Garden Place Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF684Nov 6, 2024

  Based on interview and record review, the facility failed to ensure quality of care based on professional standards of practice for one Resident (#212), in a sample of three closed records. Specifically, the facility failed to ensure staff fully assessed Resident #212 who was on a blood thinner, had expressed pain, and had a bruise to the left hip, resulting in a delay in treatment. The Resident was later identified to have a fracture to the left hip and was subsequently sent to the hospital where he/she received a blood transfusion. […]

• Actual harm, isolatedF686Aug 16, 2023

  Based on observation, interview, record review, and policy review, the facility failed to provide care and treatment consistent with professional standards of practice to prevent the development or worsening of a pressure injury for one Resident (#4), out of a total sample of 26 residents. Specifically, the facility failed to implement interventions to prevent the development of a pressure wound, assess the Resident's risk and skin per their policy, and implement interventions recommended by the wound physician timely once the area had developed, resulting in a facility acquired unstageable full thickness deep tissue injury (DTI: localized area of persistent non-blanchable discoloration resulting from intense and/or prolonged pressure and shear forces at the bone/muscle) to the left… […]

• No harm, potential for more than minimal, widespreadF812Aug 16, 2023

  Based on observation, interview, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure staff wear beard restraints in the main kitchen, during meal preparation and service; and 2. Ensure adequate sanitation of equipment in the main kitchen, and 2 of 3 nourishment kitchenettes; and 3. Ensure dietary staff wash their hands after touching a body part, before proceeding with food preparation and service; and 4. Ensure ice machines were cleaned and sanitized. […]

• No harm, potential for more than minimal, widespreadF865Aug 16, 2023

  Based on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated 4/2018 and last revised 6/2019, indicated but was not limited to: -The purpose of the committee is to review and analyze facility related data and direct appropriate actions for the facility response. […]

• No harm, potential for more than minimal, widespreadF867Aug 16, 2023

  Based on record review, policy review, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes. Specifically, the facility failed to develop and implement a QAPI plan and a Performance Improvement Project (PIP) that focuses on a high risk or problem-prone area identified through data collection and analysis. Findings include: Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI), dated 4/2018 and last revised 6/2019, indicated but was not limited to: -The purpose of the committee is to review and analyze facility related data and direct appropriate actions for the facility response. […]