Deficiency Records for Healthbridge Children's Hospital - Orange D/p Snf
Updated as of March 01, 2024
A list of the most recent deficiencies for Healthbridge Children's Hospital - Orange D/p Snf. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Use approved construction type or materials. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-28 | 2023-04-27 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-03-23 | 2023-04-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-23 | 2023-04-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-23 | 2023-04-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | 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 | 2023-03-23 | 2023-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-23 | 2023-04-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-23 | 2023-04-25 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-03-23 | 2023-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-23 | 2023-04-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-23 | 2023-04-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Use approved construction type or materials. | Fire Safety | 2019-12-16 | 2020-01-09 | 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 | 2019-12-16 | 2020-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-16 | 2020-01-09 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-11-20 | 2019-12-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-11-20 | 2019-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-20 | 2019-12-20 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-20 | 2019-12-20 | 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 | 2019-11-20 | 2019-12-20 | 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 | 2019-11-20 | 2019-12-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-20 | 2019-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-20 | 2019-12-20 | N |
| Dispose of garbage and refuse properly. | Health | 2019-11-20 | 2019-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-20 | 2019-12-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-20 | 2019-12-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-01 | 2019-03-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-03-01 | 2019-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-01 | 2019-03-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-03-01 | 2019-03-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-01 | 2019-03-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-12-21 | 2019-01-21 | 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 | 2018-12-21 | 2019-01-21 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-12-21 | 2019-01-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-12-21 | 2019-01-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-21 | 2019-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-21 | 2019-01-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-21 | 2019-01-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-21 | 2019-01-21 | 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 | 2018-12-21 | 2019-01-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-21 | 2019-01-21 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-12-21 | 2019-01-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-12-21 | 2019-01-21 | 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 | 2018-12-21 | 2019-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-21 | 2019-01-21 | 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 | 2018-12-21 | 2019-01-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-21 | 2019-01-21 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-12-21 | 2019-01-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-21 | 2019-01-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-12-21 | 2019-01-21 | N |
