2019-06-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-20 | 2019-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-20 | 2019-06-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-20 | 2019-06-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-20 | 2019-06-07 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-20 | 2019-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-20 | 2019-06-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-03-20 | 2019-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-20 | 2019-06-07 | 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 | 2019-03-20 | 2019-06-07 | 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 | 2019-03-20 | 2019-06-07 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-03-20 | 2019-06-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-20 | 2019-06-07 | 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 | 2019-03-20 | 2019-06-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-03-20 | 2019-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-20 | 2019-06-07 | 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 | 2019-03-20 | 2019-06-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-20 | 2019-06-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-20 | 2019-06-07 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-03-20 | 2019-06-07 | N |
| Keep all essential equipment working safely. | Health | 2019-03-20 | 2019-06-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-11 | 2019-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-13 | 2018-06-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-04-13 | 2018-06-07 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-15 | 2018-05-31 | 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 | 2018-05-15 | 2018-05-31 | 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 | 2018-05-15 | 2018-05-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-15 | 2018-05-31 | N |
