The Gardens And Guardian

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 3/3/2025 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. The standup cooler's door handle was sticky and had food residue on the plastic framing and glass door. e. The backsplash on the wall located over the food processor was splattered with dried food debris. f. The table next to the small oven had dried food debris. g. The meat slicer and shelf on which it was located had splattered food debris. h.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to follow its policy regarding advance directives evidenced by failing to accurately document the resident's choice of code status in the medical record for 1 (#19) out of 2 (#19 and #26) residents reviewed for advance directive. The deficient practice had the potential to affect a total census of 41 residents. Findings: On [DATE], a review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives with no date of implementation or revision, read in part: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. The policy explanation and compliance guidelines included in part: 7) Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to complete a discharge MDS (Minimum Data Set) assessment for 1 (#13) out of 1 (#13) residents sampled for resident assessment. This deficient practice had the potential to affect the census of 41 residents. Findings: Review of Resident #13's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to Displaced Trimalleolar (ankle) Fracture of the Right Lower Leg. Review of Resident #13's progress note dated 03/15/2024 revealed she was discharged from the facility back to her assisted living center home. Further review of her electronic health record revealed no discharge MDS assessment completed for 03/15/2024. On 07/10/2024 at 11:38 a.m., an interview and record review was conducted with S1DON (Director of Nursing). She confirmed that Resident #13 was admitted to the facility on [DATE] and was discharged to an assisted living center on 03/15/2024. She reviewed Resident #13's MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. All others - monitor weight monthly unless otherwise indicated by physician. The facility's PIP (Performance Improvement Project) dated 11/07/2023 revealed an identified issue with the accuracy of weights-Root cause: due to staff not in-serviced and educated on proper ways to obtain weights and too many employees are obtaining weights without checking for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Resident #3 Resident #3 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular Disease, Acute Kidney Failure, Muscle Wasting and Atrophy, and Pain. A review of an incident report dated 12/17/2023 at 2:25 p.m., revealed a note written by S6LPN that she overheard the resident chair alarm beeping .saw resident on the floor with aid assessing her . A review of the resident's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed section P-Restraints and alarms, coded of 0 for use of bed alarm and chair alarm, indicating the resident did not use either. On 01/23/2024 at 10:17 a.m., an interview was conducted with S5LPNMDS coordinator. S5LPNMDS coordinator stated that bed and chair alarms were not coded on the MDS assessment unless used for a restraint. She further stated that they were included in the resident's risk assessment when used as an intervention for fall prevention. A review of the resident's fall assessment with S5LPNMDS revealed that the resident was not assessed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure that services were provided as outlined in the physician's orders for 1 (#2) of 11 sampled residents, by failing to ensure that the resident's weight was measured weekly. Findings: A review of the facility's policy titled Weight Monitoring, read in part .Compliance Guidelines. Weight can be a useful indicator of nutritional status .Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem .5. A weight monitoring schedule will be developed upon admission for all residents .e. All others - monitor weight monthly unless otherwise indicated by the physician. Resident #2 was admitted to the facility on [DATE] with diagnoses including Myopathy, Neoplasm of Uncertain Behavior of Right Kidney, Encounter for Attention to Ileostomy, and Limitation of Activities Due to Disability. A review of care plan revealed the resident was Care planned on 07/20/2023 for a potential nutritional problem related to vitamin deficiency…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice for 1 (#R8) of 4 residents (#R8, #R9, #R10, and #R11) whose narcotic records were randomly checked, by failing to ensure that Resident #R8's narcotics record was reconciled. The facility had a census of 37. Findings: A review of the facility's policy titled Pharmacy Services, read in part: Policy. It is the policy of this facility to ensure that pharmaceutical services are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice . Pharmaceutical Services refers to the process (including documentation, as applicable) of .controlling, reconciling .5. The facility .will provide for: a. A system of medication records that enables .Accurate reconciliation and accounting for all controlled medications. Resident #R8 was admitted the facility on 04/27/2023 with diagnoses including…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that pharmaceutical services provided to meet the needs of each resident were consistent with state and federal requirements and reflect current standards of practice for 1 (#R9) of 4 residents (#R8, #R9, #R10, and #R11) whose narcotic records were randomly checked, by failing to ensure that Resident #9's controlled drug was discarded after the blister pack was punctured. Findings: A review of the facility's policy titled Pharmacy Services, read in part: Policy. It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice . Pharmaceutical Services refers to the process (including documentation, as applicable) of .storing, controlling .packaging .using and/or disposing of all medications . Resident #R9 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to accurately code the resident's Minimum Data Set (MDS) assessment for Hospice Services for 1 (#13) of 2 (#13, #8) sampled residents whose records were reviewed for Hospice Services. The deficient practice has the potential to affect a facility census of 38 residents. Findings: A review of Resident #13's medical record revealed a Quarterly MDS with an ARD (Assessment Reference Date) of 04/12/2023, read in part . Section O. 00100 - K . had a blank for Hospice while a Resident. Further review of resident #13's electronic medical record revealed a physician's order dated 07/13/2022 admit to _______ Hospice and Palliative care for Idiopathic Peripheral Autonomic Neuropathy. On 06/20/2023 at 12:45 p.m., during an interview with S1MDS nurse, she confirmed the Quarterly MDS dated [DATE] indicated Resident #13 was not receiving Hospice care. She verified that Resident #13 had an order for Hospice Service dated 07/13/2022 and the Quarterly MDS dated [DATE] was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to ensure that the correct prescribed dosage of medication was administered to residents. The facility had a census of 37 residents. Findings: Resident #141 Review of the facility's policy titled Medication Administration read in part #11. Compare medication source with MAR (Medication Administration Record) to verify resident's name, medication name, form, dose, route, and time. Review of Resident #141's physician orders 06/14/2023 revealed an order for Lactobacillus Oral Tablet (Lactobacillus) Give 4 tablets by mouth three times a day related to Bacteremia for 2 weeks. Observation of medication administration on 06/20/2023 at 8:01 a.m. revealed S3LPN administered 1 tablet of Lactobacillus to Resident #141. On 06/20/2021 at 3:14 p.m., an interview was conducted with S3LPN and she confirmed that she administered the dosage of 1 tablet of Lactobacillus to Resident #141, and that 4 tablets of Lactobacillus should have been given. On 06/21/2023 at 11:00 a.m., an interview was conducted with S2DON and she confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record reviews, and interviews, 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: (1) Ensure visitors were screened prior to entering the facility. (2) Post isolation signage and/or the correct isolation signage for 5 (Rooms A, B, C, D, and E) out of 5 isolation rooms (rooms A-E). This deficient practice had the potential to affect a census of 27. Findings: 1. A review of the facility's policy titled COVID 19 Infection Control Policy, read in part, F. Access to the Community. 1. General . B. All entry doors to the community should be secured to ensure all visitors must enter through one access point and/or main entrance . I. the main entrance door shall be locked, so that visitors must ring a bell or be let in by staff member to obtain access to the community. This protocol is to ensure each entrant has been properly screened. On 6/27/22 at 7:40 a.m., an observation was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that acceptable parameters of nutritional status was maintained for 1(#14) resident out of 1(#14) resident reviewed as evidenced by facility staff failing to follow the policy and procedure for weight assessment as well as failing to follow physician's orders. This deficient practice had the potential to effect the 24 residents that required monthly weights. FINDINGS: Review of the facility policy for Weight Assessment and Inteervention stated in part . Weight Assessment: 3. Any weight change of 5% or more since last weight assessment will be retaken the next day for confirmation. If weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. 4. The dietitian will respond within 24 hours of receipt of written notification. Resident #14 was admitted to facility on 01/28/22, with diagnoses of Cerebral Atherosclerosis, Conjunctivitis, Dementia Long-term use of anticoagulants, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the required in-service training for nurse aides failed to include documented evidence 3 (S7CNA, S8CNA, S9CNA) of 3 certified nursing assistants (CNAs) had dementia management training and 1 (S8CNA) of 3 (S7CNA, S8CNA, S9CNA) CNAs had resident abuse prevention training upon hire. This deficient practice had the potential to affect all 27 residents residing in the facility. Findings: Review of the personnel file for S7CNA revealed she was hired on 03/30/2022. There was no documented evidence she had dementia upon hire to 06/29/2022. In an interview held on 06/29/22 at 11:23 a.m., S4ADON (Assistant Director of Nursing) she confirmed there was no documentation of S7CNA's dementia training in her personnel file. Review of the personnel file for S8CNA revealed she was hired on 06/09/2022. There was no documentation she had dementia or abuse trainings upon hire to 06/29/2022 in her personnel file. In an interview held on 06/29/22 at 11:35 a.m., S4ADON confirmed there was no documented evidence of S8CNA's dementia or abuse trainings upon hire until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.