Lewis & Clark Gardens

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 24, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) out of a sample of eight residents, received adequate supervision to prevent accidents. The facility failed to respond to a door alarm timely after the resident, who was assessed by the facility to be at risk for elopement, exited the facility through an alarmed exit door without staff knowledge. The door alarm volume was not loud enough for staff to hear until they were halfway down the resident's hall. The facility also failed to complete 15 minute checks for the resident who required 15 minute checks for aggressive behavior. […]

• Immediate jeopardy, isolatedF600May 15, 2024

  Based on interview and record review, the facility failed to prevent sexual abuse between two residents (Resident #1 and Resident #2), who engaged in sexual intercourse and whose capacity to consent to sexual activity had not been determined, in a review of 13 sampled residents. Resident #1 was assessed as severely cognitively impaired and had diagnoses including Alzheimers Disease, dementia, herpes viral infection, and human immunodeficiency virus disease. Resident #2 had diagnoses including vascular dementia and depression. When Resident #2 talked to his/her responsible party after the incident, he/she told the responsible party he/she did not want the sexual activity to occur, he/she was scared, and did not want to be around Resident #1. The facility census was 85. […]

• Immediate jeopardy, isolatedF578Dec 2, 2022

  Based on interviews, record reviews, and facility policy review, it was determined the facility failed to honor an advance directive for one resident (Resident #174) of 13 residents reviewed for code status. Resident #174 had a Durable Power of Attorney (DPOA) advance directive indicating the resident's wish for do not resuscitate (DNR) if the resident was found unresponsive. On [DATE], the facility called 911 and initiated cardiopulmonary resuscitation (CPR), despite Resident #174's advance directive. Subsequently, Resident #174 received CPR for 17 minutes against the resident's wishes. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. […]

• Immediate jeopardy, isolatedF600Nov 18, 2021

  Based on interview and record review, the facility failed to ensure one resident (Resident #1) remained free from sexual abuse, when another resident with sexual and wandering behaviors (Resident #2), sexually abused Resident #1 on more than one occasion. The facility also failed to ensure two residents (Resident #5 and #6) remained free from physical and verbal abuse by Certified Nurse Assistant (CNA) E in a review of 29 sampled residents. The facility census was 73. The administrator was notified on 11/12/21, of the Immediate Jeopardy (IJ) which began on 4/26/21. […]

• Actual harm, isolatedF600Jun 23, 2025

  Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1), in a review of seven sampled residents, was free from abuse and neglect when Certified Nurse Aide (CNA) A while sweeping the resident's room, refused to assist the resident with his/her request to retrieve paper from the floor and grabbed the resident's left hand/arm pushing the resident back causing the resident to fall onto the foot board of the bed. The resident fell onto the bed then slid off the bed onto the floor. CNA A stood watching the resident with no attempt to prevent the fall or assist the resident. […]