Inspection Results » Orchard Hospital Distinct Part Skilled Nursing Facility

Health Inspection on November 6, 2018 ^[1]

1. Pattern: Immediate jeopardy to the resident health or safety

   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-04-17)

2. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. (Corrected 2019-01-31)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2019-04-17)
   • 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. (Corrected 2019-01-31)
   • Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (Corrected 2019-04-17)
   • Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. (Corrected 2019-01-31)
   • 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. (Corrected 2019-01-31)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-04-17)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-04-17)

3. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Ensure that residents are fully informed and understand their health status, care and treatments. (Corrected 2019-01-31)
   • 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. (Corrected 2019-04-17)
   • 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. (Corrected 2019-04-17)
   • Provide and implement an infection prevention and control program. (Corrected 2019-04-17)
   • 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. (Corrected 2019-04-17)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2019-04-24)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2019-04-17)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-04-17)
   • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2019-01-31)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2019-01-31)
   • Honor the resident's right to organize and participate in resident/family groups in the facility. (Corrected 2019-04-17)
   • 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 ne (Corrected 2019-01-31)
   • 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. (Corrected 2019-04-17)
   • Have policies on smoking. (Corrected 2019-01-31)
   • Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (Corrected 2019-04-17)
   • Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. (Corrected 2019-01-31)
   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2019-04-17)
   • Dispose of garbage and refuse properly. (Corrected 2019-01-31)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2019-04-17)
   • Keep all essential equipment working safely. (Corrected 2019-04-17)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2019-04-17)

4. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2019-01-31)
   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2019-01-31)
   • Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. (Corrected 2019-04-17)
   • Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Corrected 2019-01-31)
   • Assess the resident when there is a significant change in condition (Corrected 2019-04-17)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2019-01-31)
   • Provide appropriate pressure ulcer care and prevent new ulcers from developing. (Corrected 2019-01-31)

5. Pattern: No actual harm with potential for minimal harm

   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-01-31)