Garden City Healthcare Center

In the surveyor’s words

From the most serious findings on record at Garden City Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 24, 2024

  Based on observation, interview, and record review, the facility failed to protect resident rights to be free from abuse (verbal, mental, sexual, or physical abuse) and neglect (failure to provide goods and services necessary to avoid physical harm or mental anguish) for two of twenty-one sampled residents (Resident 32 and Resident 38) when the facility was aware that Resident 32 and Resident 38 were continuing to engage in sexual activity which began on or around [DATE] and: 1. The facility did not determine if Resident 32 and Resident 38 had the capacity for sexual consent (physical and psychological actions that involve sexual arousal, desire, and satisfaction); 2. […]

• Actual harm, isolatedF689Nov 24, 2025

  Based on interview and record review, the facility failed to implement appropriate safety interventions including supervision to ensure a safe environment free of accidents and hazards for one of two sampled residents (Resident 1) when:1. Resident 1 was not initially assessed (around the time of admission to the facility) accurately for an elopement risk (the potential for a vulnerable individual to leave a facility without staff awareness, leading to serious dangers like injury or even death) and Resident 1 was not reassessed for an elopement risk after Resident 1 became more confused, began to wander (aimless movement), and attempted to and expressed a desire to leave the facility on several occasions; 2. […]

• Actual harm, isolatedF689Jul 15, 2025

  Based on interview and record review, the facility failed to use safe lifting technique to move one of two sampled residents (Resident 1) from the wheelchair to the bed on 7/5/25, after Resident 1 had an assisted fall (a situation where a resident begins to fall but is supported or guided by another person to minimize the impact of the fall) to the ground.This failure resulted in Resident 1 sustaining a left distal femoral fracture (broken bone in the lower part of the left thigh bone near the knee).Findings:Review of Resident 1's admission RECORD, indicated Resident 1 was admitted to the facility with diagnosis of dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and repeated falls. […]

• No harm, potential for more than minimal, widespreadF812Oct 24, 2024

  Based on observation, interview, and record review, the facility failed to ensure the kitchen's commercial can opener blade was clean and free from metal shavings. This failure could have resulted in food borne illness (vomiting, diarrhea, nausea) for 98 residents who ate food from the kitchen. Findings: During a concurrent observation and interview on 10/21/24, at 11:40 a.m., with the Dietary Director (DD), the commercial can opener was observed to have old metal shavings on the blade of the can opener. DD acknowledged the commercial can opener was not clean and it appeared to have curled up metal shavings on the blade that occurred after a can of food was opened. […]

• No harm, potential for more than minimal, widespreadF812Sep 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure professional standards for food service safety were maintained for 91 of 91 residents who received food from the kitchen, when Dietary Aide (DA) 1 was preparing food for the facility while not wearing a beard net/restraint (used to prevent facial hair from falling into food). This failure had the potential to result in DA 1's facial hair to be introduced to the food being prepared resulting in physical and bacterial contamination. Findings: During a concurrent observation and interview with the Certified Dietary Manager (CDM), in the kitchen on 9/11/23, at 9:31 AM, DA 1 was observed preparing food in individual bowls without wearing a beard net/restraint. […]