Deficiency Records for The Orchards at Southgate
Updated as of October 01, 2018
This is not the most recent data for The Orchards at Southgate. For the most recent information, click here.
A list of the most recent deficiencies for The Orchards at Southgate. 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2018-07-16 | 2018-08-03 | Y |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-16 | 2018-08-03 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-01-23 | 2018-02-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-25 | 2018-02-14 | 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 | 2018-01-25 | 2018-02-14 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-25 | 2018-02-14 | N |
| Respond appropriately to all alleged violations. | Health | 2018-01-25 | 2018-02-14 | 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 | 2018-01-25 | 2018-02-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-01-25 | 2018-02-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-25 | 2018-02-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-25 | 2018-02-14 | 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 | 2018-01-25 | 2018-02-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-01-25 | 2018-02-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-01-25 | 2018-02-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-25 | 2018-02-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-25 | 2018-02-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-25 | 2018-02-14 | 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 | 2018-01-25 | 2018-02-14 | Y |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-11-15 | 2017-12-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-11-15 | 2017-12-05 | Y |
| Have enough nurses to care for every resident in a way that maximizes the resident's well being. | Health | 2017-11-15 | 2017-12-05 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-15 | 2017-08-25 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-02-10 | 2017-03-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-02-10 | 2017-03-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-02-10 | 2017-03-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2017-02-10 | 2017-03-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-02-10 | 2017-03-02 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-02-09 | 2017-02-24 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-02-09 | 2017-02-24 | N |
| Send unopened mail from residents and promptly deliver unopened mail to residents. | Health | 2017-02-09 | 2017-02-24 | 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 | 2017-02-09 | 2017-02-24 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-02-09 | 2017-02-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-02-09 | 2017-02-24 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-02-09 | 2017-02-24 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-02-09 | 2017-02-24 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-02-09 | 2017-02-24 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2017-02-09 | 2017-02-24 | 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 | 2017-02-09 | 2017-02-24 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-09 | 2017-02-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2017-02-09 | 2017-02-24 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-02-09 | 2017-02-24 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2017-02-09 | 2017-02-24 | N |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-02-09 | 2017-02-24 | N |
| Keep complete, dated laboratory records in the resident's file. | Health | 2017-02-09 | 2017-02-24 | N |
| Protect each resident from mistreatment, neglect and misappropriation of personal property. | Health | 2017-02-09 | 2017-02-24 | Y |
| Provide bedrooms that hold no more than 4 residents per room. | Health | 2017-02-09 | 2017-02-24 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-02-09 | 2017-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-08-18 | 2016-09-12 | Y |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-04-07 | 2016-05-06 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-04-07 | 2016-05-06 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2016-04-07 | 2016-05-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-03-02 | 2016-04-04 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-03-02 | 2016-04-04 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-03-02 | 2016-04-04 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-03-02 | 2016-04-04 | N |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | Health | 2016-03-02 | 2016-04-04 | 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 | 2016-03-02 | 2016-04-04 | N |
| Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. | Health | 2016-03-02 | 2016-04-04 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-03-02 | 2016-04-04 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-03-02 | 2016-04-04 | N |
| Provide bedrooms that hold no more than 4 residents per room. | Health | 2016-03-02 | 2016-04-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2016-03-02 | 2016-04-04 | N |
