Deficiency Records for Mayflower Gardens Convalescent Hospital
Updated as of March 01, 2024
A list of the most recent deficiencies for Mayflower Gardens Convalescent Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-08 | 2024-01-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-03 | 2023-05-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-03 | 2023-05-12 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-10 | 2023-04-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-31 | 2023-02-10 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-31 | 2023-02-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-14 | 2022-11-15 | Y |
| Post nurse staffing information every day. | Health | 2022-11-14 | 2022-11-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-10-20 | 2022-10-28 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-09-13 | 2022-10-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-13 | 2022-10-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-13 | 2022-10-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-09 | 2022-08-15 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-09 | 2022-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-04 | 2022-08-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-12 | 2022-06-10 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-01-25 | 2022-02-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-11 | 2022-01-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-21 | 2021-12-29 | Y |
| 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. | Health | 2021-11-21 | 2021-12-29 | Y |
| 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. | Health | 2021-11-21 | 2021-12-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-10 | 2021-12-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-10 | 2021-12-12 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-11-10 | 2021-12-12 | N |
| 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. | Health | 2021-11-10 | 2021-12-12 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-11-10 | 2021-12-12 | N |
| 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. | Health | 2021-11-10 | 2021-12-12 | N |
| Post nurse staffing information every day. | Health | 2021-11-10 | 2021-12-12 | N |
| 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. | Health | 2021-11-10 | 2021-12-12 | N |
| 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. | Health | 2021-11-10 | 2021-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-10 | 2021-12-12 | N |
| 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. | Health | 2021-11-10 | 2021-12-12 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-11-10 | 2021-12-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2021-12-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-10 | 2021-12-12 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-11-10 | 2021-12-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-10 | 2021-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-13 | 2021-10-15 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-13 | 2021-10-15 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-07 | 2021-05-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-27 | 2021-04-01 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-03-21 | 2019-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-21 | 2019-03-27 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-03-21 | 2019-03-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-21 | 2019-03-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-21 | 2019-03-27 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-03-21 | 2019-03-27 | N |
| 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. | Health | 2019-03-21 | 2019-03-27 | N |
| 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. | Health | 2019-03-21 | 2019-03-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-21 | 2019-03-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-21 | 2019-03-25 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Establish methods for sharing information. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-04-07 | 2018-04-27 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-04-08 | 2018-04-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-08 | 2018-04-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-08 | 2018-04-25 | N |
| 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. | Health | 2018-04-08 | 2018-04-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-08 | 2018-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-08 | 2018-04-25 | N |
