Deficiency Records for The Villages of Orleans Health and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for The Villages of Orleans Health and Rehab 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? |
|---|---|---|---|---|
| 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 | 2024-01-12 | 2024-02-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-12 | 2024-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-18 | 2023-11-16 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-21 | 2023-10-15 | 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 | 2023-08-10 | 2023-09-15 | Y |
| Have a Compliance and Ethics Program. | Health | 2023-08-10 | 2023-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-21 | 2023-09-08 | 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 | 2023-07-21 | 2023-09-08 | N |
| 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 | 2023-07-21 | 2023-09-08 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-21 | 2023-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-21 | 2023-09-08 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-21 | 2023-09-08 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-21 | 2023-09-08 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-21 | 2023-09-08 | 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 | 2023-07-21 | 2023-09-08 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-21 | 2023-09-08 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-30 | 2023-01-27 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-08 | 2022-02-25 | 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 | 2021-10-25 | 2021-12-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-25 | 2021-12-24 | Y |
| Meet other general requirements. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-10-25 | 2021-12-24 | 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 | 2021-10-25 | 2021-12-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-25 | 2021-12-24 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-26 | 2021-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-26 | 2021-06-24 | 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 | 2021-04-26 | 2021-06-24 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2021-04-26 | 2021-06-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-26 | 2021-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-26 | 2021-06-24 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-04-26 | 2021-06-24 | 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 | 2021-04-26 | 2021-06-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-26 | 2021-06-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-04-26 | 2021-06-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-04-26 | 2021-06-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-04-26 | 2021-06-24 | N |
