A list of the most recent deficiencies for Cascades at Orchard Park. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-23 | 2023-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-23 | 2023-11-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-23 | 2023-11-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-19 | 2023-11-16 | 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 | 2023-10-19 | 2023-11-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-19 | 2023-11-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-19 | 2023-11-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-19 | 2023-11-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-19 | 2023-11-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-19 | 2023-11-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-19 | 2023-11-16 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-23 | 2023-11-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-23 | 2023-11-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-23 | 2023-11-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-23 | 2023-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-23 | 2023-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-23 | 2023-10-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Meet other general requirements. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-12 | 2022-03-12 | 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 | 2022-01-12 | 2022-03-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-01-12 | 2022-03-12 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-13 | 2022-03-11 | 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 | 2022-01-13 | 2022-03-11 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-13 | 2022-03-11 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-13 | 2022-03-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-01-13 | 2022-03-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-13 | 2022-03-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-13 | 2022-03-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-13 | 2022-03-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-13 | 2022-03-11 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-13 | 2022-03-11 | N |
| 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 | 2022-01-13 | 2022-03-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-13 | 2022-03-11 | Y |
| 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 | 2022-01-13 | 2022-02-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-01 | 2019-11-30 | N |
| Use approved construction type or materials. | Fire Safety | 2019-10-01 | 2019-11-30 | 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 | 2019-10-01 | 2019-11-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-01 | 2019-11-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-01 | 2019-11-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-01 | 2019-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-01 | 2019-11-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-01 | 2019-11-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-09-26 | 2019-11-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-09-26 | 2019-11-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-26 | 2019-11-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-26 | 2019-11-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-26 | 2019-11-23 | 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 | 2019-09-26 | 2019-11-23 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-09-26 | 2019-11-23 | 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 | 2019-09-26 | 2019-11-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-26 | 2019-11-23 | 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 | 2019-09-26 | 2019-11-23 | 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 | 2019-09-26 | 2019-11-23 | 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 | 2019-09-26 | 2019-11-23 | N |
| Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised. | Health | 2019-09-26 | 2019-11-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-11-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-11-23 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2019-09-26 | 2019-11-23 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-09-26 | 2019-11-23 | N |
