Orchard Hill Senior Living

Summary: MDH found the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) to include an annual facility TB risk assessment.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) to include an annual facility TB risk assessment. [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to develop an all-hazards risk assessment emergency preparedness program and plan to include Appendix Z required contents. This had the potential to affect all residents, staff, and visitors. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

Summary: MDH found the licensee failed to ensure the resident record included the required documentation related to hospitalization for one of one resident (R3), and failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R4).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included the required documentation related to hospitalization for one of one resident (R3), and failed to ensure the resident record included a discharge summary with the required content for one of one discharged resident (R4). [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to provide smoke alarms that are interconnected so that the actuation of one alarm causes all alarms in the dwelling unit to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that are interconnected so that the actuation of one alarm causes all alarms in the dwelling unit to actuate. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) provide smoke alarms outside each separate sleeping area in the immediate vicinity of bedrooms; (iii) provide smoke [...]”

Summary: MDH found the licensee failed to maintain the portable fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the portable fire extinguishers. This deficient condition had the potential to affect all staff, residents, and visitors. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with required content and failed to conduct the required training and drills.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop the fire safety and evacuation plan with required content and failed to conduct the required training and drills. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to provide a written notice with the required content for an emergency relocation and

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with the required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation when the resident had not returned to the facility within four days for two of two residents (R1, R3). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure a written service plan was revised and signed by the resident to reflect the current services provided for three of three

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a written service plan was revised and signed by the resident to reflect the current services provided for three of three residents (R1, R2, R3). [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R1). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of three residents (R3). [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to ensure staff notified the registered nurse (RN) of increased weight change for one of one resident (R3), and failed to ensure two of two unlicensed personnel (ULP-E, ULP-F) demonstrated competency for wound care to a RN.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure staff notified the registered nurse (RN) of increased weight change for one of one resident (R3), and failed to ensure two of two unlicensed personnel (ULP-E, ULP-F) demonstrated competency for wound care to a RN. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to ensure treatment orders were accurately transcribed for one of three residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure treatment orders were accurately transcribed for one of three residents (R3). This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”