A list of the most recent deficiencies for Dunklau Gardens. 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? |
|---|---|---|---|---|
| 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 | 2023-06-09 | 2023-08-18 | 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 | 2023-06-09 | 2023-08-18 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-06-09 | 2023-08-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-09 | 2023-08-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-09 | 2023-08-18 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-06-09 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-09 | 2023-07-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-09 | 2023-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-09 | 2023-07-11 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-09 | 2023-07-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2023-06-09 | 2023-07-06 | N |
| Conform to length requirements for dead end corridors. | Fire Safety | 2023-06-09 | 2023-06-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-06-09 | 2023-06-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-09 | 2023-06-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-09 | 2023-06-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-09 | 2023-06-27 | N |
| Meet other general requirements. | Fire Safety | 2023-06-09 | 2023-06-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-09 | 2023-06-09 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-06-09 | 2023-06-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-29 | 2022-04-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-29 | 2022-04-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-29 | 2022-04-29 | 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 | 2022-03-29 | 2022-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-25 | 2022-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-25 | 2022-04-11 | 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 | 2022-03-25 | 2022-04-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-25 | 2022-04-05 | 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 | 2022-03-25 | 2022-03-25 | N |
| 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 | 2020-08-25 | 2020-10-20 | 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 | 2020-08-25 | 2020-10-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-08-25 | 2020-10-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-08-25 | 2020-10-20 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2020-08-25 | 2020-10-20 | 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 | 2020-08-27 | 2020-10-09 | 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 | 2020-08-27 | 2020-10-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-08-27 | 2020-10-09 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-08-27 | 2020-10-09 | N |
