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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-31 | 2024-01-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-12 | 2023-09-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-09-18 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-18 | 2023-08-30 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-07-19 | 2023-08-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-19 | 2023-08-25 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-18 | 2023-08-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-18 | 2023-08-03 | 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 | 2023-07-18 | 2023-07-31 | 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 | 2023-07-18 | 2023-07-31 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-18 | 2023-07-31 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-07-19 | 2023-07-28 | N |
| Keep all essential equipment working safely. | Health | 2023-07-19 | 2023-07-28 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-07-19 | 2023-07-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-19 | 2023-07-28 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-19 | 2023-07-28 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-18 | 2023-07-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-18 | 2023-07-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-18 | 2023-07-20 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-07-19 | 2023-07-19 | 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 | 2023-07-19 | 2023-07-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-19 | 2023-07-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-18 | 2023-07-19 | N |
| 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 | 2022-04-07 | 2022-06-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-07 | 2022-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-07 | 2022-06-08 | 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 | 2022-04-07 | 2022-06-08 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-08 | 2022-05-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-08 | 2022-05-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-08 | 2022-05-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-08 | 2022-05-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-08 | 2022-05-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-08 | 2022-05-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-08 | 2022-05-04 | 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 | 2022-04-07 | 2022-04-29 | N |
| Post nurse staffing information every day. | Health | 2022-04-07 | 2022-04-29 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-04-07 | 2022-04-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-04-29 | N |
| Provide immediate access to any resident. | Health | 2022-04-07 | 2022-04-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-07 | 2022-04-29 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-07 | 2022-04-29 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-07 | 2022-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-07 | 2022-04-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-07 | 2022-04-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-07 | 2022-04-29 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-07 | 2022-04-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-07 | 2022-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-07 | 2022-04-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-07 | 2022-04-29 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-04-07 | 2022-04-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-08 | 2022-04-29 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-04-08 | 2022-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-08 | 2022-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-08 | 2022-04-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-27 | 2022-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-01-31 | Y |
| 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 | 2021-11-23 | 2021-12-14 | 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 | 2021-11-23 | 2021-12-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-23 | 2021-12-14 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-11-23 | 2021-12-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-13 | 2021-10-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-13 | 2021-10-26 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-10-13 | 2021-10-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-13 | 2021-10-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-10 | 2021-08-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-10 | 2021-08-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-10 | 2021-08-17 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-03-22 | 2021-04-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-19 | 2020-01-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-19 | 2020-01-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-19 | 2020-01-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-19 | 2020-01-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-12-19 | 2020-01-29 | 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 | 2019-12-19 | 2020-01-29 | 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 | 2019-12-19 | 2020-01-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-19 | 2020-01-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-12-19 | 2020-01-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-19 | 2020-01-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-18 | 2020-01-29 | N |
