A list of the most recent deficiencies for Garden Village. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-08 | 2024-01-05 | Y |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-12-08 | 2024-01-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-05 | 2023-10-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-31 | 2023-10-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-08-31 | 2023-10-14 | 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 | 2023-08-31 | 2023-10-14 | 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 | 2023-08-31 | 2023-10-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-31 | 2023-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-31 | 2023-10-14 | 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 | 2023-08-31 | 2023-10-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-31 | 2023-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-31 | 2023-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-31 | 2023-10-14 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-31 | 2023-10-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-08-31 | 2023-10-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-31 | 2023-10-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-31 | 2023-10-14 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-08-31 | 2023-10-14 | Y |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-08-31 | 2023-10-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Meet other general requirements. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-23 | 2023-09-27 | 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 | 2023-08-23 | 2023-09-27 | 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 | 2023-08-23 | 2023-09-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-23 | 2023-09-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-13 | 2023-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-13 | 2023-08-11 | Y |
| 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 | 2023-01-06 | 2023-02-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-06 | 2022-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-30 | 2022-08-26 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-06-30 | 2022-08-26 | 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 | 2022-06-30 | 2022-08-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-06-30 | 2022-08-26 | 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 | 2022-06-30 | 2022-08-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide activities to meet all resident's needs. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-08-26 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-06-30 | 2022-08-26 | 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 | 2022-06-30 | 2022-08-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-30 | 2022-08-26 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-06-30 | 2022-08-26 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-30 | 2022-08-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-30 | 2022-08-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-30 | 2022-08-26 | 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 | 2022-06-30 | 2022-08-26 | Y |
| 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 | 2022-06-30 | 2022-08-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-30 | 2022-08-26 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2022-06-16 | 2022-07-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Develop a communication plan. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-06-16 | 2022-07-20 | N |
| Meet other general requirements. | Fire Safety | 2022-06-16 | 2022-06-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-16 | 2022-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-16 | 2022-06-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-17 | 2021-09-30 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-07-15 | 2019-09-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-07-19 | 2019-08-16 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2019-07-19 | 2019-08-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-19 | 2019-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-19 | 2019-08-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-07-19 | 2019-08-16 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-07-19 | 2019-08-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-07-19 | 2019-08-16 | 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 | 2019-07-19 | 2019-08-16 | 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 | 2019-07-15 | 2019-08-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-15 | 2019-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-07-15 | 2019-07-23 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-07-15 | 2019-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-07-15 | 2019-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-07-15 | 2019-07-18 | N |
