The Gardens at Aldersgate

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure adequate narcotic reconciliation when nursing staff failed to sign-off and sign-on each shift on the Narcotic Shift Sheet on two of three units reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents remained free from abuse when Resident (R) 1 and R2's medications were misappropriated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that medications were stored safely and securely as required.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident (R) 2 received activities of daily living (ADL) assistance with personal hygiene when staff did not provide her scheduled showers.

Inspectors wroteThe 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.

Inspectors wroteThe facility identified a census of 161 residents. The facility had one main kitchen and six kitchenette areas. Based on observation, record review, and interview, the facility failed to ensure food was properly labeled and stored in refrigerated areas. The facility failed to ensure the kitchenette areas and refrigerators were clean.

Inspectors wroteThe facility identified a census of 161 residents. The facility identified 34 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP and personal protective equipment (PPE) for Resident (R) 113. The facility additionally failed to store R11, R63, R14, R104, R43, and R9's respiratory equipment in a sanitary manner. The facility further failed to ensure linen carts were transported in a sanitary manner. [...]

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of 16 cognitively impaired, independently mobile residents. The facility additionally failed to ensure Resident (R) 50's specialized call light was in place after her room transfer, resulting in a non-injury fall. Findings Included: - On 01/05/26 at 07:10 AM, a walkthrough of the facility revealed an unlocked rehab therapy room. An inspection of the therapy room revealed an unsecured closet with a hydrocollator (a heating device that uses water baths to heat up hot pads) in the room and turned on. An inspection of the closet door revealed the lock was broken and did not work. [...]

Inspectors wroteThe facility identified a census of 161 residents. The facility had one main kitchen and six kitchenette areas. Based on observation, record review, and interview, the facility failed to ensure dietary staff had and used the provided recipe to specify instructions on the preparation of pureed foods for nine residents.

Inspectors wroteThe facility identified a census of 161 residents. The facility had one main kitchen and six kitchenette areas. Based on observation, record review, and interview, the facility failed to ensure essential kitchen and kitchenette equipment were in proper working condition.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with three sampled residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to preserve Resident (R) 7's dignity while hospice staff transported him on a shower chair from his room to the shower. The facility failed to ensure R16's dignity while assisting him with dressing, when staff left R16's door open.

Inspectors wroteThe facility had a census of 161 residents. The sample included 34 residents, with two reviewed for accommodation of needs for assistive devices. Based on observation, record review, and interview, the facility failed to utilize foot pedals during wheelchair transports for Residents (R) 34 and R33. Findings Included: - On 01/05/26 at 09:15 AM, R34 (A severely cognitively impaired resident) sat in the dining room in the facility's [NAME] Unit. Licensed Nurse (LN) LL walked over to R34 and informed him that he had a phone call at the nurse's station. LN LL proceeded to push R34 to the nurse's station without foot pedals on his wheelchair. R34 placed his feet down several times while in transport. On 01/06/26 at 07:54 AM, R33 (a resident with noted impaired mobility and weakness) wheeled herself into the large common area next to the Sunflower Unit. [...]

Inspectors wroteThe facility had a census of 161 residents. The sample included 34 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 24's protected health information (PHI) private on a medication cart parked in the main dining room. The facility also failed to provide privacy for R113 during activities of daily living.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with seven reviewed for unnecessary medication. Based on record review and interviews, the facility failed to ensure Resident (R) 9's as-needed clonazepam (antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 7 and R90 and their representatives were provided a written notification of transfer, as soon as practicable, upon their transfer to the hospital.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with six residents reviewed for activities of daily living (ADL) care. Based on observation, record review, and interviews, the facility failed to ensure staff assisted Resident (R) 8 with bathing as needed and as scheduled. Findings Included: - R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) pressure ulcer of sacral region (triangular area at the base of the spine), diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hypertension (elevated blood pressure), and congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid). [...]

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with two residents reviewed for bowel and bladder incontinence, and a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on observation, record reviews, and interviews, the facility failed to provide appropriate treatment for Resident (R) 4's indwelling catheter (tube placed in the bladder to drain urine into a collection bag). The facility also failed to ensure R4's drainage bag was not resting on the floor.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with one resident reviewed for dialysis (a procedure where impurities or wastes are removed from the blood) and end-stage renal disease (ESRD- a terminal disease of the kidneys). Based on observation, record review, and interviews, the facility failed to provide standards of care related to Resident (R) 9's dialysis.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, nine medication carts, eight treatment carts, and nine medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in two of the eight treatment carts.

Inspectors wroteThe facility identified a census of 161 residents. The sample included 34 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer or obtain an informed declination for influenza for Resident (R) 72 and the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial pneumonia infections) vaccination for R72, R16, and R4.

Inspectors wroteThe facility identified a census of 114 residents. The sample included four residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interview, the facility failed to prevent an episode of staff-to-resident physical abuse of a cognitively Impaired Resident (R) 1. This deficient practice placed R1 at ongoing risk for preventable abuse and mistreatment.

Inspectors wroteThe facility identified a census of 160 residents. The sample included three residents with three residents reviewed for dementia (a progressive mental disorder characterized by failing memory and confusion) care. Based on observation, record review, and interview the facility failed to develop an individualized dementia treatment plan to address Resident (R)1's dementia-related behaviors to promote his highest practicable quality of life and well-being. This placed R1 at risk for impaired psychosocial well-being and impaired quality of life.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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. As a result of the fall, R1 was admitted to the Intensive Care Unit (ICU) with a head laceration, a thoracic (mid-spine) fracture, and an intracranial (inside the skull) hemorrhage. [...]

Inspectors wroteThe 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. This deficient practice placed R13 and R82 at risk for complications resulting from pressure injuries and/or delayed healing.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on record review and interview, the facility failed to ensure six of the six nurse aides reviewed for regular in-service education had completed the in-service as required. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food in a sanitary manner for the residents who resided in the facility and received meals from the facility's main kitchen. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance (QAA) program failed to provide good faith efforts to identify multiple issues of concern for the 148 residents, who resided in the facility. This placed all residents at risk for unidentified and ongoing care issues.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, interview, and record review, the facility failed to date Resident(R)36's insulin (a hormone that allows cells throughout the body to uptake glucose) flex pen when opened and failed to discard R36 ' s insulin flex pen when outdated. The facility further failed to monitor the medication refrigerator temperature for 18 days. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, interview, and record review the facility failed to ensure Covid-19 (highly contagious respiratory virus) isolation protocols were followed. This deficient practice placed the residents at increased risk for COVID-19 infection.

Inspectors wroteThe facility identified a census of 148 residents. The sample included 32 residents with five residents reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer, obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV 20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

Inspectors wroteThe facility had a census of 148. The sample included 32 residents. Based on record review, interview, and observation the facility failed to treat residents with respect, dignity, and privacy during blood glucose testing. This placed the resident at risk for impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents, with seven reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician of Resident (R) 68's behaviors and refusal to take her psychotropic (any drug that affects behavior, mood, thoughts, or perceptions) medications. This placed the resident at risk for impaired care due to delayed physician involvement.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to complete a full investigation to rule out abuse or neglect after an unwitnessed fall resulting in an injury for cognitively impaired Resident (R) 105. This placed the resident at risk for further injury and unidentified abuse or neglect.

Inspectors wroteThe facility had a census of 148 residents. The Sample included 32 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 137's hospice care (specialized care for people near the end of life) and services and physician-ordered fluid restriction, which placed R137 at risk for impaired care due to uncommunicated care needs.

Inspectors wrote- R128's Electronic Medical Record (EMR) included diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease, dependence on renal dialysis, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute pulmonary edema (accumulation of extravascular fluid in the lung tissues), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, schizoaffective (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) disorder, bipolar disorder (major mental illness that caused people to have episodes of severe high and low [...]

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing for one of the five reviewed for ADLs, Resident (R)61. This placed the resident at risk for poor personal hygiene.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents with five reviewed for skin issues. Based on observation, interview, and record review the facility failed to implement protective measures for the prevention of skin tears and bruising for Resident (R) 140 who had a large amount of bruising on her forearms. This placed the resident at risk for ongoing skin issues and impaired healing.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to evaluate the effectiveness of fall interventions, change or modify the interventions that were ineffective at preventing falls, and failed to follow the plan of care for fall prevention for Resident (R)37. The facility further failed to identify causative factors and implement person-centered interventions for fall prevention for R105. This placed the residents at risk for further falls and injury.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents with three reviewed for incontinence. Based on observation, interview, and record review the facility failed to help with toileting as care planned for Resident (R) 206. This deficient practice placed R206 at risk for complications related to incontinence including urinary tract infection (UTI).

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 137's physician-ordered fluid restriction. This placed R137 at risk of complications related to fluid overload.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 128 received care and services for dialysis (a procedure where impurities or wastes were removed from the blood) consistent with professional standards of practice which included ongoing assessments of the resident's condition as well as ongoing communication and collaboration with the dialysis facility. This placed R128 at risk of complications and unmet care needs related to dialysis treatments.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents. Based on observation, record review, and interview, the facility failed to immediately involve the physician and provide supportive emotional and mental health services to attain Resident (R) 37's highest practicable mental and psychosocial well-being after she made statements of self-harm and/or verbalized feelings of sadness and the desire to die. This placed the resident at risk for unmet mental health care needs.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents with five reviewed for dementia (progressive mental deterioration characterized by confusion and memory failure) care. Based on observation, record review, and interview, the facility failed to develop and implement an individualized dementia treatment plan for Resident (R) 68, who had dementia and behaviors and failed to provide the necessary dementia care and services to attain or maintain the highest level of practicable physical, mental, and psychosocial wellbeing for R68. This placed the resident at risk for decreased quality of life.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents Based on observation, record review, and interview, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 37, who made statements of self-harm. This placed the resident at risk for further decline in her emotional and mental well-being.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R)123's use of an antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality) and failed to identify and report the lack of a 14-day stop date or specific duration for R123 and R128's as needed (PRN) antianxiety medication. This placed the residents at risk for unnecessary psychotropic (alerts mood or thoughts) medication side effects.

Inspectors wroteThe facility had a census of 148 residents. The sample included 32 residents with seven reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for Resident (R) 45 and R100. This placed the residents at risk for fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move) and physical decline.

Inspectors wrote- R128's Electronic Medical Record (EMR) included diagnoses of chronic congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), chronic kidney disease, dependence on renal dialysis, generalized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), acute pulmonary edema (accumulation of extravascular fluid in the lung tissues), anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, schizoaffective (mental disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought) disorder, bipolar disorder (major mental illness that caused people to have episodes of severe high and low [...]

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents. Based on observation, record review, and interview, the facility failed to provide accurate reconciliation of controlled drugs at the end of daily work shifts. This placed the residents at risk for misappropriation of medications for two of four medications carts.

Inspectors wroteThe facility had a census of 135. The sample included 28 residents. Based on record review, interview and observation the facility failed to treat residents with respect, dignity, and privacy during medication administration. This placed the resident at risk for impaired psychosocial wellbeing.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents with nine reviewed for nutrition. Based on observation, record review and interview, the facility failed to notify the physician of a significant weight loss for one sampled resident, Residents (R) 16. This placed the resident at risk for continued weight loss.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents, two were reviewed for abuse. Based on observation, record review, and interview the facility failed to report Resident (R) 62's unwitnessed fall with a fracture right elbow and shoulder to the State Agency (SA) as required. This placed the resident at risk for ongoing and/or unidentified abuse or neglect.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when staff failed to implement interventions on Resident(R)107's plan of care aimed to prevent falls. This placed the resident at risk for further falls and injury.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents with nine reviewed for nutrition. Based on observation, record review and interview, the facility failed to adequately monitor weights to maintain acceptable parameters of nutritional status for one sampled resident, Residents (R) 16. This placed the resident at risk for continued weight loss.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed follow up on Consultant Pharmacist (CP) recommendation to obtain a stop date and/or risk versus benefit statement for the continued use of clonazepam (psychotropic medication used for panic disorder or seizures) for Resident (R) 130 and to ensure an appropriate diagnosis for the use of R54's buspirone (antianxiety drug). This placed the residents at risk for inappropriate and unnecessary psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date and/or risk versus benefit statement for the continued use of clonazepam (psychotropic medication used for panic disorder or seizures) for Resident (R) 130 and failed to ensure an appropriate diagnosis for the use of R54's buspirone (antianxiety drug). This placed the residents at risk for inappropriate and unnecessary psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility had a census of 135 residents. The sample included 28 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attended to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 92. This placed R92 at risk for inappropriate and/or unmet end of life cares.