A list of the most recent deficiencies for Gardens at Celina. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-23 | 2022-12-19 | N |
| Respond appropriately to all alleged violations. | Health | 2022-11-23 | 2022-12-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-23 | 2022-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-23 | 2022-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-23 | 2022-12-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-11-23 | 2022-12-19 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-11-23 | 2022-12-19 | 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 | 2022-11-23 | 2022-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-23 | 2022-12-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-23 | 2022-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-23 | 2022-12-19 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-23 | 2022-12-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-22 | 2022-12-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-22 | 2022-12-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-11-22 | 2022-12-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-22 | 2022-12-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-22 | 2021-04-06 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-21 | 2019-12-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-21 | 2019-12-17 | 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 | 2019-11-21 | 2019-12-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-11-21 | 2019-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2019-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-21 | 2019-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-21 | 2019-12-17 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2019-11-21 | 2019-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-21 | 2019-12-17 | 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 | 2018-10-11 | 2018-11-05 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2018-10-11 | 2018-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-11 | 2018-11-05 | N |
