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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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-09-13 | 2024-10-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-09-13 | 2024-10-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-09-13 | 2024-10-22 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2024-09-13 | 2024-10-22 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-09-13 | 2024-10-22 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-09-13 | 2024-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-09-13 | 2024-10-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-09-13 | 2024-10-22 | Y |
| 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 | 2024-09-26 | 2024-10-14 | N |
| 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 |
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