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Deficiency Records for Country Gardens Health and Rehabilitation Center
A list of the most recent deficiencies for Country Gardens Health and Rehabilitation 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 Country Gardens Health and Rehabilitation 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-01 | 2024-09-10 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-07-01 | 2024-09-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-01 | 2024-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-01 | 2024-09-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-07-01 | 2024-09-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-01 | 2024-09-10 | 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 | 2024-07-01 | 2024-09-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-01 | 2024-09-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-07-01 | 2024-08-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-07-01 | 2024-08-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-07-01 | 2024-08-09 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-07-01 | 2024-08-09 | N |
| Provide activities to meet all resident's needs. | Health | 2024-07-01 | 2024-08-09 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-07-01 | 2024-08-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-01 | 2024-08-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-07-01 | 2024-08-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-01 | 2024-08-09 | N |
| 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 | 2024-07-01 | 2024-08-09 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2024-07-01 | 2024-08-09 | 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 | 2024-07-01 | 2024-08-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-01 | 2024-08-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2024-07-01 | 2024-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-01 | 2024-08-09 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-07-01 | 2024-08-09 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-07-01 | 2024-08-09 | N |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-07-01 | 2024-08-09 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-07-01 | 2024-08-09 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-07-01 | 2024-08-09 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2024-07-01 | 2024-08-09 | N |
| Provide training in compliance and ethics. | Health | 2024-07-01 | 2024-08-09 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-07-01 | 2024-08-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-22 | 2023-07-26 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-04-11 | 2023-06-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-03-28 | 2023-05-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-28 | 2023-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-28 | 2023-05-08 | N |
| 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 | 2023-03-28 | 2023-05-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-03-28 | 2023-05-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-28 | 2023-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-05-08 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-03-28 | 2023-05-08 | N |
| Respond appropriately to all alleged violations. | Health | 2021-10-06 | 2021-11-26 | 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 | 2019-11-01 | 2019-12-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-01 | 2019-12-09 | 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 | 2019-11-01 | 2019-12-09 | 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 | 2019-11-01 | 2019-12-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-01 | 2019-12-09 | N |
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