Deficiency Records for Garden Terrace Healthcare Center of Federal Way
Updated as of March 01, 2024
A list of the most recent deficiencies for Garden Terrace Healthcare Center of Federal Way. 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 | 2023-03-21 | 2023-04-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-21 | 2023-04-25 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-03-21 | 2023-04-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-21 | 2023-04-25 | 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 | 2023-03-21 | 2023-04-25 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-21 | 2023-04-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-21 | 2023-04-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-21 | 2023-04-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-03-15 | 2023-04-18 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-03-15 | 2023-04-06 | N |
| Establish methods for sharing information. | Fire Safety | 2023-03-15 | 2023-04-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-29 | 2021-10-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-10 | 2021-08-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-06-10 | 2021-08-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-06-10 | 2021-08-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-10 | 2021-08-02 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-06-10 | 2021-08-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-10 | 2021-08-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-08-02 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-10 | 2021-08-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-10 | 2021-08-02 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-06-10 | 2021-08-02 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | 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 | 2021-06-10 | 2021-08-02 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-06-10 | 2021-08-02 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-10 | 2021-08-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-10 | 2021-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-10 | 2021-08-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-06-10 | 2021-08-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-06-10 | 2021-08-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-07-15 | 2019-08-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-15 | 2019-08-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-15 | 2019-08-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-15 | 2019-08-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-07-15 | 2019-08-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-15 | 2019-08-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-15 | 2019-08-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-07-15 | 2019-08-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-15 | 2019-08-14 | 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 | 2019-07-15 | 2019-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-15 | 2019-08-14 | N |
| Dispose of garbage and refuse properly. | Health | 2019-07-15 | 2019-08-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-07-15 | 2019-08-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-07-09 | 2019-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-09 | 2019-08-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-09 | 2019-08-08 | N |
