Central Gardens Post Acute

In the surveyor’s words

From the most serious findings on record at Central Gardens Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF609Apr 25, 2024

  Based on Interviews and record reviews, the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility ' s policy and procedure for four of 4 sampled residents (Resident 1, Resident 2 Resident 3, and Resident 4). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents. Findings: During a review of Admission Record, dated [DATE], indicated, Resident 1, admitted to facility on [DATE], with diagnoses including: Seizures (involuntary body jerking), Adult failure to thrive, Dementia (loss of memory). […]

• No harm, potential for more than minimal, patternF655Apr 25, 2024

  Based on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for Resident 6 and a copy of the baseline care plan summary was provided to the resident and/or representative for three of 3 sampled residents (Resident 5, 6, and 7). A Baseline Care Plan (BCP) includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. […]

• No harm, potential for more than minimal, patternF759May 26, 2023

  Based on observation, interview, and record review the facility failed to maintain a medication error rate less than five percent for two out of seven Residents observed (Residents 53 and Resident 8). This created an error rate of 9.68 percent (3 errors out of thirty-one opportunities). This failure had the potential to cause worsening medical conditions for each resident. Findings. 1. Symbicort was not administered during the appropriate time frame for Resident 53 (omission of medication). 2. Depakote delayed release tablets was crushed and administered for Resident 8. 3. Lidocaine patch was not applied to Resident 8 and documented as administered (omission of medication). 1. […]

• No harm, potential for more than minimal, patternF880May 26, 2023

  Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1. The Red Zone (isolation room) door, with Resident 434 inside, was fully open while staff was cleaning the room. 2a. A dirty urinal was hung on the side rail of Resident 44's bed on 5/23/23. 2b. Resident 44's urinal jug containing urine was placed on the overbed table. 3. Staff did not perform hand hygiene after glove removal. 4. Staff did not perform hand hygiene when she entered between two residents' rooms. 5. Staff did not clean and disinfect medical equipment (blood pressure cuff) in between multiple residents (Resident 39, Resident 53, and Resident 44). […]

• No harm, potential for more than minimal, patternF584Mar 14, 2023

  Based on observation, interviews and record reviews, the facility failed to have an effective system in place to manage residents ' belongings for Resident 1, 2, and 3, three of six sampled residents. The facility failed to: A. Accurately inventory resident ' s belongings B. Properly store/safe guard resident ' s belongings C. have an effective system in place to update Resident's inventory list on a regular basis These failures resulted in Resident 1 ' s clothing being found stored in Resident 2 ' s closet and Resident 1 ' s inventoried jewelry was missing. Resident 2 had personal items missing for 16 months and her inventory list was not updated to reflect the loss. Resident 3 ' s glasses were not entered into his inventory list upon admission. […]