Gardens Court

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF689Jan 8, 2026

  Based on record review and interviews, the facility failed to provide care and services to prevent accidents for 4 of 4 sampled residents, as evidenced by failure to ensure Resident #111 had adequate supervision during transfer, failure to ensure Resident #70 had padded side rails and floor mats near the bed, failure to ensure Resident #121 had padded side rails, and failure to investigate an accident reported on Resident #85.The findings included:1) Record review revealed Resident #111 was admitted to the facility on [DATE]. Review of the annual assessment dated [DATE] documented Resident #111 required substantial assistance with going from sitting to lying position, going from lying to sitting and transferring from bed to chair. […]

• No harm, potential for more than minimal, isolatedF692Jan 8, 2026

  Based on record review and interviews, the facility failed to provide care and services to prevent electrolyte imbalance as evidenced by ensuring Resident #14 had adequate hydration, for 1 of 1 sampled resident reviewed for hydration. The findings included: Record review revealed Resident #14 was readmitted to the facility on [DATE]. Review of medical diagnosis revealed Resident #14 had a history of dysphagia (difficulty swallowing) following cerebral infarction (stroke), gastrostomy (feeding tube), dementia (memory loss). […]

• No harm, potential for more than minimal, isolatedF550Jul 11, 2024

  Based on policy review, interview and record review, the facility failed to treat 3 of 4 sampled residents in a dignified manner (Residents #67, #103, and #35). The findings included: Review of the facility policy titled, dignity revised on 09/25/23, documented, each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. […]

• No harm, potential for more than minimal, isolatedF842Jul 11, 2024

  Based on policy review, record review, and interview, the facility failed to ensure complete and accurate documentation in the medical records for 3 of 28 sampled residents. The record lacked the refusal to utilize an anchor to prevent infections during the use of an indwelling urinary catheter for Resident #44; contained two orders for the use of the indwelling urinary catheter with two different sized catheters for Resident #44; lacked any documentation related to an observed dressing the left elbow of Resident #103, and lacked complete information related to an issue with a wound dressing for Resident #159. The findings included: Review of the policy titled, Nursing Documentation revised 08/10/23 documented, Medical Records . […]

• No harm, potential for more than minimal, isolatedF686Jun 15, 2023

  Based on clinical and administrative record review and staff interview, the facility failed to provide the necessary treatment prescribed by the physician for 1 of 3 sampled residents, reviewed for pressure ulcers (Resident # 1). The findings included: Review of the clinical record for Resident # 1 revealed that the resident was originally admitted to the facility on [DATE]. The resident was admitted to the facility with a pressure ulcer. Review of the Wound Care Notes from April 2023 revealed on 04/05/23, the physician documented that the resident had a Stage IV pressure Injury Sacral region, Osteomyelitis, MRSA (Methicillin-resistant Staphylococcus aureus). The Stage IV decubitus measured 6.5 x 6.5 x 0.3 cm. No surrounding erythema present, 100% granulation tissue within injury. […]