Deficiency Records for Orchard Gardens
Updated as of November 01, 2020
This is not the most recent data for Orchard Gardens. For the most recent information, click here.
A list of the most recent deficiencies for Orchard Gardens. 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 a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-03-02 | 2020-04-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-03-02 | 2020-04-09 | 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 | 2020-03-02 | 2020-04-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-02 | 2020-04-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-03-02 | 2020-04-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-01-21 | 2020-02-27 | 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 | 2020-01-21 | 2020-02-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-21 | 2020-02-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-21 | 2020-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-21 | 2020-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-21 | 2020-02-27 | 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 | 2020-01-21 | 2020-02-27 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2020-01-21 | 2020-02-27 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-01-21 | 2020-02-27 | 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 | 2020-01-21 | 2020-02-27 | 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 | 2020-01-21 | 2020-02-27 | 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 | 2020-01-21 | 2020-02-27 | 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 | 2020-01-21 | 2020-02-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2020-01-21 | 2020-02-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-01-21 | 2020-02-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-21 | 2020-02-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-01-21 | 2020-02-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-21 | 2020-02-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-21 | 2020-02-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-05 | 2020-01-03 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-10-15 | 2019-10-23 | 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 | 2019-09-24 | 2019-10-23 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-24 | 2019-10-23 | 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 | 2019-09-24 | 2019-10-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-24 | 2019-10-23 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-08-13 | 2019-08-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-13 | 2019-08-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-08-13 | 2019-08-30 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-09-11 | 2018-10-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-08 | 2018-08-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-05-08 | 2018-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-07-03 | 2018-07-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-07-03 | 2018-07-27 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-03 | 2018-07-27 | 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 | 2018-07-03 | 2018-07-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-03 | 2018-07-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-05-08 | 2018-05-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-08 | 2018-05-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-05-08 | 2018-05-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-02-20 | 2018-03-29 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2017-12-11 | 2018-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-12-11 | 2018-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2017-12-11 | 2018-03-29 | 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 | 2017-12-11 | 2018-03-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2017-12-11 | 2018-03-29 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2017-12-11 | 2018-03-29 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2017-12-11 | 2018-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2017-12-11 | 2018-03-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2017-12-11 | 2018-03-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-12-11 | 2018-03-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-11 | 2018-01-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-12-11 | 2018-01-20 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2017-12-11 | 2018-01-20 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2017-12-11 | 2018-01-20 | 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 | 2017-12-11 | 2018-01-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2017-12-11 | 2018-01-20 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2017-12-11 | 2018-01-20 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2017-12-11 | 2018-01-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2017-12-11 | 2018-01-20 | Y |
| 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 | 2017-12-11 | 2018-01-20 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2017-12-11 | 2018-01-20 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2017-12-11 | 2018-01-20 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-11 | 2018-01-20 | 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 | 2017-12-11 | 2018-01-20 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2017-12-11 | 2018-01-20 | 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 | 2017-12-11 | 2018-01-20 | 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 | 2017-12-11 | 2018-01-20 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2017-12-11 | 2018-01-20 | Y |
| 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 | 2017-12-11 | 2018-01-20 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2017-12-11 | 2018-01-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-11 | 2018-01-20 | 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 | 2017-12-11 | 2018-01-20 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2017-12-11 | 2018-01-10 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2017-09-12 | 2017-10-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-09-12 | 2017-10-12 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-12 | 2017-10-12 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-09-12 | 2017-10-12 | Y |
