CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Thalia Gardens Rehabilitation and Nursing
View the most recent health deficiencies and inspection results for Thalia Gardens Rehabilitation and Nursing. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Thalia Gardens Rehabilitation and Nursing. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-15 | 2023-12-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-08-15 | 2023-12-05 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-15 | 2023-12-05 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2023-08-15 | 2023-12-05 | 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 | 2023-08-15 | 2023-12-05 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-15 | 2023-09-29 | 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 | 2022-06-09 | 2022-08-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-09 | 2022-08-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-09 | 2022-08-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-09 | 2022-08-23 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| 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 | 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 |
| 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-09 | 2022-07-24 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-06-09 | 2022-07-24 | N |
| Ensure each resident receives an accurate assessment. | 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 |
| 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 |
| 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 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 |
| 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 |
| 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 |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-09 | 2022-07-24 | 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 | 2019-08-29 | 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 | 2019-08-29 | 2019-11-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-29 | 2019-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-29 | 2019-11-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-29 | 2019-11-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-08-29 | 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 | 2019-08-29 | 2019-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-29 | 2019-11-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-29 | 2019-11-07 | 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 |
| 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 |
| 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 |
| Provide safe and appropriate respiratory care for a resident when needed. | 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 |
| 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 |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-29 | 2019-10-07 | 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 |
| Meet other general requirements. | Fire Safety | 2018-05-04 | 2018-06-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-05-04 | 2018-06-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-05-04 | 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 | 2018-05-04 | 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 | 2018-05-04 | 2018-06-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-05-04 | 2018-06-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-04 | 2018-06-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-05-04 | 2018-06-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2026-04-28 | Not Fixed | N |
| Post nurse staffing information every day. | Health | 2026-04-28 | Not Fixed | 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 | 2026-04-28 | Not Fixed | N |
| Ensure each resident receives an accurate assessment. | Health | 2026-04-28 | Not Fixed | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2026-04-28 | Not Fixed | N |
| Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | Health | 2026-04-28 | Not Fixed | N |
| 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 | 2026-04-28 | Not Fixed | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2026-04-28 | Not Fixed | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2026-04-28 | Not Fixed | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2026-04-28 | Not Fixed | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2026-04-28 | Not Fixed | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2026-04-28 | Not Fixed | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2026-04-28 | Not Fixed | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2026-04-28 | Not Fixed | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-04-28 | Not Fixed | Y |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2026-04-28 | Not Fixed | Y |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2026-04-28 | Not Fixed | 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 | 2026-04-28 | Not Fixed | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2026-04-28 | Not Fixed | Y |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2026-04-28 | Not Fixed | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2026-04-28 | Not Fixed | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2026-04-28 | Not Fixed | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2026-04-28 | Not Fixed | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2026-04-28 | Not Fixed | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2026-04-28 | Not Fixed | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2026-04-28 | Not Fixed | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2026-04-28 | Not Fixed | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2026-04-28 | Not Fixed | 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 | 2026-04-28 | Not Fixed | 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 | 2026-04-28 | Not Fixed | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2026-04-28 | Not Fixed | N |