Deficiency Records for Thalia Gardens Rehabilitation and Nursing
Updated as of April 01, 2024
A list of the most recent deficiencies for Thalia Gardens Rehabilitation and Nursing. 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? |
|---|---|---|---|---|
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-10 | 2023-06-30 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-05-10 | 2023-06-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-10 | 2023-06-17 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-05-10 | 2023-06-06 | 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 | 2023-05-10 | 2023-06-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-10 | 2023-06-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-09 | 2022-09-26 | 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 | 2022-07-07 | 2022-08-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-07 | 2022-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-07 | 2022-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-07-07 | 2022-08-23 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-06-09 | 2022-07-24 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-06-09 | 2022-07-24 | 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 | 2022-06-09 | 2022-07-24 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-06-09 | 2022-07-24 | 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 | 2022-06-09 | 2022-07-24 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-09 | 2022-07-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-09 | 2022-07-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-09 | 2022-07-24 | 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 | 2022-06-09 | 2022-07-24 | 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 | 2022-06-09 | 2022-07-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-06-09 | 2022-07-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-09 | 2022-07-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-06-09 | 2022-07-24 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-09 | 2022-07-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-06-09 | 2022-07-24 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-06-09 | 2022-07-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-06-09 | 2022-07-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-28 | 2021-07-30 | Y |
| 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 | 2019-09-19 | 2019-11-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-19 | 2019-11-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-29 | 2019-10-07 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-08-29 | 2019-10-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-29 | 2019-10-07 | 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 | 2019-08-29 | 2019-10-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-29 | 2019-10-07 | 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 | 2019-08-29 | 2019-10-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-08-29 | 2019-10-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-29 | 2019-10-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-29 | 2019-10-07 | 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 | 2019-08-29 | 2019-10-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-08-29 | 2019-10-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-29 | 2019-10-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-29 | 2019-10-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-29 | 2019-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-29 | 2019-10-07 | 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 | 2019-08-29 | 2019-10-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-29 | 2019-10-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-08-29 | 2019-10-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-29 | 2019-10-07 | N |
| Keep all essential equipment working safely. | Health | 2019-08-29 | 2019-10-07 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-29 | 2019-10-07 | N |
| Meet other general requirements. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-16 | 2018-06-07 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-05-04 | 2018-05-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-04 | 2018-05-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-04 | 2018-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-04 | 2018-05-22 | 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 | 2018-05-04 | 2018-05-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-04 | 2018-05-22 | 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 | 2018-05-04 | 2018-05-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-04 | 2018-05-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-04 | 2018-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-04 | 2018-05-22 | 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 | 2018-05-04 | 2018-05-22 | 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 | 2018-05-04 | 2018-05-22 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish methods for sharing information. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-04 | 2018-05-22 | N |
