Florentine Gardens

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 29, 2021

  Based on medical record review, review of fall investigations, observations, staff interview and policy review, the facility failed to provide Resident #100 adequate supervision and/or assistive devices to prevent falls resulting in injuries. This resulted in Actual Harm on 09/15/21 when Resident #100 was found on the floor next to her bed without non-skid socks or appropriate footwear on and the resident subsequently sustained a fractured left olecranon (elbow). Additionally, this resulted in Actual Harm on 09/22/21 when Resident #100 was not adequately supervised in the dining room following dinner, the resident's personal safety alarm (PSA) was not properly attached resulting in the resident falling and subsequently sustaining a right [CONDITION(S)] requiring surgical repair. […]

• No harm, potential for more than minimal, widespreadF812Aug 1, 2022

  Based on observation, staff interview, and policy review, the facility failed to ensure food was labeled, dated, and stored in a safe manner. This had the potential to affect all 66 residents residing in the facility who received their meals from the kitchen. The facility census was 66. Findings include: Observations during the initial tour on 07/25/22 from 9:01 A.M. to 9:28 A.M. revealed the following: Observation on 07/25/22 at 9:05 A.M. revealed one dented can of tropical fruit salad and one dented can of fancy midwest tomato sauce. Observation on 07/25/22 at 9:07 A.M. revealed one unlabeled and undated bag of breadcrumbs. Observation on 07/25/22 at 9:09 A.M. revealed one bag of fried chicken legs, unlabeled and undated, in the freezer. Observation on 07/25/22 at 9:10 A.M. […]

• No harm, potential for more than minimal, patternF657Aug 1, 2022

  Based on medical record reviews, resident interviews, staff interviews, and review of facility policy, the facility failed to conduct care conferences. This affected four (Resident #21, #26, #3, and #7) of four residents reviewed for care conferences. The facility's census was 66. Findings include: 1. Review of the medical record for Resident #21 revealed an admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Minimum Data Set (MDS) assessment for Resident #21 dated 05/07/22 revealed the resident was cognitively impaired and required extensive assistance of staff with activities of daily living (ADLs). Review of the progress note for Resident #21 dated 05/03/22 revealed staff offered to have a care conference for the resident, but she declined to attend. […]

• No harm, potential for more than minimal, patternF921Nov 29, 2021

  Based on observations, review of the facility incident log and staff interviews, the facility failed to ensure all wheelchair brakes were in safe working order. This had the potential to affect five (#29, #38, #54, #22, and #12. of 34) resident wheelchairs checked. The facility census was 68. Findings include: Observations during a tour of the facility with the Maintenance Director on 10/29/21 from 12:25 P.M. through 1:12 P.M. revealed loosened brakes on wheelchairs for Resident #29, #38, #54, #22, and #12. The Maintenance Director confirmed the wheelchairs had brakes that needed to be tightened. Review of facility incident log revealed Resident #54 and #12 had falls that were unrelated to loosened brakes on wheelchairs. Resident #29, #38, or #22 had falls in the past six months. […]

• No harm, potential for more than minimal, isolatedF554Jun 5, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to obtain an order for self-administration of medication and failed to assess the resident's capacity to self-administer medication prior to leaving medication in the room for 1 (Resident #49) of 19 sampled residents. Findings included: A facility policy titled, Self-Administration of medications, dated 10/30/2017, indicated, Each resident who desires to self-administer medication is permitted to do so if the interdisciplinary team has determined that the practice would be safe for the resident and other residents in the facility. An admission Record revealed the facility admitted Resident #49 on 05/08/2024. […]