A list of the most recent deficiencies for Gardens of Mcgregor and Amasa Stone. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-09-01 | 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 | 2023-08-10 | 2023-09-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-09-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-08 | 2023-09-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-10 | 2023-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-04-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-03 | 2022-03-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-03 | 2022-03-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-21 | 2021-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-07-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-06 | 2021-04-16 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2021-03-25 | 2021-04-16 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-03-25 | 2021-04-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-03-25 | 2021-04-16 | Y |
| 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 | 2019-12-12 | 2020-02-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-11 | 2020-02-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-11 | 2020-02-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-11-01 | 2018-12-10 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-11-01 | 2018-12-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-01 | 2018-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-01 | 2018-12-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-01 | 2018-12-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-01 | 2018-12-10 | 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 | 2018-11-01 | 2018-12-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-01 | 2018-12-10 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-10-31 | 2018-12-10 | 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 | 2018-10-31 | 2018-12-10 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-31 | 2018-12-10 | N |
