Gardens at St Henry the

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Sep 4, 2025

  Based on observations, staff interview and facility policy review, the facility failed to maintain a safe sanitary kitchen. This had the possibly to affect 23 out 25 residents who receive food from the kitchen. The facility identified Resident #1 and #2 did not receive food from the kitchen. The facility census was 25. Findings Include: Observation of the kitchen on 09/02/25 at 9:48 A.M. revealed the trash can by the food serving table had a flip lid. The here was observed multiple areas of thick food particles on the can. Observation of the kitchen freezer revealed the door handles had a red sticky substance on them as did the surface of the refrigerator behind the door handles. These findings were verified with Dietary Manager #106 at the time of the observation. […]

• No harm, potential for more than minimal, isolatedF690Sep 4, 2025

  Based upon observation and interview the facility failed to properly place a catheter bag. This affected one (#33) of one residents in the facility with a catheter. Census was 25. Records Reviews for Resident #33 revealed resident was admitted on [DATE] with diagnosis fracture of shaft of humerus and left arm, major depressive disorder, anxiety, and panic disorder.The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #33 was cognitively intact and was admitted with suprapubic catheter due to neuromuscular dysfunction of bladder. Observation of Resident #33 on 09/02/25 at 10:38 A.M. revealed suprapubic catheter bag laying on the floor folded in half beside Resident #33's bed.Interview with RN #101 verified suprapubic catheter bag was laying on the floor beside the bed.

• No harm, potential for more than minimal, isolatedF694Sep 4, 2025

  Based on observation, medical record review, staff interview, and policy review the facility failed to provide care for peripherally inserted central catheter. This directly affected one resident, #12, of one reviewed for intravenous catheters. The facility census was 25.Findings Include:Review of the medical record of Resident #12 revealed an admission date of 03/18/25. Diagnoses include urinary tract infection and Extended-Spectrum Beta-Lactamase in urine. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 to be cognitively intact. The assessment indicated no intravenous catheter. Review of the physician order dated 08/25/25 revealed an order to change the midline dressing every week. The order indicated this should occur on Mondays. […]

• No harm, potential for more than minimal, isolatedF761Sep 4, 2025

  Based on observation, staff interview, and policy review the facility failed to ensure medications were securely stored. This had the potential to affect two residents, (#18 and #19), identified by the facility as being confused and independently mobile residents. The facility census was 25. Findings Include:Observation on 09/02/25 at 8:50 A.M. an antibiotic was noted on the medication cart which was located in the hallway. The cart was unattended. Registered Nurse (RN) #110 was observed to exited a resident room and verified the medication had been lying on the medication cart unattended. The medication was labeled Resident #12 and contained Ertapenem sodium (antibiotic) solution reconstituted 1 gram. […]

• No harm, potential for more than minimal, isolatedF880Sep 4, 2025

  Based on observation, medical record review, staff interview, and policy review the facility failed to follow infection control procedures for residents in isolation. This directly affected one resident, (#12), and had the potential to affect five residents, #01, #02, #12, #16, and #33, on isolation. The facility census was 25.Findings Include:Review of the medical record of Resident #12 revealed an admission date of 03/18/25. Diagnoses include urinary tract infection and Extended-Spectrum Beta-Lactamase in urine. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed Resident #12 to be cognitively intact. The assessment indicated no isolation. Review of the physician order dated 08/26/25 revealed an order for contact isolation. Observation on 09/02/25 at 8:45 A.M. […]