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Deficiency Records for Episcopal Church Home The Gardens
View the most recent health deficiencies and inspection results for Episcopal Church Home The Gardens. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Episcopal Church Home The Gardens. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2026-04-09 | 2026-05-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2026-04-09 | 2026-05-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2026-04-09 | 2026-05-11 | 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 | 2026-04-09 | 2026-05-11 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-04-09 | 2026-05-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2026-04-09 | 2026-05-11 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2026-04-09 | 2026-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-04-09 | 2026-05-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-11-20 | 2026-01-02 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2025-08-18 | 2025-10-29 | 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 | 2025-08-18 | 2025-10-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-08-18 | 2025-10-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-08-18 | 2025-10-29 | Y |
| 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 | 2025-08-18 | 2025-10-22 | Y |
| 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 | 2025-08-18 | 2025-10-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-05-19 | 2025-06-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-26 | 2025-06-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2025-03-26 | 2025-06-02 | 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 | 2024-09-12 | 2024-11-04 | 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 | 2024-09-12 | 2024-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-12 | 2024-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-12 | 2024-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-12 | 2024-11-04 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2024-09-12 | 2024-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-12 | 2024-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-12 | 2024-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-12 | 2024-10-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-04 | 2024-03-29 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-03 | 2023-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-03 | 2023-09-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-03 | 2023-09-12 | 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 | 2023-08-03 | 2023-09-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-03 | 2023-09-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-03 | 2023-09-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-03 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-03 | 2023-09-12 | 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 | 2023-08-03 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-03 | 2023-09-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-08-03 | 2023-09-12 | N |