Garnet Hill Rehabilitation and Skilled Care

In the surveyor’s words

From the most serious findings on record at Garnet Hill Rehabilitation and Skilled Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 6, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of five residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse. Resident #1 was cognitively impaired and had diagnoses of Alzheimer's. Resident #1 was sexually assaulted by a visitor whom she did not know, on 11/28/24. An IJ was identified on 12/05/24. The IJ template was provided to the facility on [DATE] at 4:04 PM. […]

• Actual harm, isolatedF689Dec 8, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure that the residents environment remained free of accident and hazards for 2 of 6 residents (Resident #12 and #97) reviewed for accident and hazard free environment. The facility failed to ensure a water leak in Resident #12's bathroom was properly repaired, and the Resident had an accident as a result of the continued water leak. Resident #12 had a hematoma to the front right side of head and a and a bruise to her right arm. […]

• Actual harm, isolatedF760Jun 12, 2023

  Based on interview and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1 the prescribed quantity of fentanyl patches as ordered by the physician. This deficient practice could affect all residents who receive medication from the facility and place them at risk for negative side effects, decline in health, hospitalization , or death . […]

• Actual harm, isolatedF580Jun 18, 2022

  Based on observation, interview and record review, the facility failed to notify the resident representative and the resident's physician, when there was significant change in resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. LVN B failed to notify the responsible party/resident representative and the resident's physician when Resident #1 fell from her bed on 05/22/22, which resulted in a fracture of the left medial femoral condyle (knee area), failed to place the incident on the 24-hour report for ongoing monitoring on 5/22/22, and failed to document any assessments of the resident post fall on 5/22/22. LVN B completed late entry notes 06/02/22 to document fall that occured on 05/22/22. […]

• Actual harm, isolatedF689Jun 18, 2022

  Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Residents # 1) of four residents reviewed for transfers. CNA A failed to transfer Resident #1 safely when she failed to use a gait belt and lifted the resident under her armpits when transferring her from the bed to the wheelchair which resulted in a fracture of the left medial femoral condyle (knee area). These failures could place residents who require transfer assistance at risk for a fall injury. Findings included: Record review of Resident #1's quarterly MDS assessment, dated 04/22/22, reflected an admitted [DATE]. […]