Garden Gate Health Care Facility

Inspectors wroteBased on observation, interviews, and record review conducted during the Standard survey completed on 3/19/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for five (B Unit dining room, D Unit dining room, C Unit hallway, A Unit hallway, and Main dining room) of five test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #38, #54, #60, #79, #87, #92, #101, #104, #118, #120, #127, #143, #145, and #173 were involved. Residents attending the resident council meeting also expressed concerns about food and food temperatures.

Inspectors wroteBased on observations, interviews, and record review conducted during a Complaint (NY00353368) investigation during the Standard survey completed on 3/19/25, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen. Specifically, the kitchen had unlabeled and undated food items stored in the freezer and coolers. The main kitchen coffee maker was not functioning and kitchen equipment was not cleaned after previous use. There was food and trash debris on the kitchen and dish washing room floors; there were un-covered meal trays with un-eaten food on open carts, on top of tray caddies, on the counters in the main dining room and hallway adjacent to the main dining room. Additionally, there were fruit flies observed on several occasions. Resident #137 was involved.

Inspectors wroteBased on observation, interview and record review conducted during a Standard Survey completed 3/19/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for one of one facility. Specifically, staff were not wearing face masks in resident care areas and were not immunized with the Influenza vaccine and New York State had declared Influenza Prevalent. The finding is: The policy titled Influenza (Seasonal/H1N1) Program - Employees/ Volunteers/Students documented, employees, volunteers and students are provided with influenza immunization, based on availability, unless medically contraindicated. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/19/25, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (Residents #6 and #63) of eight residents reviewed for activities of daily living. Specifically, Resident #6 had a moderate amount of chin and upper lip hair and Resident #63 had long fingernails on both hands with dark brown debris underneath on multiple observations. Staff did not offer or provide shaving or nail care during care observations.

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 3/19/25 the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #120) of three residents reviewed for nutrition. Specifically, weekly weights recommended by the dietician were not obtained consistently by the dietician as planned and Resident #120 had a continued weight loss. The finding is: The policy titled Weight Monitoring revised 5/2013 documented a weight record is used to facilitate monitoring of changes in weights on a weekly or monthly basis. Admission/ re-admission weights are obtained weekly for the first four weeks, then monthly thereafter unless more frequent monitoring is indicated by the resident's condition. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during a Standard survey completed on 3/19/25, the facility did not ensure that the resident environment remained as free from accident hazards as was possible and that each resident received adequate supervision to prevent accidents for one (Resident #115) of three residents reviewed. Specifically, Resident #115 was served regular consistency soup with intact broccoli pieces and the soup should have been pureed. The finding is: The policy and procedure titled Accident/Incident Investigation and Prevention with a revised date of 6/23 documented the facility provides an environment that is free from accident hazards and provided supervision to each resident to prevent avoidable accidents. [...]

Inspectors wroteBased on interview and record review conducted during a Standard survey completed on 3/19/25, the facility did not ensure that the pharmacist reported irregularities to the Attending Physician, the Director of Nursing and the facility's Medical Director, and that these reports were acted upon for one (Resident #145) of five residents reviewed for drug regimen reviews. Specifically, recommendations made by the Consultant Pharmacist on 1/17/25 were not reported to the Attending Physician, and the facility's Medical Director. Additionally, these recommendations were not acted upon. The finding is: The policy titled Unnecessary Medications Medication Regimen Review, last revised 10/2018, documented the Consultant Pharmacist conducted a medical record review and assessed the drug therapy of each resident monthly. [...]

Inspectors wroteBased on record review and interviews conducted during the Standard survey completed on 3/19/25, the facility did not ensure that the facility's infection and control program included antibiotic use protocols and a system to monitor antibiotic use for two (Resident #16 and #52) of two residents reviewed. Specifically, Resident #16 was receiving an antibiotic since 10/30/24 and Resident #52 was receiving an antibiotic since 10/2/21. The use of the antibiotic was not monitored and tracked by the Infection Preventionist (IP) / Antibiotic Stewardship Program.

Inspectors wroteBased on observation, interview, and record review during a complaint investigation (NY00353368 & NY00369586) conducted during a Standard survey completed on 3/19/2025, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (A Unit, C Unit, and D unit) of four resident units observed. Specifically, there were issues with walls in disrepair or spackled and not sanded or painted (C Unit); floors in resident rooms and common areas with black debris (C and D Units); an over the bed light that was not functioning and accessible to the resident (C Unit); and soiled and rusty commode chairs (C Unit).

Inspectors wroteBased on observations, interviews, and record review completed during a complaint investigation (Complaint #NY00335847), the facility did not ensure that each resident received adequate treatment and services for a foley catheter (tube that drains urine) for one (Resident #4) of two residents reviewed for catheter care. Specifically, staff did not keep the urine collection bag below the level of Resident #4's bladder during care and the resident had a history of frequent urinary tract infections. The finding is: Review of the policy titled Catheter Drainage Bag Care dated 1/01/2000 revealed urinary drainage bag care is performed appropriately to prevent complications caused by the presence of an indwelling urethral catheter. [...]

Inspectors wroteBased on observation, interview, and record review completed during a complaint investigation (Complaint #NY00335847), the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one (Resident #4) of three residents reviewed for infection control practices. Specifically, Resident #4 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during care while emptying a urine drainage bag, applying a skin treatment, and while handling soiled linens. Additionally, there were no receptacles for soiled linen or personal protective equipment in or near the resident's room. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 10/18/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was implemented for each resident. Specifically, for one (Resident #62) of one resident reviewed for vascular ulcers was observed without their heel booties as planned. The finding is: The facility policy and procedure (P&P) titled Interdisciplinary Care Planning, last revised 2/10/23 documented a comprehensive resident-centered Care Plan is developed by the Interdisciplinary team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay. 1. Resident #62 had diagnoses that included type II diabetes with other circulatory complications including skin ulcers, Alzheimer's disease, and atherosclerosis (hardening of the arteries). [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Standard survey completed on 10/18/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain good nutrition for one (Resident #100) of two residents reviewed for ADL assistance with meals. Specifically, Resident #100 required continual verbal and physical assistance with eating and was not provided continual verbal or physical assistance during meals. The finding is: The policy and procedure (P&P) titled Eating Assistance revised 5/07, documented facility staff was responsible for assisting and/or feeding residents as needed. [...]

Inspectors wroteBased on interview, observation, and record review conducted during a Standard survey completed on 10/18/23, the facility did not ensure that food and drink were prepared by methods that conserved flavor and appearance, were palatable and at a safe and appetizing temperature. Specifically, two (Units B and D) of four test trays had issues with food and beverages served at suboptimal temperatures and were not palatable. Residents #11, #12, #113, #165, and Resident Council were involved.

Inspectors wroteBased on interviews and record review conducted during a Complaint investigation (Complaint #NY00286781) during the Standard survey completed on 2/11/22, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #108) of two residents reviewed for abuse. Specifically, the facility's investigation of an abuse allegation lacked documented statements from all staff members involved. The finding is: The facility policy and procedure (P&P) titled, Abuse Reporting and Facility Incident Reporting revised 4/7/21, documented upon receiving reports of abuse, the supervisor immediately examines the resident. Findings of the examination are recorded in the resident's medical record. For each incident reported, the facility should have the following information gathered and available: witness statement(s); [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard Survey completed on 2/11/22, the facility did not ensure the environment remained as free of accident hazards as possible for one (Resident #70) of seven residents reviewed. Specifically, Resident #70 sustained a superficial L shaped scratch to the base of left index finger and a superficial scratch on their right forearm from an over the bed table that was in disrepair with jagged, sharp, and peeling laminate separating from the table. The finding is: Review of facility policy titled Accident/Incident (A/I) Continuous Quality Improvement Summary Investigation and Prevention last revised 4/15 documented the following: -All accidents/incidents are recorded, investigated and corrective measures initiated. [...]

Inspectors wroteBased on observation, interview, and record review conducted during the Standard survey completed on 2/11/22, the facility did not ensure that a resident with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTI's) to the extent possible. Specifically, one (Resident #9) of three residents reviewed for urinary catheters had issues that involved improper urinary catheter care and the lack of maintaining proper infection control measures for a resident with a history of UTI's. The finding is: The facility policy and procedure (P&P) titled Incontinent Care dated 1/1/2000 documented the purpose was to prevent skin breakdown caused by bacteria from urine/feces and to avoid infections and odor. Explain procedure to resident and bring equipment to bedside. Place on a clean barrier. [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 2/11/22, the facility did not maintain drugs and biologicals labelled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one (A Station) of four units reviewed. Specially, inspection of medication room and Team 3/Long Term (LT) medication cart had multi-dose vials of insulin that were expired or outdated beyond the opened/use by expiration date and open multi-dose vials of insulin that were, open, not labeled with open/discard date. This involved Residents #50 and 98. The finding is: [...]

Inspectors wroteBased on observation, interview and record review conducted during the Standard survey completed on 2/11/22, the facility did not establish and maintained 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 and infections. Specifically, two (Unit A and B) of three resident units observed for infection control practices during blood glucose monitoring nursing staff did not properly clean and disinfect shared glucose meters between resident use in accordance with the manufacture's guidelines. Residents #14, #31 and #73 were involved. In addition, two (Resident #9 and 98) of three residents observed for infection control practices during fecal incontinent care staff were observed to empty the dirty washbasin water directly into the sink of shared bathrooms.

Inspectors wroteBased on observation, interview and record review conducted during the Standard Survey 2/11/22, a resident has the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriated. Specifically, the facility did not ensure a resident assessment was completed to determine their ability to safely self-administer/inject medication when clinically appropriate for one (Resident #67) of one resident reviewed. Additionally, there was no physician's order for self-administration/injection of Glatiramer Acetate Solution (medication used to treat multiple sclerosis), and it was not developed into Resident #67's comprehensive care plan (CCP). The finding is: [...]

Inspectors wroteBased on interview, observations, and record review conducted during a Complaint investigation (NY00288068) during the Standard survey completed on 2/11/22, it was determined that the facility did not ensure a safe, clean, comfortable environment and provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, three of three shower rooms (Units A, C, D) and two of four resident units (Units C and D) had issues that involved floors, walls and garbage cans soiled and/or in disrepair, garbage and debris on the floors, soiled privacy curtains, and soiled linens that were not properly disposed.