Garden Village

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 13, 2023

  Based on interview and record review, the facility failed to provide the level of supervision necessary to prevent accidents related to resident-to-resident altercations for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for accidents, hazards, and supervision. This deficient practice allowed Resident 1 to initiate physical altercations with five different residents (2, 3, 4, 5 and 6), successfully leave the facility unsupervised (elope), and placed other residents at risk for serious injury, serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF689Oct 29, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents received assessments and supervision for 2 of 5 residents (Resident 84 and 143) reviewed for elopement/missing person, implement risk assessments and supervision for 1 of 3 residents (Resident 73) reviewed for hot liquids, and implement safety interventions for 1 of 2 residents (Resident 12) reviewed for smoking to prevent accidents and hazards. This failed practice placed residents at risk for accidents, injuries, and the potential risk of fire. […]

• Actual harm, isolatedF684Oct 29, 2024

  Based on observation, interview, and record review, the facility failed to assess for change in conditions related to skin and constipation, follow hospice and physician orders, and obtain and report labs for 7 of 8 residents (Residents 83, 79, 12, 5, 4, 30, and 68) reviewed for quality of care. These failures placed all residents at risk for delay of treatment, unmet care needs, and negative health outcomes. Resident 83 experienced harm when they obtained a facility acquired pressure injury (PI, localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices). Additionally, Resident 79 experienced harm when they continued to have seizures when they did not receive medications indicated for seizures in a timely manner. […]

• Actual harm, isolatedF760Oct 29, 2024

  Based on interview and record review the facility failed to ensure a resident was free from significant medication errors for 1 of 5 residents (Resident 54) reviewed for hospitalization . Resident 54 experienced harm when they received an antipsychotic medication (a class of drugs used to treat symptoms of psychosis and other mental health disorders) that caused acute toxic encephalopathy (indicates brain dysfunction caused by toxic exposure in the absence of primary structural brain disease) and increased sleepiness that resulted in a four-day hospitalization . Findings included . […]

• Actual harm, isolatedF600Oct 5, 2023

  Based on interview and record review, the facility failed to effectively implement and evaluate line-of-site supervision to prevent abuse or mistreatment for 4 of 7 residents (Resident 2, 3, 4, and 5) reviewed for sexual abuse. The failure to consistently implement supervision interventions to potentially prevent four sexual abuse incidents in a seven-day period resulted in Resident 4 experiencing psychological harm when the sexual abuse triggered post-traumatic stress suicide ideation, and Resident 5 experiencing psychological harm when applying the reasonable person approach. […]