Deficiency Records for Merriam Gardens Healthcare and Rehabilitation
Updated as of April 01, 2024
A list of the most recent deficiencies for Merriam Gardens Healthcare and Rehabilitation. 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-06-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-26 | 2023-06-09 | Y |
| 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. | Health | 2023-04-26 | 2023-06-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-26 | 2023-06-09 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-04-26 | 2023-06-09 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-04-26 | 2023-06-09 | 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 | 2023-04-26 | 2023-06-09 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-26 | 2023-06-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-26 | 2023-06-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-06-09 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-26 | 2023-06-09 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-03-13 | 2023-04-28 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-02-16 | 2023-03-24 | 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 | 2023-02-16 | 2023-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-16 | 2023-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-02-16 | 2023-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-03-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-16 | 2023-03-24 | N |
| 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. | Health | 2023-02-16 | 2023-03-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-03-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-08 | 2022-02-11 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-07-14 | 2021-08-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-21 | 2021-07-22 | 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 | 2021-06-21 | 2021-07-22 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-06-21 | 2021-07-22 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-21 | 2021-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-21 | 2021-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-21 | 2021-07-22 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2019-10-29 | 2019-11-29 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-29 | 2019-11-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-29 | 2019-11-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-29 | 2019-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-29 | 2019-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-29 | 2019-11-29 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-29 | 2019-11-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-10-29 | 2019-11-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-26 | Not Fixed | N |
