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Deficiency Records for Harvard Gardens Rehabilitation and Care Center
A list of the most recent deficiencies for Harvard Gardens Rehabilitation and Care 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 Harvard Gardens Rehabilitation and Care 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? |
|---|---|---|---|---|
| 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 | 2024-02-22 | 2024-03-08 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-22 | 2024-03-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-22 | 2024-03-08 | 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 | 2024-02-22 | 2024-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-18 | 2024-01-19 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-28 | 2023-12-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-28 | 2023-12-06 | N |
| Use approved construction type or materials. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-20 | 2023-12-06 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-28 | 2023-11-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-28 | 2023-11-29 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-28 | 2023-11-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-28 | 2023-11-29 | N |
| Respond appropriately to all alleged violations. | Health | 2023-09-28 | 2023-11-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-28 | 2023-11-29 | 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 | 2023-09-28 | 2023-11-29 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-28 | 2023-11-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-28 | 2023-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-11-29 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-09-28 | 2023-11-29 | N |
| Have policies on smoking. | Health | 2023-09-28 | 2023-11-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-11-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-28 | 2023-11-29 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-09-28 | 2023-11-29 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-28 | 2023-11-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-11-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-28 | 2023-11-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-28 | 2023-11-29 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-28 | 2023-11-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-11-29 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-09-20 | 2023-11-27 | 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 | 2023-09-20 | 2023-11-27 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-20 | 2023-11-27 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-20 | 2023-11-27 | 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 | 2023-01-13 | 2023-01-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-01 | 2023-01-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-01 | 2023-01-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-01 | 2023-01-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-11-01 | 2023-01-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-01 | 2023-01-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-01 | 2023-01-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-01 | 2023-01-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-01 | 2023-01-26 | 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 | 2022-11-01 | 2023-01-26 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-11-01 | 2023-01-26 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-11-01 | 2023-01-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-01 | 2023-01-26 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-11-01 | 2023-01-26 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-01 | 2022-12-30 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-06-17 | 2022-07-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-17 | 2022-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-17 | 2022-07-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-08 | 2022-03-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-20 | 2022-02-09 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-04 | 2021-05-18 | 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 | 2021-05-04 | 2021-05-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-04 | 2021-05-18 | 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 | 2021-05-04 | 2021-05-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-04 | 2021-05-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-04 | 2021-05-18 | 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 | 2021-05-03 | 2021-05-18 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-05-03 | 2021-05-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-03 | 2021-05-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-03 | 2021-05-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-05-03 | 2021-05-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-03 | 2021-05-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-11 | 2019-09-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-06-11 | 2019-09-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-11 | 2019-09-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-20 | 2019-09-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-06-20 | 2019-09-19 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-20 | 2019-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-20 | 2019-09-19 | 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 | 2019-06-20 | 2019-09-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-06-20 | 2019-09-19 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-20 | 2019-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-06-20 | 2019-09-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-20 | 2019-09-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-20 | 2019-09-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-06-20 | 2019-09-19 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2019-06-20 | 2019-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-20 | 2019-09-19 | N |
| Dispose of garbage and refuse properly. | Health | 2019-06-20 | 2019-09-19 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-06-20 | 2019-09-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-06-20 | 2019-09-19 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2019-06-20 | 2019-09-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-06-20 | 2019-09-19 | 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 | 2019-06-20 | 2019-09-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-06-20 | 2019-09-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-11 | 2019-09-19 | N |
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