Gardens at Celina

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 22, 2021

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record reviews, observations, hospital medical record review, facility investigation review, facility policy review, in-service review, facility corrective action plan review, resident and staff interviews, the facility failed to ensure adequate supervision was provided to prevent the elopement of a resident with cognitive impairment who was assessed as being at risk for elopement. This resulted in Actual Harm when Resident #01 left the facility and was found in a residential neighbor's driveway with a closed fracture of the right hand and facial abrasions from a fall. […]

• No harm, potential for more than minimal, widespreadF727Nov 23, 2022

  Based on review of staffing tool and staff interview, the facility failed to have a Registered Nurse (RN) on duty for eight consecutive hours daily. This affected all 22 residents residing in the facility. Findings include: Review of the staffing tool from 11/06/22 to 11/12/22 revealed on 11/11/22 (Friday) the facility had an RN on duty for only one hour and on 11/12/22 (Saturday) the facility had an RN on duty for only six hours and 15 minutes. Interview on 11/23/22 at 11:55 A.M. with Administrator provided verification of the lack of RN coverage on the two days. Administrator additionally indicated the DON worked 16 hours on 11/10/22 (Thursday) and DON did not work any hours on 11/11/22.

• No harm, potential for more than minimal, widespreadF867Nov 23, 2022

  Based on staff interview, record review, and review of the Certification and Survey Provider Enhanced Reporting system (CASPER), the facility failed to have an effective quality assurance program to address repeated concerns identified during three consecutive annual surveys. This affected all residents in the facility. The facility census was 22. Findings include: Review of the Certification and Survey Provider Enhanced Reporting system (CASPER) report dated 10/28/22 revealed the facility received a deficiency for failing to be free from unnecessary psychotropic medications during the annual surveys completed in October 2018 and November 2019. […]

• No harm, potential for more than minimal, patternF880Nov 5, 2024

  Based on observation, staff interview, and facility policy review, the facility failed to ensure medications were handled in a hygienic manner. This affected five residents (#01, #02, #13, #14, and #25) of five reviewed for medication administration. The facility census was 25. Findings include: Observation on 11/05/24 from 7:10 A.M. to 7:45 A.M. revealed Registered Nurse (RN) #100 administering medications to facility residents. RN #100 obtained the medications for Resident #01 to include Calcium (supplement) 600 milligrams (mg) with Vitamin D3 (vitamin) tablet, Acidophilus (probiotic) capsule, and Iron (supplement) 325 mg tablet. RN #100 opened the Acidophilus capsule with ungloved hands and poured the powder into a dish of applesauce and administered the medications to Resident #01. […]

• No harm, potential for more than minimal, patternF812Nov 23, 2022

  Based on observations, staff interviews, and review of the facility policies, the facility failed to store and prepare food in a sanitary manner, failed to completely cover hair during meal service, and failed to accurately monitor sanitizer levels in the sanitation buckets used to clean the kitchen. This had the potential to affect all residents in the facility except one (#5) who was identified as receiving no food by mouth. The facility census was 22. Findings include: 1. Observations during the initial tour of the kitchen on 11/21/22 at 8:07 A.M. revealed unsealed ham, unsealed hotdogs, an undated opened package of ham, and pizza sauce dated 11/02/22 in the walk-in refrigerator. Further observation revealed omelets open to the air in the freezer. […]