A list of the most recent deficiencies for The Gardens at Blue Ridge. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-12 | 2024-01-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-12 | 2024-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-12 | 2024-01-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-12 | 2024-01-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-12-12 | 2024-01-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-12-12 | 2024-01-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-07 | 2024-01-16 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-07 | 2024-01-16 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-12-07 | 2024-01-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-07 | 2024-01-16 | 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 | 2023-12-07 | 2024-01-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-01-23 | 2023-03-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-23 | 2023-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-23 | 2023-03-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-23 | 2023-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-23 | 2023-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-23 | 2023-03-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-01-11 | 2023-02-21 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-11 | 2023-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-11 | 2023-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-11 | 2023-02-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-11 | 2023-02-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-11 | 2023-02-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-11 | 2023-02-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-01-11 | 2023-02-21 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-01-11 | 2023-02-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-11 | 2023-02-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-15 | 2022-10-04 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-01-18 | 2022-03-21 | N |
| Meet other general requirements. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-18 | 2022-02-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-06 | 2022-02-01 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-01-06 | 2022-02-01 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-01-06 | 2022-02-01 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-01-06 | 2022-02-01 | 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 | 2022-01-06 | 2022-02-01 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2022-01-06 | 2022-02-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-01-06 | 2022-02-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-06 | 2022-02-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-01-06 | 2022-02-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-06 | 2022-02-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-06 | 2022-02-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-01-06 | 2022-02-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-02-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-06 | 2022-02-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-01-06 | 2022-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-06 | 2022-02-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-06 | 2022-02-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-06 | 2022-02-01 | 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 | 2022-01-06 | 2022-02-01 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-01-06 | 2022-02-01 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-01-06 | 2022-02-01 | 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 | 2022-01-06 | 2022-02-01 | 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 | 2022-01-06 | 2022-02-01 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-01-06 | 2022-02-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-02-01 | N |
| Report COVID19 data to residents and families. | Health | 2022-01-06 | 2022-02-01 | 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 | 2022-01-06 | 2022-02-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-06 | 2022-02-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-06 | 2022-02-01 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-11-30 | 2021-12-14 | Y |
| 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 | 2021-08-30 | 2021-09-28 | Y |
| 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 | 2021-07-15 | 2021-08-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-15 | 2021-08-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-15 | 2021-08-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-15 | 2021-08-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-13 | 2021-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-13 | 2021-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-13 | 2021-06-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-05-13 | 2021-06-08 | Y |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-06-29 | Not Fixed | Y |
