A list of the most recent deficiencies for The Gardens at Stroud. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-03 | 2023-12-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-03 | 2023-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-03 | 2023-12-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-11-03 | 2023-12-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-03 | 2023-12-04 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-11-03 | 2023-12-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-03 | 2023-12-04 | 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 | 2023-11-03 | 2023-12-04 | 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 | 2023-11-03 | 2023-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-03 | 2023-12-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-07 | 2023-10-11 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-09-07 | 2023-10-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-07 | 2023-10-11 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-07 | 2023-10-11 | Y |
| Implement a program that monitors antibiotic use. | Health | 2023-09-07 | 2023-10-11 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2023-02-15 | 2023-04-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-02-15 | 2023-03-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-16 | 2023-01-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-12-16 | 2023-01-16 | 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 | 2022-12-16 | 2023-01-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-12-16 | 2023-01-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-16 | 2023-01-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-12-16 | 2023-01-16 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2022-12-16 | 2023-01-16 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-12-16 | 2023-01-16 | 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 | 2022-12-16 | 2023-01-16 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-16 | 2023-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-16 | 2023-01-16 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-16 | 2023-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-16 | 2023-01-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-12-16 | 2023-01-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-01 | 2022-09-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-01 | 2022-09-19 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-02 | 2022-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-09-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-04-08 | 2022-05-03 | Y |
| 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 | 2022-04-08 | 2022-05-03 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-08 | 2022-05-03 | 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 | 2022-01-14 | 2022-04-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-01-14 | 2022-04-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-14 | 2022-04-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-14 | 2022-04-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-01-14 | 2022-04-08 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-14 | 2022-03-16 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-01-14 | 2022-03-16 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-01-14 | 2022-03-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-14 | 2022-03-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-01-14 | 2022-03-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-14 | 2022-03-16 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-01-14 | 2022-03-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-14 | 2022-03-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-21 | 2021-10-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-21 | 2021-10-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-21 | 2021-09-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-21 | 2021-09-15 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-07-21 | 2021-09-15 | 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 | 2021-07-21 | 2021-09-15 | 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 | 2023-10-11 | Not Fixed | Y |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2023-10-11 | Not Fixed | Y |
