A list of the most recent deficiencies for Garden Place Healthcare. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-08-30 | 2023-10-07 | 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 | 2023-08-30 | 2023-10-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-30 | 2023-10-07 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-08-16 | 2023-09-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-08-30 | 2023-09-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-16 | 2023-09-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-08-16 | 2023-09-13 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-16 | 2023-09-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-16 | 2023-09-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-16 | 2023-09-13 | N |
| Respond appropriately to all alleged violations. | Health | 2023-08-16 | 2023-09-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-16 | 2023-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-16 | 2023-09-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-16 | 2023-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-16 | 2023-09-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-16 | 2023-09-13 | 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 | 2023-08-16 | 2023-09-13 | 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 | 2023-08-16 | 2023-09-13 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-08-16 | 2023-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-16 | 2023-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-16 | 2023-09-13 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-08-16 | 2023-09-13 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-08-16 | 2023-09-13 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-08-16 | 2023-09-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-16 | 2023-09-13 | N |
| Keep all essential equipment working safely. | Health | 2023-08-16 | 2023-09-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-03 | 2021-04-06 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-01 | 2020-09-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-04 | 2020-03-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2020-02-04 | 2020-03-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-04 | 2020-03-17 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-02-04 | 2020-03-17 | 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 | 2020-02-04 | 2020-03-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-04 | 2020-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-04 | 2020-03-17 | 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 | 2020-02-04 | 2020-03-17 | 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 | 2020-02-04 | 2020-03-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-04 | 2020-03-17 | N |
| Keep all essential equipment working safely. | Health | 2020-02-04 | 2020-03-17 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2020-02-04 | 2020-03-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-23 | 2019-06-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-23 | 2019-06-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-11 | 2019-03-22 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-02-11 | 2019-03-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-11 | 2019-03-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-02-11 | 2019-03-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-11 | 2019-03-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-02-11 | 2019-03-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-11 | 2019-03-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-11 | 2019-03-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-11 | 2019-03-22 | 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 | 2019-02-11 | 2019-03-22 | 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 | 2019-02-11 | 2019-03-22 | 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 | 2019-02-11 | 2019-03-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-11 | 2019-03-22 | N |
| 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 | 2019-02-11 | 2019-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-11 | 2019-03-22 | N |
