Garden Place Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and individualize a comprehensive care plan for three Residents (#5, #73, #29), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #5, to ensure a comprehensive care plan was developed and implemented related to his/her use of antipsychotic medications;2. For Resident #73, to ensure a comprehensive care plan was developed and implemented related to his/her use of antipsychotic medications; and3. For Resident #29, to ensure a comprehensive care plan was developed and implemented related to his/her smoking status and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for four Residents (#23, #6, #2, #12), out of a total sample of 24 residents. Specifically, the facility failed:1. For Resident #23, to implement physician's orders for air mattress settings;2. For Resident #6, to transcribe and implement Urology orders (a) for change in Foley catheter size, and (b) for frequency of Foley catheter changes;3. For Resident #2, to obtain a physician's order for treatment to the Resident's right thigh surgical wound; and4. For Resident #12, to follow physician's orders to notify the Resident's cardiologist for systolic blood pressure below 90 mmHg (millimeters of mercury) and/or heart rate below 60 bpm (beats per minute).

Inspectors wroteBased on record review and interview, the facility failed to provide care and services consistent with professional standards of practice for one Resident (#2) who required hemodialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to), out of a total sample of 24 residents. Specifically, the facility failed:a. to ensure nursing staff did not obtain blood pressures from the Resident's arms, where his/her AV fistulas (arteriovenous fistula, where an artery and vein connect directly, allowing blood to flow) used for hemodialysis access were located; andb. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that all drug records were in order and an accurate account of all controlled substances (drugs or chemicals that the government regulates for its manufacture, possession, and use, that are classified into schedules based on their potential for abuse) was maintained for one Resident (#15), from a total sample of 24 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor and appearance as well as being palatable, attractive and at safe, appetizing temperatures for two of two test trays.

Inspectors wroteBased on observations and interviews, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure food items were properly dated and stored in the main kitchen and equipment was maintained in a sanitary manner;2. Ensure the ice machine in the main kitchen was maintained in a clean, sanitary condition; and3. Handle ready-to-eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another).

Inspectors wroteBased on observation, interview, and document review, 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 potential transmission of communicable diseases and infections. Specifically, the facility failed:1. For Resident #2, to implement Enhanced Barrier Precautions; and2. For Resident #77, to perform hand hygiene during medication administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#8 and #9), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended influenza and pneumococcal vaccinations, residents/residents' representatives were educated on the benefits and potential side effects of the vaccines, and were offered and administered (if applicable) the vaccines in a timely manner. Specifically, the facility failed:1. For Resident #8, to ensure influenza and pneumococcal vaccines were administered after the Resident had consented to receive the vaccines; and 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure two Residents (#8 and #9), out of a total sample of five residents reviewed for immunizations, were screened for eligibility to receive the recommended COVID-19 vaccination, residents/residents' representatives were educated on the benefits and potential side effects of the vaccine, and were offered and administered (if applicable) the vaccine in a timely manner. Specifically, the facility failed:1. For Resident #8, to ensure COVID-19 vaccine was administered after the Resident had consented to receive the vaccine; and 2. For Resident #9, to ensure the Resident's medical record included documentation that indicated the Resident's Representative was provided education regarding the benefits and potential side effects of COVID-19 vaccination and either consented to receive or refused vaccine administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure quality of care based on professional standards of practice for one Resident (#212), in a sample of three closed records. Specifically, the facility failed to ensure staff fully assessed Resident #212 who was on a blood thinner, had expressed pain, and had a bruise to the left hip, resulting in a delay in treatment. The Resident was later identified to have a fracture to the left hip and was subsequently sent to the hospital where he/she received a blood transfusion. The Resident was determined to not be a candidate for surgery and was admitted to a hospice house.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the environment was free from accident hazards for Residents on the secure unit ([NAME]) and for two Residents (#105 and #79) in a total sample of 24 residents. Specifically, the facility failed: 1. To ensure hazardous items (bleach wipes, razors, medications) were not accessible to cognitively impaired residents on the secure unit; 2. For Resident #105, assessed at a high risk for elopement/wandering, to ensure the Resident was provided the indicated intervention of a wander guard; and 3. For Resident #79, to ensure that alcohol brought in by family was securely stored.

Inspectors wroteBased on observation and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure food items were properly dated and stored in the main kitchen and kitchenettes; 2. Ensure four of four ice machines were maintained in a clean and sanitary condition; and 3. Ensure one of three unit kitchenettes was maintained in a clean and sanitary condition.

Inspectors wroteBased on record review and interview, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was active and current for administration of an antipsychotic medication for one Resident (#66), out of 24 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#33), out of 24 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address his/her cancer treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care were met for two Residents (#33 and #18), of 24 sampled residents. Specifically, the facility failed: 1. For Resident #33, to ensure his/her Dexamethasone (a corticosteroid to treat/prevent inflammation) orders were accurately transcribed, administered, and documented; and 2. For Resident #18, to administer Propranolol (a medication that affects the heart and circulation and is used to treat conditions such as heart rhythm disorders and other heart or circulatory conditions) in accordance with prescriber orders.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide pain management interventions for one Resident (#105) with tooth pain, out of 24 sampled residents. Specifically, for Resident #105, the facility failed to provide prescribed, as needed, pain relief for tooth pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#412), out of 24 sampled residents. Specifically, the facility failed to assess and monitor the Resident's left Arteriovenous (AV) fistula (a surgically connected artery and vein used for long term dialysis) site.

Inspectors wroteBased on interview and record review, the facility failed to assess a history of trauma and failed to assess for triggers to avoid potential re-traumatization for one Resident (#105) with a history of trauma, out of a total sample of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to act upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for one Resident (#6), out of a total sample of 24 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendation to consider obtaining a lab to monitor the efficacy of Levothyroxine (a hormone used to treat thyroid disorder).

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to provide timely dental services for one Resident (#105), of 24 sampled residents. Specifically, for Resident #105, the facility failed to initiate a timely dental appointment for tooth pain.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who developed redness and irritation to his/her facial area after being shaved by a staff member, the Facility failed to ensure they maintained complete and accurate medical/clinical records, when there was no nursing documentation in the Medical Record related to Resident #1's razor burn to his/her facial area, there was no documentation to support nursing assessed the razor burn to his/her facial area and/or monitored the progress towards healing. Finding Include: Review of the Facility Policy titled, Charting and Documentation, dated as last revised 10/2019, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition should be documented in the resident's medical record. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide care and treatment consistent with professional standards of practice to prevent the development or worsening of a pressure injury for one Resident (#4), out of a total sample of 26 residents. Specifically, the facility failed to implement interventions to prevent the development of a pressure wound, assess the Resident's risk and skin per their policy, and implement interventions recommended by the wound physician timely once the area had developed, resulting in a facility acquired unstageable full thickness deep tissue injury (DTI: localized area of persistent non-blanchable discoloration resulting from intense and/or prolonged pressure and shear forces at the bone/muscle) to the left lateral heel of Resident #4 that had worsened within a week of development.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Ensure staff wear beard restraints in the main kitchen, during meal preparation and service; and 2. Ensure adequate sanitation of equipment in the main kitchen, and 2 of 3 nourishment kitchenettes; and 3. Ensure dietary staff wash their hands after touching a body part, before proceeding with food preparation and service; and 4. Ensure ice machines were cleaned and sanitized.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes. Specifically, the facility failed to develop and implement a QAPI plan and a Performance Improvement Project (PIP) that focuses on a high risk or problem-prone area identified through data collection and analysis.

Inspectors wroteBased on policy review, grievance book review, and interview, the facility failed to implement their grievance policy and ensure that: 1a. For Resident #65, one grievance voiced by the Resident during a Resident Council meeting held on 8/14/23 was addressed and immediate actions taken to resolve the grievance related to an alleged violation involving abuse, was reported to the Department of Public Health (DPH) as required, and investigated; and b. a second grievance voiced by the Resident during the Resident Council meeting involving an alleged violation involving abuse was reported to DPH within the required timeframe; 2. three of seven grievances reviewed were resolved within three to five working days of the receipt of the grievance; 3. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to resubmit a Level II Preadmission Screening and Resident Review (PASRR- screen to determine if a resident had an intellectual or developmental disability and/or serious mental illness (ID/DD/SMI) and needed further evaluation) for one Resident (#11), out of a total sample of 26 residents, who exceeded the approved period for nursing facility level of care by 1566 days.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure ongoing communication and collaboration was maintained with the dialysis center for two Residents (#4 and #76), out of two dialysis Residents in the facility.

Inspectors wroteBased on observation, policy review, interview, and record review, the facility failed to ensure its staff properly assessed four Residents (#29, #65, #73, and #90), out of a total sample of 26 residents, for the risk of entrapment from bed rails and conducted regular maintenance inspections of the bed rails.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that each resident receives food prepared by methods that conserve nutritive value, flavor, and appearance, and is palatable, attractive, and at a safe and appetizing temperature.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure standards of practice were implemented to prevent the spread of potential infection on 2 out of 4 resident dining areas. Specifically, Certified Nursing Assistants (CNAs), and Nursing Staff failed to assist the residents with hand hygiene prior to meal service.

Inspectors wroteBased on observation, and staff interview, the facility failed to ensure that equipment was in good working order. Specifically, the facility failed to: 1. Ensure that equipment was in good working order in the nourishment kitchenettes; and 2. Ensure that one Resident (#268), out of a total sample of 26 residents, had a safe, functioning bed.

Inspectors wroteBased on document review, policy review, and interview, the facility failed to conduct inspections of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment in two of four units (A Wing and [NAME]).

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to provide dignified dining experiences on 2 out of 4 units. Specifically, the facility failed to ensure staff delivered meals to all residents seated at the table simultaneously, resulting in residents waiting an extended period of time to receive their meal, while watching their tablemates eat.

Inspectors wroteBased on record review and interview, the facility failed to notify the attending physician of a consultant's recommendations in a timely manner, for one Resident (#20), from a total sample of 26 residents, resulting in an eight day delay in obtaining a urine for a culture and sensitivity (laboratory tests to check for urinary tract infection and microorganisms).

Inspectors wroteBased on policy review, document review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#65), out of a total sample of 26 residents, for two allegations brought forward during a Resident Council meeting held on 8/14/23. Specifically, the facility failed to: a. Follow their policy for investigating and reporting an alleged violation related to abuse; and b. Follow their policy for reporting an alleged violation related to sexual abuse.

Inspectors wroteBased on policy review and interview, the facility failed to ensure that staff reported to the Department of Public Health (DPH) immediately, but no later than two hours, alleged violations of abuse reported during a Resident Council meeting held on 8/14/23, by one Resident (#65), out of a total sample of eight residents in attendance.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure staff implemented the facility's abuse policy for one Resident (#65), out of a total sample of 26 residents. Specifically, the facility failed to follow their policy for investigating an alleged violation of abuse voiced by the Resident during a Resident Council meeting held on 8/14/23.

Inspectors wroteBased on policy review, record review, and interview, the facility failed to develop and implement the Plan of Care for two Residents (#11 and #90), out of a total sample of 26 residents. Specifically, the facility failed to implement fall prevention interventions for two residents.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to follow standards of practice for one Resident (#38), in a total sample of 26 residents. Specifically, the facility failed to ensure nursing staff observed the consumption of administered medication prior to leaving the room.

Inspectors wroteBased on observation, interviews, and review of facility policies and manufacturer's instructions, the facility failed to label medications in accordance with currently accepted professional principles, and the expiration date when applicable. Specifically, the facility failed to: 1. Ensure staff labeled medications in accordance with currently accepted professional principles, for 2 of 3 medication carts observed; and 2. Ensure staff stored all drugs and biologicals under proper temperature controls in 2 of 3 medication carts observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain laboratory services timely, resulting in a 15-day delay in treatment for one Resident (#20), out of a total sample of 26 residents. Specifically, the facility failed to notify the physician of a recommendation to obtain a urine culture and sensitivity (lab testing for urinary tract infection and effective antibiotic) for eight days and failed to collect the urine timely once an order was obtained, resulting in a total delay of 15 days.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to have an effective policy which addressed the reheating of residents' food brought in from home in accordance with professional standards to ensure food safety. Specifically, the facility failed to provide a thermometer or device (T-stick) and adequate reheating instructions to reheat residents' food brought in from home to an internal temperature of 165 degrees Fahrenheit (F) to prevent potential foodborne illnesses.