The Gardens at Aldersgate

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (May 1, 2026)

FEnsure residents have reasonable access to and privacy in their use of communication methods.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0576 · Deficient, Provider has date of correction (Feb 20, 2026)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Feb 20, 2026)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Feb 20, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Feb 20, 2026)

EEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0805 · Deficient, Provider has date of correction (Feb 20, 2026)

EKeep all essential equipment working safely.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0908 · Deficient, Provider has date of correction (Feb 20, 2026)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (Feb 20, 2026)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Feb 20, 2026)

DKeep residents' personal and medical records private and confidential.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0583 · Deficient, Provider has date of correction (Feb 20, 2026)

DPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0605 · Deficient, Provider has date of correction (Feb 20, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Deficient, Provider has date of correction (Feb 20, 2026)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Deficient, Provider has date of correction (Feb 20, 2026)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Feb 20, 2026)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Feb 20, 2026)

DEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Feb 20, 2026)

DDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Deficient, Provider has date of correction (Feb 20, 2026)

DProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Past Non-Compliance (Jul 9, 2025)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0744 · Complaint inspection · Deficient, Provider has date of correction (Jan 10, 2025)

FObserve each nurse aide's job performance and give regular training.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0730 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

FSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Potential for more than minimal harm · Administration Deficiencies · Tag F0867 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

EDevelop and implement policies and procedures for flu and pneumonia vaccinations.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0883 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DRespond appropriately to all alleged violations.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0610 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0677 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0742 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0744 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DProvide medically-related social services to help each resident achieve the highest possible quality of life.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0745 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Complaint inspection · Deficient, Provider has date of correction (Mar 19, 2024)

EProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Deficient, Provider has date of correction (Sep 23, 2022)

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

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (Sep 23, 2022)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Deficient, Provider has date of correction (Sep 23, 2022)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (Sep 23, 2022)

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Sep 23, 2022)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (Sep 23, 2022)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Sep 23, 2022)

DImplement 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Sep 23, 2022)

DArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Potential for more than minimal harm · Administration Deficiencies · Tag F0849 · Deficient, Provider has date of correction (Sep 23, 2022)