The Gardens at Aldersgate

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 7, 2024

  The facility reported a census of 148 residents. The sample included eight residents. Based on record review, observation, and interviews, the facility failed to ensure a safe environment free from preventable accidents for Resident (R) 1, when R1 slipped from the sling during a staff-assisted transfer using a Hoyer lift (full body mechanical lift). On 03/04/24 at 08:20 AM Certified Nurse Aide (CNA) M and CNA O attempted to transfer R1 from his bed to his chair using the Hoyer lift with a toileting sling. R1 slipped out of the opening in the toileting sling and fell to the floor. R1 hit his head on the metal leg of the Hoyer lift. […]

• Actual harm, isolatedF689Oct 2, 2024

  The facility identified a census of 152 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to ensure Resident (R) 1 remained free from avoidable accidents when staff failed to provide care safely using the required number of staff per the resident's plan of care. Subsequently, R1 sustained a dislocated right shoulder and a fractured right humerus (upper arm bone). This deficient practice also placed R1 at risk for increased pain and impaired well-being. […]

• Actual harm, isolatedF689May 9, 2024

  The facility identified a census of 145 residents. The sample included three residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure an environment free from accidents for Resident (R)1. As a result, R1 sustained an avoidable injury to her leg, which required sutures. This also placed R1 at risk for increased pain and impaired well-being. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of Bell's palsy (paralyzed on one side of the face), localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic pain, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). […]

• Actual harm, isolatedF686Feb 22, 2024

  The facility had a census of 148 residents. The sample included 32 residents with nine reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to provide off-loading interventions to prevent the re-opening of a healed pressure ulcers for Resident (R)13 and failed to implement interventions immediately upon discovering the pressure injury. The facility also failed to ensure staff completed a weekly wound assessment which included wound measurements for R82 who had multiple skin issues. […]

• No harm, potential for more than minimal, widespreadF576Jan 7, 2026

  The facility had a census of 161 residents. The sample included 34 residents. Based on the record review and interview, the facility failed to consistently deliver residents' mail on Saturdays.Findings included:- On 01/06/25 at 11:00 AM, during the resident council meeting, Resident (R) 141 stated the facility did not deliver residents' mail on Saturdays.01/07/25 at 08:00 AM, Administrative Staff B stated she was responsible for delivering mail to residents. She sorts out the mail for each unit and delivered it to the unit manager during the week; if they were busy, she delivered it to the residents. […]