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Deficiency Records for Gardens Nursing and Rehab Center
A list of the most recent deficiencies for Gardens Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Gardens Nursing and Rehab 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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-27 | 2024-10-31 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-08-27 | 2024-10-31 | 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 | 2024-08-30 | 2024-10-28 | Y |
| 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 | 2024-08-30 | 2024-10-28 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-08-30 | 2024-10-28 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2024-08-30 | 2024-10-28 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-08-30 | 2024-10-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-30 | 2024-10-28 | 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 | 2024-08-30 | 2024-10-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-30 | 2024-10-28 | N |
| 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 | 2024-08-30 | 2024-10-28 | N |
| Post nurse staffing information every day. | Health | 2024-08-30 | 2024-10-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-08-30 | 2024-10-28 | 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 | 2024-08-30 | 2024-10-28 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-08-30 | 2024-10-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2024-08-30 | 2024-10-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-30 | 2024-10-28 | N |
| Dispose of garbage and refuse properly. | Health | 2024-08-30 | 2024-10-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-08-30 | 2024-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-30 | 2024-10-28 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2024-08-30 | 2024-10-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-08-30 | 2024-10-28 | N |
| Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. | Health | 2024-08-30 | 2024-10-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-30 | 2024-10-28 | 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 | 2024-08-30 | 2024-10-28 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-08-30 | 2024-10-28 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-08-30 | 2024-10-28 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-30 | 2024-10-28 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-08-30 | 2024-10-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-08-01 | 2024-08-31 | 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 | 2023-10-03 | 2024-02-02 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-10-03 | 2024-02-02 | Y |
| Meet other general requirements. | Fire Safety | 2023-05-17 | 2023-09-20 | 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 | 2023-05-17 | 2023-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-17 | 2023-09-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-17 | 2023-06-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-05-17 | 2023-06-26 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-19 | 2023-06-23 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-05-19 | 2023-06-23 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-19 | 2023-06-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-19 | 2023-06-23 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-05-19 | 2023-06-23 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-08 | 2022-05-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-03-08 | 2022-05-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-10 | 2022-05-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-10 | 2022-05-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-10 | 2022-05-09 | N |
| Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2022-03-10 | 2022-05-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-10 | 2022-05-09 | 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 | 2022-03-10 | 2022-05-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-10 | 2022-05-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-10 | 2022-05-09 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-10 | 2022-05-09 | 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 | 2022-03-10 | 2022-05-09 | Y |
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