Orchard Valley Health and Rehabilitation

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Quality of Life and Care Deficiencies

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.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.

Nutrition and Dietary Deficiencies

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.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

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.

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

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.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Environmental Deficiencies

Provide bedrooms that don't allow residents to see each other when privacy is needed.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Nutrition and Dietary Deficiencies

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Egress Deficiencies

Install proper backup exit lighting.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Administration Deficiencies

Hire a qualified full-time social worker in a facility with more than 120 beds.