ORANGE HEALTHCARE & WELLNESS CENTRE, LLC

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 23, 2026

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected July 12, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 1, 2026

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

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 — Deficient, Provider has date of correction, corrected January 23, 2026

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected January 23, 2026

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2026

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2026

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

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 — Deficient, Provider has date of correction, corrected September 30, 2025

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

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 — Deficient, Provider has date of correction, corrected January 30, 2026

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected September 30, 2025

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected January 30, 2026

Keep all essential equipment working safely.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 21, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected March 21, 2025

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 1, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

Implement a program that monitors antibiotic use.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected September 27, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected September 16, 2024

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 31, 2025

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 31, 2024

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2024

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2024

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

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 — Deficient, Provider has date of correction, corrected December 31, 2024

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected November 5, 2024

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected August 8, 2024

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 — Deficient, Provider has date of correction, corrected August 8, 2024

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 4, 2024

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 — Deficient, Provider has date of correction, corrected October 11, 2024

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 Rights Deficiencies — Deficient, Provider has date of correction, corrected October 31, 2024

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected August 30, 2024

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 1, 2024

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 12, 2024

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 — Deficient, Provider has date of correction, corrected October 11, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 9, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 10, 2023

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected November 10, 2023

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected November 10, 2023

Dispose of garbage and refuse properly.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 29, 2024

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

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 16, 2024

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected November 23, 2023

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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 — Deficient, Provider has date of correction, corrected November 23, 2023

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 — Deficient, Provider has date of correction, corrected December 15, 2021

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

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 — Deficient, Provider has date of correction, corrected December 15, 2021

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 Rights Deficiencies — Deficient, Provider has date of correction, corrected November 23, 2023

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected December 15, 2021