The Gardens and Guardian

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Mar 5, 2025

  Based on observations, interviews, and policy and procedure reviews, the facility failed to maintain a clean and sanitary kitchen to prevent cross contamination and the high likelihood of foodborne illnesses to the 40 residents who ate meals prepared from the facility's kitchen. This deficient practice resulted in an Immediate Jeopardy (IJ) on [DATE] at 10:35 AM when the following was observed in the facility's kitchen during the initial tour: 1. Equipment and Food Prep Area a. The ice machine's air filter had an accumulation of lint build up. b. The ice machine's gutter located under the interior portion of the lift cover had an accumulation of lint build up. c. The countertop under a juice dispenser had a dried tan colored residue. d. […]

• No harm, potential for more than minimal, widespreadF880Feb 22, 2023

  Based on observations, interviews and policy review, the facility failed to maintain an effective infection control and prevention program and implement accepted infection control practices to help to prevent and control the spread of infectious communicable disease, COVID-19, by failing to ensure laundry staff used the appropriate PPE (personal protective equipment) while handling soiled laundry from COVID-19 isolation rooms. This deficient practice has the potential to affect 41 residents who reside in the facility. Finding: Review of the policy titled Contaminated laundry revealed the following in part: The use of proper Personal Protective Equipment (PPE) is required while completing laundry tasks. […]

• No harm, potential for more than minimal, patternF867Jan 23, 2024

  Based on review of facility's policy and procedure, record review and interview, the facility failed to effectively implement and monitor the facility's Performance Improvement Project (PIP) implemented on 11/07/2023 by failing to: 1. Conduct weekly meeting from 11/07/2023 to 12/14/2023, 2. Implement interventions in a timely manner, 3. Timely calibrated the facility's scale and, 4. Provide documented evidence of monitoring performance of the identified indicators. This deficient practice had the potential to affect a census of 37 residents. Findings: Review of the facility's Policy titled Weight Monitoring read in part, Compliance Guidelines: 5. A weight monitoring schedule will be developed upon admission for all residents: e. […]

• No harm, potential for more than minimal, patternF610Aug 17, 2022

  Based on interview and record review the facility failed to conduct an investigation for an allegation of abuse for 1 (#6) of 6 (#1, #2, #3, #4 #5 and #6) sampled residents. Findings: Review of the facility's Resident Abuse policy revealed in part . The facility will develop and implement procedures to include .investigation, protection, and reporting/response to insure freedom from physical and mental abuse, neglect and 3. Prevention b. Completion of the appropriate state forms for the reporting of alleged abuse and/or neglect and filing it in a timely manner. With appropriate investigation of it by the DON and/or her designee and records to be maintained and readily assessable to state and local authorities for review. […]

• No harm, potential for more than minimal, patternF880Aug 17, 2022

  Based on observation and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases, COVID-19, and infections by failing to wear appropriate Personnel Protectective Equipment while providing care for a newly admitted unvaccinated resident in isolation for 1 (#3) out of 1 (#3) resident in isolation. Findings: Review of the provider's Infection Control Policy revealed in part .#2. For isolate residents (including recent move-in if unvaccinated) staff must wear all 4 pieces of PPE (Personnel Protective Equipment) while attending to resident. A) Eye protection (goggles/face shield) . B) Mask - Single use only . […]