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Deficiency Records for Episcopal Church Home The Gardens
A list of the most recent deficiencies for Episcopal Church Home The Gardens. 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 Episcopal Church Home The Gardens. 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? |
|---|---|---|---|---|
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2024-09-12 | 2024-11-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-09-12 | 2024-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-09-12 | 2024-11-04 | 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 | 2024-09-12 | 2024-11-04 | 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 | 2024-09-12 | 2024-11-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-09-12 | 2024-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-12 | 2024-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-09-12 | 2024-11-04 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-10 | 2024-10-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-04 | 2024-03-29 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-31 | 2023-09-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-08-03 | 2023-09-12 | 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 | 2023-08-03 | 2023-09-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-03 | 2023-09-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-03 | 2023-09-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-03 | 2023-09-12 | 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 | 2023-08-03 | 2023-09-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-03 | 2023-09-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-03 | 2023-09-12 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-07-31 | 2023-09-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-24 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-24 | 2022-05-20 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-03-24 | 2022-05-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-23 | 2022-05-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-23 | 2022-05-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-23 | 2022-05-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-23 | 2022-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-23 | 2022-05-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-23 | 2022-05-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-15 | 2022-01-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-15 | 2022-01-21 | Y |
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