The Gardens

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Jul 17, 2026

  Based on interview, document review, and facility policy review, the facility failed to implement the interdisciplinary water management process described in their policy and failed to conduct a facility-specific risk assessment of its water system to identify vulnerabilities to water-borne pathogens. These deficient practices had the potential to affect all 65 residents who currently resided in the facility.Findings included: A facility policy titled, Legionella Water Management Program revised 07/2017, indicated, 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. […]

• No harm, potential for more than minimal, patternF641Jul 17, 2026

  Based on interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for 3 (Residents #9, #46, and #57) of 5 sampled residents reviewed for unnecessary medications.Findings included: A facility policy titled, Resident Assessment Instrument, revised 09/2010, indicated A comprehensive assessment of a resident's needs shall be made within fourteen days of the resident's admission. The policy specified, 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. 1. An admission Record revealed the facility admitted Resident #46 on 08/02/2024. […]

• No harm, potential for more than minimal, patternF567Sep 13, 2024

  Based on record review and interview, the facility failed to ensure residents had access to their trust account money on nights and weekends for three (#3, 17, and #34) of three residents reviewed for access to their trust account money. The business office manager identified seven current residents who had money in the trust account. Findings: The facility policy Trust Fund Petty Cash Imprest Fund. read in part, .cash is disbursed to Residents from the trust fund petty cash imprest fund Monday through Friday, 9:00 a.m. to 4:00 p.m. daily, excluding weekends and holidays . On 09/11/24 at 9:26 a.m., Resident #34 stated they could not get money on weekends or at night, and they had to ask in advance if they wanted money on the weekends. […]

• No harm, potential for more than minimal, patternF568Sep 13, 2024

  Based on record review and interview the facility failed to provide notices to Medicaid recipients trust account holder when balances was within $200 of the resource limit for a medicaid recipient resident for two (#1 and #17) of three sampled residents reviewed for active trust account balances. The Business office manger identified seven residents that have money in the trust account, were current residents and had Medicaid as their payer source. Findings: The facility policy Notification of Certain Balances read in part, .It is the policy of this facility to notify Residents or their legal representatives when their trust fund balances approach the limits of Medicaid eligibility .written notification of trust fund balance .will be mailed/delivered to Residents or their legal… […]

• No harm, potential for more than minimal, patternF569Sep 13, 2024

  Based on record review and interview, the facility failed to close out trust accounts and convey funds within 30 days for three (#108, 109, 110 and #11) of four residents reviewed for open trust accounts and had been discharged from the facility over 30 days. The Business Office Director identified eight residents who no longer resided in the facilty and trust accounts were not closed out within 30 days. Findings: The facility policy Conveyance of Funds Upon a Residents Death read in part, .It is the policy of this facility that upon death of a Resident with personal funds on deposit with the facility, the facility will promptly convey such funds, along with a final accounting of such funds .accounting will be made within thirty (30) days of the death . […]