The Gardens Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 16, 2024

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who were wearing a wander guard bracelet (monitoring device that triggers an alarm when the resident gets close to or goes through a door equipped with the alarm; this device is applied to residents at risk for elopement [a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave]), out of a total six sampled resident, did not leave the facility unnoticed by staff. On 1/13/2024 around 3:15 p.m., Resident 1 was noticed missing from the facility. […]

• Actual harm, isolatedF689Apr 21, 2023

  Based on interview and record review, the facility failed to provide the needed supervision and assistance to prevent falls and injuries for one of two sampled residents (Resident 1). For Resident 1, who had history of falls before admission and was confused, the facility failed to ensure: 1. Resident 1 ' s fall risk care plan interventions were evaluated (reviewed and revised) for effectiveness and develop new interventions based on the individual needs of the resident. 2. The Interdisciplinary Team (IDT, group of professionals from different health care disciplines who participate in the care of the resident) including the attending physician, met to identify causative factors for Resident 1 ' s repeated incidents of falls while attempting to use the bathroom. […]

• Actual harm, isolatedF689Aug 16, 2022

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had poor safety awareness, had history of falls, and was admitted to the facility for rehabilitation after a fall at home resulting in a left [CONDITION(S)] (break of a bone), was provided a safe environment and supervision as indicated in the facility ' s policies, by not: 1. Reviewing and revising the plan of care after Resident 1 fell on [DATE] and on 6/9/2022. 2. […]

• No harm, potential for more than minimal, widespreadF837Sep 28, 2023

  Based on observation, interview and record review, the facility's governing body failed to ensure a licensed Administrator (ADM) was responsible for management of the facility and present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT) was performing administrative tasks without the presence of the ADM at the facility. As a result, there was an increased risk of inadequate management of the facility and affect the safety and overall well-being of the residents. Findings: On 9/27/2023 at 7:48 a.m., during an observation of the bulletin board, the ADM's license was posted indicating ADM was the ADM of the facility. […]

• No harm, potential for more than minimal, patternF604Jul 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints (refers to means of purposely limiting or obstructing the freedom of a person's bodily movement) to one of three sampled residents (Resident 30) investigated under the physical restraints care area by failing to: - Obtain a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and developed and implemented a care plan on the use of low air loss mattress with bilateral bolsters (a soft foam pillow or wedge attached to a bed or chair that acts as a physical barrier to keep a resident from rolling out or sliding forward,… […]