Episcopal Church Home the Gardens

Allow residents to self-administer drugs if determined clinically appropriate.

Rule F0554. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 11, 2026.

Keep residents’ personal and medical records private and confidential.

Rule F0583. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 11, 2026.

Provide safe and appropriate respiratory care for a resident when needed.

Rule F0695. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 11, 2026.

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Rule F0756. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 11, 2026.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 11, 2026.

Provide and implement an infection prevention and control program.

Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: May 11, 2026.

Ensure services provided by the nursing facility meet professional standards of quality.

Rule F0658. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jan 2, 2026.

Honor the resident’s right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Rule F0550. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 29, 2025.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 29, 2025.

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Rule F0700. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 22, 2025.

Ensure that residents are free from significant medication errors.

Rule F0760. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 29, 2025.

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.

Rule F0849. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 29, 2025.

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Rule F0909. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Oct 22, 2025.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Rule F0609. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 27, 2025.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Rule F0657. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 2, 2025.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Jun 2, 2025.

Provide care by qualified persons according to each resident’s written plan of care.

Rule F0659. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

Provide care and assistance to perform activities of daily living for any resident who is unable.

Rule F0677. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Rule F0684. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

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.

Rule F0758. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

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.

Rule F0761. D: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Rule F0812. F: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

Provide and implement an infection prevention and control program.

Rule F0880. E: no actual harm, potential for more than minimal harm. Correction date, as CMS recorded it: Nov 4, 2024.

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Rule F0689. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Nov 4, 2024.

Develop and implement a complete care plan that meets all the resident’s needs, with timetables and actions that can be measured.

Rule F0656. D: no actual harm, potential for more than minimal harm. From a complaint. Correction date, as CMS recorded it: Mar 29, 2024.