A list of the most recent deficiencies for The Gardens at West Shore. 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? |
|---|---|---|---|---|
| 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 | 2023-11-16 | 2023-12-19 | 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 | 2023-11-16 | 2023-12-19 | N |
| Respond appropriately to all alleged violations. | Health | 2023-11-16 | 2023-12-19 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-11-16 | 2023-12-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-16 | 2023-12-19 | 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 | 2023-11-16 | 2023-12-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-16 | 2023-12-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-16 | 2023-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-16 | 2023-12-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-16 | 2023-12-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-16 | 2023-12-19 | 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 | 2023-11-16 | 2023-12-19 | 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 | 2023-11-16 | 2023-12-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-16 | 2023-12-19 | 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 | 2023-11-16 | 2023-12-19 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-16 | 2023-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-26 | 2023-11-07 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2023-09-08 | 2023-09-12 | 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 | 2023-08-09 | 2023-09-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-09 | 2023-09-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-09 | 2023-09-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-09 | 2023-09-05 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-09 | 2023-09-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-27 | 2023-09-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-16 | 2023-06-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-25 | 2023-05-10 | 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 | 2023-04-10 | 2023-04-25 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-12 | 2023-01-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-12 | 2023-01-31 | 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 | 2023-01-12 | 2023-01-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-12 | 2023-01-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-12 | 2023-01-31 | Y |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-12-01 | 2022-12-22 | 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 | 2022-12-01 | 2022-12-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-01 | 2022-12-22 | N |
| Provide activities to meet all resident's needs. | Health | 2022-12-01 | 2022-12-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-01 | 2022-12-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-01 | 2022-12-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-01 | 2022-12-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-01 | 2022-12-22 | 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 | 2022-12-01 | 2022-12-22 | 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 | 2022-12-01 | 2022-12-22 | N |
| Provide or obtain dental services for each resident. | Health | 2022-12-01 | 2022-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2022-12-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-12-01 | 2022-12-22 | 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 | 2022-12-01 | 2022-12-22 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-08 | 2022-12-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-08 | 2022-12-22 | 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 | 2022-11-08 | 2022-12-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-08 | 2022-12-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-08 | 2022-12-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-08 | 2022-12-22 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-11-08 | 2022-12-22 | 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 | 2022-09-02 | 2022-09-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-02 | 2022-09-20 | 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 | 2022-09-02 | 2022-09-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-02 | 2022-09-20 | 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 | 2022-07-07 | 2022-07-26 | 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 | 2022-02-04 | 2022-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-04 | 2022-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-04 | 2022-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-28 | 2022-02-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-16 | 2022-01-11 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-11-18 | 2021-12-29 | 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 | 2021-11-18 | 2021-12-29 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-18 | 2021-12-29 | N |
| Respond appropriately to all alleged violations. | Health | 2021-11-18 | 2021-12-29 | 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 | 2021-11-18 | 2021-12-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2021-12-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-11-18 | 2021-12-29 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-11-18 | 2021-12-29 | 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 | 2021-11-18 | 2021-12-29 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-11-18 | 2021-12-29 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-11-18 | 2021-12-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2021-12-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-18 | 2021-12-29 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-11-18 | 2021-12-29 | 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 | 2021-11-18 | 2021-12-29 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2021-11-18 | 2021-12-29 | 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 | 2021-09-16 | 2021-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-16 | 2021-10-06 | Y |
| 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 | 2021-09-16 | 2021-10-06 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-16 | 2021-10-06 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-08-04 | 2021-09-13 | 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 | 2021-08-04 | 2021-09-13 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-08-04 | 2021-09-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-04 | 2021-09-13 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-08-04 | 2021-09-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-04 | 2021-09-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-04 | 2021-09-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-07 | 2021-06-01 | Y |
