Orchardview Post-Acute and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Orchardview Post-Acute and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF578Mar 16, 2021

  Based on facility policy review, medical record review, review of hospital records, review of Emergency Medical Services (EMS) documentation, interview, and review of hospice documentation, the facility failed to establish mechanisms for documenting and communicating the resident's wishes for end of life care to staff responsible for the resident's care and failed to honor those wishes for 3 of 23 residents (Resident #3, Resident #1, Resident #2) reviewed. The facility's failure to honor the residents' and/or representative(s) wishes to refuse resuscitative measures and life sustaining treatment for [REDACTED].#1, and #2 placed the residents in Immediate Jeopardy (IJ) (A situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely… […]

• Immediate jeopardy, patternF657Mar 16, 2021

  Based on review of facility policy, medical record review, review of Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, EMS (Emergency Medical Service) documentation review, Hospital documentation review, observation, and interview, the facility failed to revise a comprehensive care plan to include code status, Advance Directive, and/or Physician's Order for Scope of Treatment (POST) form for 3 residents (Resident #3, Resident #1, and Resident #2) of 20 residents reviewed for care plans. […]

• Immediate jeopardy, patternF678Mar 16, 2021

  Based on review of facility policy, medical record review, review of hospital records, review of Emergency Medical Services (EMS) records, interview, and review of hospice documentation, the facility failed to ensure a process was in place to ensure residents end of life wishes were honored for 4 residents (Resident #3, Resident #1, Resident #2 and Resident #4) of 23 residents reviewed for code status. The facility failed to make readily available a physician's orders [REDACTED].#1, failed to obtain an updated physician's orders [REDACTED].#3 and #2, and failed to make readily available a physician's orders [REDACTED].#4. […]

• Immediate jeopardy, patternF835Mar 16, 2021

  Based on medical record review, review of hospice documentation, review of facility documentation, review of the Quality Assurance Performance Improvement (QAPI) committee monthly meetings and sign in sheets, and interview, the facility's Administrator failed to take effective systemic action after being made aware of a widespread problem related to resident's code status in the EHR (Electric Health Record) not corresponding to the resident's code status on the paper POST (Physician Orders for Scope of Treatment) form. This failure resulted in 3 residents' (Resident #3, Resident #1, and Resident #2) end of life wishes not being honored and 1 resident's (Resident #4) end of life wishes not being readily available in the medical record. […]

• Immediate jeopardy, patternF867Mar 16, 2021

  Based on review of facility policy, medical record review, review of facility documentation, review of the Quality Assurance Performance Improvement (QAPI) meeting documentation, and interview, the facility's QAPI committee failed to take effective action aimed at performance improvement, measure the success of the intervention, and track performance to ensure improvements were realized and sustained after identifying a problem with POST forms. The QAPI committee failed to take effective corrective action which resulted in the facility failing to honor end of life decisions for 3 residents (Resident #3, Resident #2, and Resident #1), and the facility failing to have end of life decisions available in the medical record for 1 resident (Resident #4) of 23 residents reviewed, and had the… […]