A list of the most recent deficiencies for The Gardens Healthcare Center. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-01-12 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-29 | 2024-01-12 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-29 | 2024-01-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-30 | 2023-12-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-16 | 2023-12-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-16 | 2023-12-07 | 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 | 2023-11-16 | 2023-12-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-07 | 2023-12-06 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-11-07 | 2023-12-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-11-07 | 2023-12-06 | Y |
| 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 | 2023-09-28 | 2023-10-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-28 | 2023-09-28 | Y |
| 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 | 2023-08-09 | 2023-09-09 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-09 | 2023-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-09 | 2023-09-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-15 | 2023-06-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-15 | 2023-06-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-16 | 2022-09-09 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-05 | 2021-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-05 | 2021-12-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-11-05 | 2021-12-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-05 | 2021-12-02 | 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 | 2021-11-05 | 2021-12-02 | 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 | 2021-11-05 | 2021-12-02 | 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 | 2021-11-05 | 2021-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-05 | 2021-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-05 | 2021-12-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-11-05 | 2021-12-02 | 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 | 2021-11-05 | 2021-12-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-09-06 | 2019-10-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-08-30 | 2019-09-25 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-30 | 2019-09-25 | 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 | 2019-08-30 | 2019-09-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-08-30 | 2019-09-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-30 | 2019-09-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Establish methods for sharing information. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-27 | 2018-09-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-27 | 2018-09-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-27 | 2018-09-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-08-27 | 2018-09-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-27 | 2018-09-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-27 | 2018-09-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-27 | 2018-09-14 | 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 | 2018-08-27 | 2018-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-27 | 2018-09-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-27 | 2018-09-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-08-27 | 2018-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-27 | 2018-09-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-27 | 2018-09-14 | N |
