Garden Isle Healthcare and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 10, 2023

  Based on observation, interview, and record review, the facility failed to store, label, monitor, and discard food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure all perishable or refrigerated food items were labeled, dated, and monitored. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility. […]

• No harm, potential for more than minimal, patternF623Feb 21, 2025

  4) R65 was first admitted to the facility on [DATE] for long-term placement. Review of R65's EHR revealed that on 10/18/24, R65 was transferred to an acute care facility for a higher level of care. Documentation of facility sending a written notification of discharge to the LTCO was not found in the EHR. On 02/19/25 at 03:26 PM, requested a copy of written notifications of discharge for all four residents from the Director of Nursing (DON). Documents were submitted for review on 02/20/25. On 02/20/25 at 11:16 AM, review of the documents submitted revealed that the LTCO was not notified of the discharges until 02/19/25. On 02/20/25 at 02:20 PM, concurrent record review and interview was conducted with DON in her office. […]

• No harm, potential for more than minimal, patternF550Feb 23, 2024

  Based on observation, staff interview and policy review, the facility failed to ensure the resident's right to a dignified existence and treat each resident with respect and dignity for (4) residents. Resident (R)35, R67, R30, R60 residents sampled. Findings include: 1) R60 was admitted to the facility on [DATE] with diagnosis which includes cancer, aphasia (the loss of the ability to understand or express speech), seizure disorder, and malnutrition. Review of R60's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/24, Section C. Cognitive Patterns, R60's Brief Interview for Mental Status (BIMS) was 4, indicating R60's cognition is severely impaired. Section GG. […]

• No harm, potential for more than minimal, patternF725Jul 7, 2023

  Based on observations, record reviews, and interviews, the facility failed to provide the needed number of staff for adequate care be provided to the residents. This is evidenced by: 1) an unmanned nursing station of a unit not providing supervision of a resident and of visitors entering the facility, 2) closure of a nursing unit, 3) untimely care and response to resident call lights 4) lack of staff to meet the expected number needed for adequate care of residents and 5) double assignments given to staff providing direct care to residents. Findings include: 1) On 07/05/23 at 09:00 AM, upon entrance of the facility, observed a unit's nursing station with no staff available. State agency (SA) waited five minutes for assistance from staff. […]

• No harm, potential for more than minimal, patternF740Jul 7, 2023

  Based on observations, record review, and interview, the facility failed to ensure that necessary behavioral health services were provided to all three residents in the sample. The facility did not implement a supportive, person-centered environment for R1, R2, and R3, by not adequately monitoring their behavioral health needs, and identifying and/or implementing specialized interventions for them. This deficient practice does not provide a supportive physical, mental, and psychosocial environment for all residents with behavioral health needs. Findings include: 1) Record review of the facility's completed Event Report dated 05/07/23 to the Office of Health Care Assurance (OHCA) obtained from the Aspen Complaints/Incidents Tracking System (ACTS) 10268. […]