Garden Park Nursing & Rehab CTR, LLC

In the surveyor’s words

From the most serious findings on record at Garden Park Nursing & Rehab CTR, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 1, 2022

  Based on record review, interviews and observation the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for accidents. The facility failed to use a two-person transfer, as determined necessary by resident #1's minimum data set during a transfer resulting in a femur fracture. The deficient practice resulted in actual harm for resident #1, on 4/22/2022 when resident #1 was lowered to the floor during a transfer to the shower chair. Resident #1 required two person assistance for transfers and was lowered to the floor when resident #1's knees buckled while being transferred from the wheelchair to the shower chair by one staff person. […]

• No harm, potential for more than minimal, patternF577Sep 10, 2025

  Based on observation and interview the facility failed to ensure the most recent survey results were readily accessible to the residents, family members or anyone to review. Findings: An observation on 09/08/2025 at 10:00 a.m. failed to reveal the most recent survey result was in the facility's survey binder. During an interview on 09/08/2025 at 10:01 a.m. with S1 Administrator confirmed most the recent survey was not in survey binder and should have been.

• No harm, potential for more than minimal, patternF604Sep 10, 2025

  Based on record reviews, observations and interviews, the facility failed to ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for 3 (#15, #58, #139) of 3 (#15, #58, #139) residents reviewed for restraints . The facility failed to ensure:1. a pre-restraint assessment and written consent were in place for the use of Resident #15's lap buddy and 2. a pre-restraint assessment and written consent were in place for the use of Resident #58 and Resident #139's self-releasing seat belt. […]

• No harm, potential for more than minimal, patternF605Sep 10, 2025

  Based on record review and interviews, the facility failed to ensure a resident with an order for psychotropic medication as needed (PRN) was not subjected to chemical restraints for 1 (#139) of 4 (#3, #7, #10 and #139) residents reviewed for unnecessary medications. The facility failed to ensure Resident #139's PRN order for psychotropic medication was limited to 14 days. Findings:Review of Resident #139's medical record revealed an admit date of 11/12/2018 with diagnoses including in part muscle wasting and atrophy, cognitive communication deficit, dementia in other diseases classified elsewhere, severe, with mood disturbance.Review of Resident #139's physician orders revealed an order dated 01/28/2025 for Vistaril oral capsule 25 mg (milligram) (Hydroxyzine Pamoate); give 1 capsule by… […]

• No harm, potential for more than minimal, patternF641Sep 10, 2025

  Based on record review and interview, the facility failed to ensure resident assessments accurately reflected the resident's status for 1(#137) of 1(#137) resident out a total of 46 sampled residents whose assessments were reviewed. The facility failed to complete Resident #137's discharge assessment. Findings: Review of Resident #137's medical record revealed an admission date of 03/11/2025 and a discharge date of 03/17/2025 with a diagnosis of but not limited to low back pain, schizophrenia, hypertensive chronic kidney disease with stage 4 chronic kidney disease, generalized muscle weakness, essential hypertension, and muscle wasting and atrophy. […]