Deficiency Records for Orchard Hill Rehabilitation and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Orchard Hill Rehabilitation and Healthcare Center. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-23 | 2021-08-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-30 | 2021-08-10 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2021-06-30 | 2021-08-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-30 | 2021-08-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-30 | 2021-08-10 | 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 | 2021-06-30 | 2021-08-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-30 | 2021-08-10 | 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 | 2021-06-30 | 2021-08-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-06-30 | 2021-08-10 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2021-06-30 | 2021-08-10 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-06-30 | 2021-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-30 | 2021-08-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-30 | 2021-08-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-30 | 2021-08-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-06-30 | 2021-08-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-30 | 2021-08-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-30 | 2021-08-10 | 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 | 2021-06-30 | 2021-08-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-30 | 2021-08-10 | 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 | 2021-06-30 | 2021-08-10 | N |
| Post nurse staffing information every day. | Health | 2021-06-30 | 2021-08-10 | 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 | 2021-06-30 | 2021-08-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-30 | 2021-08-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-30 | 2021-08-10 | N |
| Provide or obtain dental services for each resident. | Health | 2021-06-30 | 2021-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-30 | 2021-08-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-30 | 2021-08-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-06-30 | 2021-08-10 | 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 | 2021-06-30 | 2021-08-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-30 | 2021-08-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-30 | 2021-08-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-30 | 2021-08-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-30 | 2021-08-10 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-06-30 | 2021-08-10 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-23 | 2021-07-30 | 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 | 2021-06-23 | 2021-07-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-23 | 2021-07-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-23 | 2021-07-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-26 | 2018-11-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-09-26 | 2018-11-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-09-26 | 2018-11-08 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2018-09-26 | 2018-11-08 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-09-26 | 2018-11-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-09-26 | 2018-11-08 | 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 | 2018-09-26 | 2018-11-08 | 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 | 2018-09-26 | 2018-11-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-09-26 | 2018-11-08 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-26 | 2018-11-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-26 | 2018-11-08 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-09-26 | 2018-11-08 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-09-26 | 2018-11-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-26 | 2018-11-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-26 | 2018-11-08 | 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 | 2018-09-26 | 2018-11-08 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-26 | 2018-11-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-26 | 2018-11-08 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-09-26 | 2018-11-08 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-09-26 | 2018-11-08 | 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 | 2018-09-26 | 2018-11-08 | 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 | 2018-09-26 | 2018-11-08 | 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 | 2018-09-26 | 2018-11-08 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-26 | 2018-11-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-09-26 | 2018-11-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-26 | 2018-11-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-26 | 2018-11-08 | N |
| Meet other general requirements. | Fire Safety | 2018-10-15 | 2018-11-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-10-15 | 2018-11-01 | 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 | 2018-10-15 | 2018-11-01 | 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 | 2018-10-15 | 2018-11-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-15 | 2018-11-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-10-15 | 2018-11-01 | 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 | 2018-10-15 | 2018-11-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-06-16 | 2017-07-21 | 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 | 2017-06-16 | 2017-07-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-16 | 2017-07-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2017-06-16 | 2017-07-21 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2017-06-16 | 2017-07-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-06-06 | 2017-07-14 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-06-06 | 2017-07-14 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-06-06 | 2017-07-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-06-06 | 2017-07-14 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-06 | 2017-07-14 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-06 | 2017-07-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-06-06 | 2017-07-14 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-06 | 2017-07-14 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-06-06 | 2017-07-14 | N |
| Ensure that residents receive proper treatment and assistive devices to maintain their vision and hearing. | Health | 2017-06-06 | 2017-07-14 | N |
| Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion, unless it is unavoidable due to resident?s clinical condition. | Health | 2017-06-06 | 2017-07-14 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-06-06 | 2017-07-14 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-06 | 2017-07-14 | N |
| Provide or obtain dental services for each resident. | Health | 2017-06-06 | 2017-07-14 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-06-06 | 2017-07-14 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-06-06 | 2017-07-14 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-06-06 | 2017-07-14 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2017-06-06 | 2017-07-14 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-06 | 2017-07-14 | N |
