Deficiency Records for Country Gardens Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Country Gardens Health and Rehabilitation 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-22 | 2023-07-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-11 | 2023-06-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-28 | 2023-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-28 | 2023-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-05-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-28 | 2023-05-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-06 | 2021-11-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-02 | 2021-09-18 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-02 | 2021-09-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-06 | 2021-08-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-08-06 | 2021-08-28 | 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 | 2019-11-01 | 2019-12-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-01 | 2019-12-09 | 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 | 2019-11-01 | 2019-12-09 | 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 | 2019-11-01 | 2019-12-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-01 | 2019-12-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-09-11 | 2018-10-10 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2018-09-11 | 2018-10-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-09-11 | 2018-10-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-11 | 2018-10-10 | 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 | 2018-09-11 | 2018-10-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-09-11 | 2018-10-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-09-11 | 2018-10-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-09-11 | 2018-10-10 | N |
| Respond appropriately to all alleged violations. | Health | 2018-09-11 | 2018-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-11 | 2018-10-10 | 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 | 2018-09-11 | 2018-10-10 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-11 | 2018-10-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-11 | 2018-10-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-11 | 2018-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-09-11 | 2018-10-10 | 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 | 2018-09-11 | 2018-10-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-09-11 | 2018-10-10 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-09-11 | 2018-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-11 | 2018-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-11 | 2018-10-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-09-12 | 2018-10-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-09-12 | 2018-10-02 | 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 | 2018-09-12 | 2018-09-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-12 | 2018-09-20 | N |
