Garden Terrace Alzheimer's Center of Excellence

In the surveyor’s words

From the most serious findings on record at Garden Terrace Alzheimer's Center of Excellence, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 24, 2021

  Based on observations, record review, and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as was possible; and that each resident received adequate supervision and assistance devices to prevent accidents for six of six residents (#10, #9, #6, #3, #11, and #1) reviewed for falls out of fifteen total sample residents. The facility failed to ensure interventions to prevent falls were implemented and evaluated for effectiveness for Residents #10, #9, #6, #3, and #11. This failure resulted in multiple repeated falls for Resident #10 for which he sustained fractures of the sacrum and hip and a fall for Resident #9 which resulted in a [MEDICAL CONDITION]. […]

• Actual harm, isolatedF758Feb 24, 2021

  Based on observations, record review, and interviews, the facility failed to ensure residents who had not used [CONDITION(S)] drugs were not given these drugs unless the medication was medically necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use [CONDITION(S)] drugs received gradual dose reductions and behavioral interventions in an effort to discontinue these drugs for two Residents (#11 and #1) out of five residents reviewed for [CONDITION(S)] medication use out of fifteen sample residents. Specifically, the facility failed to: -Ensure the use of an anti-anxiety medication was justified in the absence of non-pharmacological interventions and was not in excess given Resident #11's age and stature. […]

• No harm, potential for more than minimal, widespreadF570May 18, 2021

  Based on record review and interviews the facility failed to ensure a surety bond or otherwise provide assurance satisfactory to the secretary, to assure the security of all personal funds of residents deposited with the facility. Specifically the facility failed to ensure the surety bond had the correct amount to cover the entire balance for the resident's personal needs account at the facility. Findings include: I. The Resident Trust policy and procedure, dated 3/10/16, was provided by the nursing home administrator (NHA) on 5/17/21 at 8:30 a.m. It read, in pertinent part: Through the facility's legal and risk services department, a surety bond is purchased each year. […]

• No harm, potential for more than minimal, widespreadF867Feb 24, 2021

  Based on record review and interviews, the facility failed to ensure a Quality Assurance and Performance Improvement process that took actions aimed at performance improvement and after implementing actions, measured success and tracked performance to ensure improvements were realized and sustained. Specifically, the facility failed to ensure a systemic action plan was implemented to decrease the incidents of falls for all residents in the facility. Cross-reference F689 Accidents Findings include I. Facility policy and procedure The Quality Assessment and Assurance Committee Meetings policy, 12/28/2020, was provided by the director of nursing (DON) on 2/24/21 at 4:50 p.m. […]

• No harm, potential for more than minimal, patternF605May 1, 2025

  Based on record review and interviews, the facility failed to ensure that three (#57, #10 and #51) of five residents out of 35 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Residents #57, #10 and #51, the facility failed to: -Adequately identify and monitor target behaviors for psychotropic medications; -Identify resident specific interventions for behaviors; and, -Provide adequate documentation to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications. Findings include: I. […]