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Deficiency Records for Garden Village

A list of the most recent deficiencies for Garden Village. 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 Garden Village. 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?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-05-16 2024-06-07 Y
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Health 2024-03-19 2024-04-05 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-12-08 2024-01-05 Y
Provide care or services that was trauma informed and/or culturally competent. Health 2023-12-08 2024-01-05 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-10-05 2023-10-14 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-08-31 2023-10-14 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-08-31 2023-10-14 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 2023-08-31 2023-10-14 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 2023-08-31 2023-10-14 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-08-31 2023-10-14 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-08-31 2023-10-14 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 2023-08-31 2023-10-14 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-08-31 2023-10-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-31 2023-10-14 N
Provide and implement an infection prevention and control program. Health 2023-08-31 2023-10-14 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-08-31 2023-10-14 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 2023-08-31 2023-10-14 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-08-31 2023-10-14 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-08-31 2023-10-14 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 2023-08-31 2023-10-14 Y
Develop, implement, and/or maintain an effective training program for all new and existing staff members. Health 2023-08-31 2023-10-14 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-08-23 2023-09-27 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2023-08-23 2023-09-27 N
Include a process for Emergency Preparedness collaboration. Fire Safety 2023-08-23 2023-09-27 N
List the names and contact information of those in the facility. Fire Safety 2023-08-23 2023-09-27 N
Establish emergency prep training and testing. Fire Safety 2023-08-23 2023-09-27 N
Meet other general requirements. Fire Safety 2023-08-23 2023-09-27 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-08-23 2023-09-27 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 2023-08-23 2023-09-27 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2023-08-23 2023-09-27 N
Provide properly protected cooking facilities. Fire Safety 2023-08-23 2023-09-27 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-08-23 2023-09-27 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2023-08-23 2023-09-27 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-23 2023-09-27 N
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Fire Safety 2023-08-23 2023-09-27 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-08-23 2023-09-27 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-08-23 2023-09-27 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-08-23 2023-09-27 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-08-23 2023-09-27 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-08-23 2023-09-27 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2023-08-23 2023-09-27 N
Have proper medical gas storage and administration areas. Fire Safety 2023-08-23 2023-09-27 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-07-13 2023-08-11 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-13 2023-08-11 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 2023-01-06 2023-02-08 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-06 2022-10-14 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2022-06-30 2022-08-26 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2022-06-30 2022-08-26 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2022-06-30 2022-08-26 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 2022-06-30 2022-08-26 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-06-30 2022-08-26 N
Provide activities to meet all resident's needs. Health 2022-06-30 2022-08-26 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-06-30 2022-08-26 N
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. Health 2022-06-30 2022-08-26 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 2022-06-30 2022-08-26 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-06-30 2022-08-26 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 2022-06-30 2022-08-26 N
Perform COVID19 testing on residents and staff. Health 2022-06-30 2022-08-26 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-06-30 2022-08-26 Y
Respond appropriately to all alleged violations. Health 2022-06-30 2022-08-26 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 2022-06-30 2022-08-26 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 2022-06-30 2022-08-26 Y
Provide and implement an infection prevention and control program. Health 2022-06-30 2022-08-26 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-06-30 2022-08-26 Y
Establish staff and initial training requirements. Fire Safety 2022-06-16 2022-07-21 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-06-16 2022-07-20 N
Develop a communication plan. Fire Safety 2022-06-16 2022-07-20 N
Provide properly protected cooking facilities. Fire Safety 2022-06-16 2022-07-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-06-16 2022-07-20 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-06-16 2022-07-20 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2022-06-16 2022-07-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-06-16 2022-07-20 N
Ensure that testing and maintenance of electrical equipment is performed. Fire Safety 2022-06-16 2022-07-20 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2022-06-16 2022-07-20 N
Meet other general requirements. Fire Safety 2022-06-16 2022-06-24 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-06-16 2022-06-17 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-06-16 2022-06-16 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2019-07-15 2019-09-13 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-07-19 2019-08-16 N
Assure the security of all personal funds of residents deposited with the facility. Health 2019-07-19 2019-08-16 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2019-07-19 2019-08-16 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2019-07-19 2019-08-16 N
Provide enough food/fluids to maintain a resident's health. Health 2019-07-19 2019-08-16 N
Ensure that the resident and his/her doctor meet face-to-face at all required visits. Health 2019-07-19 2019-08-16 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 2019-07-19 2019-08-16 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 2019-07-19 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 2019-07-15 2019-08-12 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2019-07-15 2019-07-26 N
Install corridor and hallway doors that block smoke. Fire Safety 2019-07-15 2019-07-23 N
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. Fire Safety 2019-07-15 2019-07-22 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2019-07-15 2019-07-22 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2019-07-15 2019-07-18 N

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