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Deficiency Records for Country Lane Gardens Rehab and Nursing Ctr
A list of the most recent deficiencies for Country Lane Gardens Rehab and Nursing Ctr. 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 Lane Gardens Rehab and Nursing Ctr. 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 dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-07-08 | 2024-08-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-07-08 | 2024-08-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-07-08 | 2024-08-01 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-07-08 | 2024-08-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-08 | 2024-08-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-08 | 2024-08-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-08 | 2024-08-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-07-08 | 2024-08-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-08 | 2024-08-01 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2024-07-08 | 2024-08-01 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-07-08 | 2024-08-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-07-08 | 2024-08-01 | 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 | 2024-07-08 | 2024-08-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-07-08 | 2024-08-01 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-07-08 | 2024-08-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-08 | 2024-08-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-07-08 | 2024-08-01 | 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 | 2024-06-24 | 2024-08-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2024-06-24 | 2024-08-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-06-24 | 2024-08-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-02 | 2024-04-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-02 | 2024-04-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-02 | 2024-04-18 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-04-02 | 2024-04-18 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-26 | 2024-03-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-08 | 2023-11-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-08 | 2023-11-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-09 | 2023-02-03 | Y |
| 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 | 2023-01-09 | 2023-02-03 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-09 | 2023-02-03 | 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 | 2023-01-09 | 2023-02-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-09 | 2023-02-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-22 | 2022-08-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-22 | 2022-08-05 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-07-22 | 2022-08-05 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-04-25 | 2022-06-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-25 | 2022-06-02 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-25 | 2022-06-02 | 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 | 2022-04-25 | 2022-06-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-25 | 2022-06-02 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-25 | 2022-06-02 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-04-25 | 2022-06-02 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-04-25 | 2022-06-02 | 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 | 2022-04-25 | 2022-06-02 | 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 | 2022-04-25 | 2022-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-25 | 2022-06-02 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-25 | 2022-06-02 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-25 | 2022-06-02 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-04-25 | 2022-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-06-02 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-18 | 2022-06-02 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-04-19 | 2022-06-02 | N |
| Respond appropriately to all alleged violations. | Health | 2022-03-05 | 2022-03-21 | Y |
| 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 | 2022-03-05 | 2022-03-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-21 | 2021-11-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-09-26 | 2019-11-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-26 | 2019-11-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-26 | 2019-11-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-26 | 2019-11-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-09-26 | 2019-11-19 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-09-26 | 2019-11-19 | N |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2019-09-26 | 2019-11-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-09-26 | 2019-11-19 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-26 | 2019-11-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-26 | 2019-11-19 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-26 | 2019-11-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-26 | 2019-11-19 | 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 | 2019-09-26 | 2019-11-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-09-26 | 2019-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-26 | 2019-11-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-26 | 2019-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-26 | 2019-11-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-26 | 2019-11-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-09-26 | 2019-11-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-03 | 2019-11-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-03 | 2019-11-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-03 | 2019-11-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-03 | 2019-11-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-03 | 2019-11-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-03 | 2019-10-25 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-10-03 | 2019-10-25 | N |
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