Prestige Gardens Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Prestige Gardens Rehabilitation and Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF695Nov 18, 2021

  Based on medical record review, review of downloaded ventilator data, review of the policy Invasive Mechanical Ventilation, staff interviews, interview with Respiratory Therapist Specialist (RTS) #600, interview with Police Detective #10, the facility failed to ensure necessary life sustaining respiratory services were provided by timely answering a ventilator's (a mechanical device required for the breathing) alarm after the resident's ventilator tubing had become disconnected from his [CONDITION(S)]. This resulted in Immediate Jeopardy and serious life-threatening harm for Resident #04 when the ventilator was found alarming for over an hour, the tubing was not connected to the resident and had gone unnoticed by any of the facility staff. […]

• Actual harm, isolatedF697May 13, 2025

  Based on observation, medical record review, resident and staff interviews, and review of a facility policy, the facility failed to ensure pain was adequately addressed and managed for a resident with complaints of pain. This resulted in actual harm when Resident #159 experienced severe breakthrough pain from a fractured tibia and fibula and was not assessed for pain or offered pain relieving interventions, including medications, to treat the resident's pain. The resident was observed multiple times displaying outward expressions of pain including moaning, tearfulness, and fist-clinching, during general observations and during direct care. This affected one (#159) of two residents reviewed for pain. The census was 56. […]

• No harm, potential for more than minimal, widespreadF804May 13, 2025

  Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to provide palatable meals to the residents. This had the potential to affect all 56 residents living in the facility whom all ate meals from the kitchen. The facility census was 56. Findings include: Observation of a lunch test tray meal on 05/07/25 at 11:52 A.M. revealed the meatloaf served was dark, crunchy, and dry. Interview with Regional Director of Dining Services #150 on 05/07/25 at 11:58 A.M. confirmed the meatloaf was dry. He stated it stayed in the oven too long. Interview with three (#46, 51, and 53) residents on 05/07/25 from 12:00 P.M. to 12:06 P.M. confirmed the meatloaf served to them was dry, crunchy, and cut too thin. […]

• No harm, potential for more than minimal, widespreadF880May 13, 2025

  Based on observation, staff interview, and policy review, the facility failed to maintain proper infection control practices in handling soiled linens, sanitizing glucometers, and providing care of a gastrostomy tube. This deficient practice had the potential to affect all 56 residents residing in the facility. The census was 56. Findings included: 1. Observation on 05/08/25 at 5:10 A.M. revealed Certified Nurse Aide (CNA) #26 was walking in the 400 hall while carrying unbagged linens. Interview on 05/08/25 at 5:11 A.M. with CNA #26 confirmed he was carrying unbagged linens and recently walked out of a resident's room. CNA #26 confirmed dirty linens were to be placed in a bag prior to leaving a resident's room. […]

• No harm, potential for more than minimal, widespreadF881May 13, 2025

  Based on medical record review, review of infection control logs, and staff interview, the facility failed to ensure an adequate and complete antibiotic stewardship program was implemented to monitor for possible infections within the facility and determine appropriateness of antibiotic use. This had the potential to affect all 56 residents residing in the facility. The facility census was 56. Findings include: 1. Review of the facility infection logs dated between November 2024 and April 2025 revealed the facility did not include any other possible infectious findings or residents with possible symptoms of an infection that were not started on antibiotics. The facility only included those residents who were started on an antibiotic medication on their infection control tracking logs. […]