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Deficiency Records for Memorial Gables
A list of the most recent deficiencies for Memorial Gables. 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 Memorial Gables. 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? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-06-13 | 2024-07-12 | 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 | 2024-06-13 | 2024-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-06-13 | 2024-07-12 | 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 | 2024-06-13 | 2024-07-12 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-06-13 | 2024-07-12 | 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 | 2024-06-13 | 2024-07-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-06-13 | 2024-07-12 | N |
| Keep all essential equipment working safely. | Health | 2024-06-13 | 2024-07-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-06-11 | 2024-07-12 | 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 | 2024-06-11 | 2024-07-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-06-11 | 2024-07-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-21 | 2024-03-22 | 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 | 2023-04-03 | 2023-04-21 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-07-14 | 2022-08-26 | 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 | 2022-07-14 | 2022-08-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-14 | 2022-08-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-11 | 2022-08-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-11 | 2022-08-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-11 | 2019-08-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-07-11 | 2019-08-16 | 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 | 2019-07-11 | 2019-08-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-11 | 2019-08-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-11 | 2019-08-16 | 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 | 2019-07-11 | 2019-08-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-11 | 2019-08-16 | 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 | 2019-07-10 | 2019-08-16 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-07-10 | 2019-08-16 | 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 | 2019-07-10 | 2019-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-07-10 | 2019-08-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-07-10 | 2019-08-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-07-10 | 2019-08-16 | N |
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