Deficiency Records for Prestige Care and Rehabilitation - The Orchards
Updated as of March 01, 2024
A list of the most recent deficiencies for Prestige Care and Rehabilitation - The Orchards. 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? |
|---|---|---|---|---|
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-10-20 | 2023-11-30 | N |
| 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 | 2023-10-20 | 2023-11-30 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-10-20 | 2023-11-30 | 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 | 2023-10-20 | 2023-11-30 | 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 | 2023-10-20 | 2023-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-20 | 2023-11-30 | 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 | 2023-10-20 | 2023-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-20 | 2023-11-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-10-20 | 2023-11-30 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-20 | 2023-11-30 | N |
| Provide or obtain dental services for each resident. | Health | 2023-10-20 | 2023-11-30 | 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 | 2023-10-20 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-20 | 2023-11-30 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-10-20 | 2023-11-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-20 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-20 | 2023-11-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-10-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-03 | 2022-08-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-03 | 2022-08-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-08 | 2022-08-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-08 | 2022-08-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-08 | 2022-08-31 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-07-08 | 2022-08-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-24 | 2019-07-10 | 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 | 2019-05-24 | 2019-07-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-24 | 2019-07-10 | 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 | 2019-05-24 | 2019-07-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-24 | 2019-07-10 | 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 | 2019-05-24 | 2019-07-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-24 | 2019-07-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-05-24 | 2019-07-10 | 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 | 2019-05-24 | 2019-07-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-24 | 2019-07-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Meet other general requirements. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-11-01 | 2019-01-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-10 | 2018-09-20 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2018-08-10 | 2018-09-20 | 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 | 2018-08-10 | 2018-09-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-10 | 2018-09-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-10 | 2018-09-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-08-10 | 2018-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-10 | 2018-09-20 | 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 | 2018-08-10 | 2018-09-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-10 | 2018-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-10 | 2018-09-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-10 | 2018-09-20 | 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 | 2018-08-10 | 2018-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-10 | 2018-09-20 | 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 | 2018-08-10 | 2018-09-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-08-10 | 2018-09-20 | 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 | 2018-08-10 | 2018-09-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-10 | 2018-09-20 | 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 | 2018-08-10 | 2018-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-10 | 2018-09-20 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-08-10 | 2018-09-20 | N |
| Meet other general requirements. | Fire Safety | 2017-10-24 | 2017-12-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2017-10-24 | 2017-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-10-24 | 2017-12-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-10-24 | 2017-12-12 | N |
