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Deficiency Records for Garden Court Nursing and Rehabilitation Center
A list of the most recent deficiencies for Garden Court Nursing 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 Garden Court Nursing 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-13 | 2024-09-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-13 | 2024-09-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-05-13 | 2024-09-03 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-23 | 2024-09-03 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-07-23 | 2024-09-03 | N |
| 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 | 2024-07-23 | 2024-09-03 | N |
| Provide or obtain dental services for each resident. | Health | 2024-07-23 | 2024-09-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-23 | 2024-09-03 | 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 | 2024-07-23 | 2024-09-03 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-23 | 2024-09-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-23 | 2024-09-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-23 | 2024-09-03 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-23 | 2024-09-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-23 | 2024-09-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-23 | 2024-09-03 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-23 | 2024-09-03 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2024-07-23 | 2024-09-03 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-23 | 2024-09-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-23 | 2024-09-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-07-23 | 2024-09-03 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-07-23 | 2024-09-03 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-07-23 | 2024-09-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-06-05 | 2024-09-03 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-06-05 | 2024-09-03 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-07-09 | 2024-09-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-06-05 | 2024-07-09 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-05 | 2024-07-09 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-06-05 | 2024-07-09 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2024-06-05 | 2024-07-09 | Y |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2024-06-05 | 2024-07-09 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-06-06 | 2024-06-21 | 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 | 2024-06-06 | 2024-06-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-06 | 2024-06-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-06-06 | 2024-06-21 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-06-06 | 2024-06-21 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-06-06 | 2024-06-21 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-06-06 | 2024-06-21 | 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 | 2024-04-11 | 2024-05-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-11 | 2024-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-09 | 2024-01-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-25 | 2023-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-25 | 2023-11-13 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-09-25 | 2023-11-13 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2023-09-25 | 2023-11-13 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-25 | 2023-11-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-25 | 2023-11-13 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-04 | 2023-08-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-14 | 2023-06-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-14 | 2023-06-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-11 | 2023-04-21 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-04-11 | 2023-04-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-11 | 2023-04-21 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-03-15 | 2023-04-05 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-03-15 | 2023-04-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-15 | 2023-04-05 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-01-04 | 2023-01-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-04 | 2023-01-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-06 | 2023-01-23 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2022-12-06 | 2023-01-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-07 | 2023-01-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-07 | 2023-01-23 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-07 | 2023-01-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-07 | 2023-01-23 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-11-07 | 2023-01-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-11-07 | 2023-01-23 | 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 | 2022-11-07 | 2023-01-23 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-07 | 2023-01-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-07 | 2023-01-23 | N |
| 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 | 2022-11-07 | 2023-01-23 | 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 | 2022-11-07 | 2023-01-23 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-11-07 | 2023-01-23 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-07 | 2023-01-23 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-11-07 | 2023-01-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-11-01 | 2023-01-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-01 | 2022-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-06 | 2022-10-06 | 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 | 2022-06-06 | 2022-06-23 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-05-20 | 2022-06-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-20 | 2022-06-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-20 | 2022-06-23 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-31 | 2022-06-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-03-31 | 2022-06-23 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-31 | 2022-06-23 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-31 | 2022-06-23 | 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 | 2022-02-03 | 2022-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-19 | 2022-02-25 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-03 | 2022-02-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-03 | 2022-02-25 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-03 | 2022-02-25 | Y |
| 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 | 2022-01-03 | 2022-02-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-03 | 2022-02-25 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-01-03 | 2022-02-25 | Y |
| 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 | 2019-12-18 | 2020-01-10 | 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 | 2019-12-18 | 2020-01-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-18 | 2020-01-10 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-18 | 2020-01-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-12-18 | 2020-01-10 | 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 | 2019-12-18 | 2020-01-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-18 | 2020-01-10 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-18 | 2020-01-10 | 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 | 2019-12-18 | 2020-01-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-18 | 2020-01-10 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2019-12-18 | 2020-01-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-12-17 | 2020-01-10 | N |
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