Deficiency Records for Mayflower Gardens Convalescent Hospital
Updated as of April 01, 2021
This is not the most recent data for Mayflower Gardens Convalescent Hospital. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-08 | 2021-01-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-05 | 2020-10-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-25 | 2020-10-09 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-25 | 2020-10-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-04 | 2019-12-15 | Y |
| 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. | Health | 2019-12-04 | 2019-12-15 | 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 |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-04-02 | 2017-04-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-04-02 | 2017-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-04-02 | 2017-04-24 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-02 | 2017-04-24 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-04-02 | 2017-04-24 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-04-02 | 2017-04-24 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-02 | 2017-04-24 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-04-02 | 2017-04-24 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-04-02 | 2017-04-24 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-04-02 | 2017-04-24 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-04-02 | 2017-04-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-04-01 | 2017-04-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-01-22 | Not Fixed | N |
