Deficiency Records for The Gardens at Aldersgate
Updated as of May 01, 2024
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Deficiency Records for The Gardens at Aldersgate
A list of the most recent deficiencies for The Gardens at Aldersgate. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Gardens at Aldersgate. 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? |
|---|---|---|---|---|
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-20 | 2024-04-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-22 | 2024-03-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-02-22 | 2024-03-19 | N |
| Respond appropriately to all alleged violations. | Health | 2024-02-22 | 2024-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-22 | 2024-03-19 | 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 | 2024-02-22 | 2024-03-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-22 | 2024-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-22 | 2024-03-19 | 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 | 2024-02-22 | 2024-03-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-22 | 2024-03-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-02-22 | 2024-03-19 | 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 | 2024-02-22 | 2024-03-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-22 | 2024-03-19 | 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 | 2024-02-22 | 2024-03-19 | 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 | 2024-02-22 | 2024-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-22 | 2024-03-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-22 | 2024-03-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-22 | 2024-03-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-07-18 | 2023-08-18 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-19 | 2022-11-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-18 | 2022-09-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-18 | 2022-09-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-18 | 2022-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-09-23 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-18 | 2022-09-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-18 | 2022-09-23 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-08-18 | 2022-09-23 | 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 | 2022-08-18 | 2022-09-23 | Y |
| 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. | Health | 2022-08-18 | 2022-09-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-24 | 2022-06-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-19 | 2022-01-31 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-09-29 | 2021-10-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-29 | 2021-10-15 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-04-15 | 2021-05-27 | 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 | 2021-04-15 | 2021-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-15 | 2021-05-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-04-15 | 2021-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-15 | 2021-05-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-15 | 2021-05-27 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-04-15 | 2021-05-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-15 | 2021-05-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-15 | 2021-05-27 | 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 | 2021-03-15 | 2021-03-19 | N |
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