Gardens at West Shore, The

In the surveyor’s words

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

• Immediate jeopardy, patternF725Jan 12, 2023

  Based on clinical record review, review of facility staffing data, and resident and staff interviews, it was determined that the facility failed to provide adequate and sufficient nursing staff to provide medication administration in accordance with professional standards of practice and physician orders for 32 out of 33 residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32) on the Alzheimer's Care Unit (ACU). […]

• Immediate jeopardy, patternF760Jan 12, 2023

  Based on clinical record review and staff interviews, it was determined that the facility failed to follow accepted professional standards and principles for administering medications to ensure the prevention of significant medication errors for 29 out of 33 residents sampled (Residents 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 27, 28, 29, 30, 31, 32) on the ACU (Alzheimer Care Unit). This resulted in an Immediate Jeopardy situation since the missed medications had the potential to cause the residents discomfort or pain, to exacerbate behaviors and medical conditions including blood pressure, cardiac and diabetic issues, increase the potential for seizures, and jeopardized the health and safety of 29 of 33 residents reviewed. […]

• Immediate jeopardy, isolatedF689Jul 1, 2026

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). This failure resulted in an immediate jeopardy situation.Review of facility policy, titled Elopement, revised June 2023, read, in part, It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury. […]

• Immediate jeopardy, isolatedF689Feb 9, 2026

  Based on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance by failing to provide adequate supervision to prevent an elopement of a resident identified as being at risk for elopement (Resident 3). Resident 3 was found in the street approximately 0.3 miles away from the facility. This failure placed a total of eight additional residents in an Immediate Jeopardy situation who were identified as at risk for elopement and not on a locked unit (Residents 6, 7, 8, 9, 10, 11, 12 and 13). […]

• Actual harm, isolatedF600Feb 9, 2026

  Based on facility policy review, clinical record review, review of select facility documents, and staff interviews, it was determined that the facility failed to ensure each resident the right to be free from neglect, which resulted in actual harm as evidenced by superficial incontinence associated dermatitis for one out of three residents reviewed (Resident 2). Findings include:Review of facility policy, titled Abuse Policy read, in part, The resident has the right to be free from neglect. […]