Gardner Heights Health Care Center, Inc

In the surveyor’s words

From the most serious findings on record at Gardner Heights Health Care Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 27, 2023

  Based on clinical record reviews, facility documentation, facility policy and interviews, for 2 of 6 sampled residents who were reviewed for elopement risk (Resident #1 and Resident #2), the facility failed to provide the necessary supervision for Resident #1 to prevent an elopement resulting in a finding of Immediate Jeopardy. Further, the facility failed to implement their policy for the use of wanderguard devices or other interventions based on the interdisciplinary team's assessment for Resident #2 when identified to be at risk for elopement. The findings include: 1.Resident #1 was admitted from a retirement housing community with diagnoses that included dementia. […]

• No harm, potential for more than minimal, widespreadF812Aug 19, 2024

  Based on observations, staff interviews, facility documentation and facility policy related to the dishwasher temperatures in the Dietary Department, the facility failed to identify when dishwasher temperatures were below the manufacturers guidelines. The findings include: On 8/16/24 at 9:45 observation of the dishwashing room in the Dietary Department with the Dietary Manager identified Dietary Aide (DA) #3 approximately half way through scraping and putting dirty dishes from breakfast through the dishwasher. The Dietary Manager identified the dishwashing machine was a high temperature machine. […]

• No harm, potential for more than minimal, patternF584Apr 27, 2026

  Based on observations, review of facility documentation, review of facility policy/procedures and interviews, the facility failed to ensure the radiators did not have sharp areas exposed, were free of rust, were secured to the wall, and missing molding repaired to maintain a homelike environment. The findings include: Observations on the Laurel unit on 4/20/26 from 10:46 AM to 11:17 AM, identified the following: room [ROOM NUMBER]: The end cap on the right side of the radiator located along the wall under the window was located on the floor by the radiator, leaving multiple sharp surfaces exposed. […]

• No harm, potential for more than minimal, patternF687Apr 27, 2026

  Based on observations, clinical record reviews, review of facility documentation, review of facility policy and interviews for two of six sampled residents (Resident #3 and Resident #56) reviewed for foot care, the facility failed to ensure the resident received podiatry services for trimming of toenails. The findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included type II diabetes, polyneuropathy, and atrophic disorder of the skin. The admission MDS assessment dated [DATE] identified Resident #3 was cognitively intact, had no behaviors, required substantial/maximal assistance with bed mobility, and personal hygiene, and independent for dressing. […]

• No harm, potential for more than minimal, patternF550Aug 19, 2024

  Based on observations, interviews, review of the clinical record, and facility policy in 1 of 3 dining rooms (Laurel dining room) observed for Residents (Resident #31, #42, #44, #45, #52, #93 and Resident #99) who were dining, the facility failed to provide a dignified dining experience. The findings include: 1. Resident #31's diagnoses included Alzheimer's disease, dysphasia, ventricular tachycardia and anxiety disorder. The Resident Care Plan dated 6/24/24 identified Resident #31 was at an increased risk for decreased nutritional status. […]