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Deficiency Records for The Gardens

A list of the most recent deficiencies for 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 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?
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-01-04 2024-01-31 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 2023-07-19 2023-08-16 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-01-12 2022-03-01 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-01-12 2022-03-01 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 2022-01-12 2022-03-01 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 2022-01-12 2022-03-01 Y
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 2022-01-12 2022-03-01 Y
Ensure medication error rates are not 5 percent or greater. Health 2022-01-12 2022-03-01 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 2022-01-12 2022-03-01 Y
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2022-01-12 2022-03-01 Y
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 2022-01-12 2022-03-01 Y
Provide and implement an infection prevention and control program. Health 2022-01-12 2022-03-01 Y
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-01-04 2022-03-01 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-01-04 2022-03-01 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-01-04 2022-03-01 N
Reasonably accommodate the needs and preferences of each resident. Health 2019-07-23 2019-08-20 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-07-23 2019-08-20 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-07-23 2019-08-20 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2019-07-23 2019-08-20 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2019-07-23 2019-08-20 N
Have exits that are accessible at all times. Fire Safety 2019-07-16 2019-08-19 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-07-16 2019-08-16 N

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