Episcopal Church Home the Gardens

In the surveyor’s words

From the most serious findings on record at Episcopal Church Home the Gardens, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 3, 2023

  Based on observation, interview, and record review, the facility failed to implement individualized fall interventions for 2 of 3 residents (R27, R35) and failed to ensure a route cause analysis was completed and new interventions were implemented following a fall for 1 of 1 resident (R6), who was at risk for and had a history of falls. This resulted in harm when R6 had a subsequent fall on 5/16/23 and sustained a lumbar fracture. Findings include: R6's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition and diagnoses of congestive heart failure (CHF), unspecified fall, abnormalities of gait and mobility, low back pain, and history of falling. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2026

  Based on observation, interview, and document review, the facility failed to ensure foods were stored in a manner to prevent spoilage and freezer burn and failed to ensure food items in 6 out of 6 kitchenettes were sealed, labeled and dated. This had the potential to affect all residents who reside in the facility. Findings include:An observation on 4/7/26 at 3:22 p.m., the 2nd floor kitchenette was reviewed. The freezer had undated, opened packages of bacon, pancakes, waffles, hot dog buns and a container of red and white substance. Nursing assistant (NA)-H verified these items and stated all items should have been sealed, dated and labeled.An observation on 4/8/26 at 8:16 a.m., the 3rd floor kitchenette was reviewed. […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2024

  Based on observation, interview and record review the facility failed to have a process in place to monitor refrigerator, dishwasher and breakfast food temperatures in all six unit kitchens in the care facility. In addition the facility failed to ensure opened food and beverage containers were dated to prevent unsafe consumption by residents. This had the ability to affect all 55 residents residing in the care facility. Findings include: During interview and observation on 9/9/24 at 11:45 a.m., the registered dietician (RD) stated there was one central kitchen where lunch and dinner were cooked, and each resident floor (two through seven) had their own full kitchen. Breakfast was cooked to order for each resident on the floors and lunch and dinner were kept warm in a steamer on the floors. […]

• No harm, potential for more than minimal, widespreadF880Aug 3, 2023

  Based on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) was utilized to prevent the spread of infection when rinsing contaminated laundry. Furthermore, the facility failed to transport clean laundry in a manner which ensured protection from dust and soil. This had the potential to impact all 60 residents who reside in the facility. Findings include: R51's annual Minimum Data Set (MDS) dated [DATE], indicated R51 was cognitively intact and had diagnoses of heart disease and diabetes. R10's quarterly MDS dated [DATE], indicated R10 had cognitive impairment and diagnosis of dementia. An observation on 7/31/23 at 9:03 a.m., a white laundry basket was on the floor outside of R51's room. […]

• No harm, potential for more than minimal, patternF880Apr 9, 2026

  Based on observation, interview, and document review the facility failed to ensure appropriate glove use and hand hygiene for 1 of 1 resident (R19) during personal cares. The facility further failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R19) who had a nephrostomy tube and for 1 of 1 resident (R4) who had a catheter and was receiving catheter cares. The facility also failed to ensure 1 of 1 resident (R54) on droplet precautions was wearing a mask when out of her room. This had the potential to affect all 10 residents residing on the 3rd floor. […]