Garden Park Health Care Center

In the surveyor’s words

From the most serious findings on record at Garden Park Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 2, 2022

  Based on medical record review, interview with staff and the resident's representative, review of hospital records, review of information from MapQuest, review of a weather report, and review of a facility policy, the facility failed to assess and develop a care plan regarding the cognitive status, wandering or elopement risk factors and level of supervision for newly admitted Resident #12, resulting in the resident eloping from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death when on 02/07/22 at 7:56 P.M., Resident #12 exited the facility, without staff knowledge, was found by police and taken to the hospital for evaluation. […]

• Actual harm, isolatedF760Mar 2, 2022

  Based on medical record review, review of hospital records, observation, staff interview, review of electronic mail (email) communication, review of the facility medication error log, review of a written statement and review of facility policy, the facility failed to administer resident medications as ordered resulting in significant medication errors. This resulted in Actual Harm when Resident #51 was given another residents medication and the resident was subsequently admitted to the hospital with altered mental status, low blood pressure (which can cause [CONDITION(S)] or dizziness because the brain doesn't receive enough blood) and required intravenous (IV) fluids. […]

• No harm, potential for more than minimal, widespreadF730Aug 7, 2025

  Based on personnel record review, staff interview, and review of the facility policy, the facility failed to ensure Certified Nursing Assistants (CNAs) received annual performance evaluations. This had the potential to affect all of the residents residing in the facility. The facility census was 48 residents.Findings include: Review of the personnel file for Certified Nursing Assistant (CNA) #213 revealed a hire date of 03/27/23 with no performance evaluations from 03/27/24 to 08/07/25. Review of the personnel file for CNA #224 revealed a hire date of 08/29/23 with no performance evaluations from 08/29/23 to 08/07/25. Interview on 08/07/25 at 8:47 A.M. with Human Resources #202 verified the facility had not completed annual performance evaluations for CNAs #213 and #224. […]

• No harm, potential for more than minimal, widespreadF880Aug 7, 2025

  Based on personnel record review, staff interview, and review of the facility policy, the facility failed to implement their tuberculosis (TB) control plan for tuberculosis testing of newly hired employees. This had the potential to affect all of the residents residing in the facility. Based on observation, staff interview, and review of the facility policy, the facility also failed to ensure staffed practiced appropriate hand hygiene during medication administration. This affected four (#11, #31, #36, and #47) of four residents observed for medication administration. […]

• No harm, potential for more than minimal, widespreadF947Aug 7, 2025

  Based on personnel record review, staff interview, and review of the facility policy, the facility failed to ensure Certified Nursing Assistants (CNAs) received at least twelve hours of in service annually. This had the potential to affect all of the residents residing in the facility. The facility census was 48.Findings include:Review of the personnel file for Certified Nursing Assistant (CNA) #209 revealed a hire date of 05/20/80 with no documented in-service education from 05/20/24 to 08/07/25.Review of the personnel file for CNA #213 revealed a hire date of 03/27/23 with no documented in-service education from 03/27/24 to 08/07/25Review of the personnel file for CNA #224 revealed a hire date of 08/29/13 with no documented in-service education from 08/29/23 to 08/07/25.Interview on… […]