Deficiency Records for Flora Gardens Care Center
Updated as of May 01, 2022
This is not the most recent data for Flora Gardens Care Center. For the most recent information, click here.
A list of the most recent deficiencies for Flora Gardens Care Center. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-01-10 | 2022-01-27 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-10 | 2022-01-27 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2021-08-17 | 2021-09-10 | N |
| 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 | 2021-07-09 | 2021-07-21 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-05-04 | 2021-05-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-23 | 2021-01-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-10-23 | 2021-01-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-23 | 2020-11-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-10-23 | 2020-11-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-10-23 | 2020-11-16 | 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 | 2020-10-23 | 2020-11-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-08-21 | 2020-09-04 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-12-16 | 2020-02-07 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-12-16 | 2020-02-07 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-12-16 | 2020-02-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-12-16 | 2020-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-16 | 2020-02-07 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-12-13 | 2020-01-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-12-13 | 2020-01-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-12-13 | 2020-01-14 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-12-13 | 2020-01-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-13 | 2020-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-13 | 2020-01-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-12-13 | 2020-01-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-13 | 2020-01-14 | N |
| 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. | Health | 2019-12-13 | 2020-01-14 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-12-13 | 2020-01-14 | 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 | 2019-12-13 | 2020-01-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-13 | 2020-01-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-13 | 2020-01-14 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Develop a communication plan. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Establish methods for sharing information. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-16 | 2020-01-14 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2019-12-16 | 2020-01-14 | 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 | 2019-01-15 | 2019-05-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-15 | 2019-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-17 | 2019-02-11 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-01-17 | 2019-02-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-17 | 2019-02-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-17 | 2019-02-11 | N |
| Post nurse staffing information every day. | Health | 2019-01-17 | 2019-02-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-17 | 2019-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-15 | 2019-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-01-15 | 2019-02-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-01-17 | 2019-02-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-01-17 | 2019-02-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-01-17 | 2019-02-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-17 | 2019-02-10 | 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 | 2019-01-17 | 2019-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-17 | 2019-02-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-17 | 2019-02-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-01-17 | 2019-02-10 | N |
