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? |
---|---|---|---|---|
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 residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-04-13 | 2021-04-30 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-13 | 2021-04-30 | 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 | 2021-03-15 | 2021-03-19 | N |
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 | 2019-07-23 | 2019-08-08 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-07-23 | 2019-08-08 | 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 | 2019-07-23 | 2019-08-08 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-23 | 2019-08-08 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-23 | 2019-08-08 | N |
Provide activities to meet all resident's needs. | Health | 2019-07-23 | 2019-08-08 | N |
Assist a resident in gaining access to vision and hearing services. | Health | 2019-07-23 | 2019-08-08 | 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 | 2019-07-23 | 2019-08-08 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-07-23 | 2019-08-08 | 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 | 2019-07-23 | 2019-08-08 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-07-23 | 2019-08-08 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-07-23 | 2019-08-08 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-23 | 2019-08-08 | N |
Provide and implement an infection prevention and control program. | Health | 2019-07-23 | 2019-08-08 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-23 | 2019-08-08 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2018-12-14 | 2019-01-07 | 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 | 2018-12-14 | 2019-01-07 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Meet other general requirements that are deficient. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-14 | 2019-01-07 | N |