Garden Terrace Alzheimer's Center of Excellence

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

A licensure survey was completed on 4/28/25 to 5/1/25. One deficiency were cited. Based on observations, record review and interviews, the facility failed to ensure that four (#17, #21, #37 and #95) of ten residents out of 35 sample residents met all the requirements for placement on the secure locked unit. Specifically, the facility failed to ensure Residents #17, #21, #37 and #95, who resided on the secured locked unit, had all requirements met for placement, including an initial evaluation of the necessity for placement, a continued stay review evaluation and that the resident representative had given informed written consent for placement.Findings include: I. Resident #17A. Resident statusResident #17, age 84, was admitted on 9/26/24. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia.The 3/22/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. The behavior and wandering sections of the assessment had not been completed. B. Record reviewResident #17' s elopement care plan, initiated 11/12/24, revealed the resident had a diagnosis of unspecified dementia and as a result, was at risk for exit seeking, wandering and elopement. Interventions, revised on 11/12/24, included documenting wandering behavior and attempting diversional interventions.-Review of Resident #17' s electronic medical record (EMR) revealed there was not an initial assessment for placement, a 30-day continued stay evaluation, or a written informed consent for placement from the resident' s representative documented for Resident #17.II. Resident #21A. Resident statusResident #21, age 87, was admitted on 3/31/25. According to the April 2025 CPO, diagnoses included vascular dementia.The 4/2/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. A depression screening, dated 4/2/25, revealed the resident was moderately depressed and had expressed feeling down and that he would be bette..

A recertification survey with Incident #39445 and Incident #39698 was completed on 4/28/25 to 5/1/25. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 4/28/25 to 5/1/25. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication storage rooms.Specifically, the facility failed to ensure vaccinations were not stored in dormitory style fridges.Findings include:I. Professional referenceAccording to the Vaccine Storage and Handling Tool-kit, dated 3/29/24, retrieved on 5/5/25 from https://www.cdc.gov/vaccin.. Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was not greater than five percent (%).Specifically, the facility had a medication error rate of 8%, which was two errors out of 25 opportunities for error. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed., E.sevier, St. Louis Missouri, pp. 606-607. "Take appropriate actions to ensure the p.. Based on observations, record review, and interviews, the facility failed to ensure one (#57) of two residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure staff provided wound care per physician' s order for Resident #57. Findings include:I. Facility policyThe Physician Orders policy, revised February 202.. Based on record review and interviews, the facility failed to develop and implement policies and procedures related to COVID-19 immunizations for one (#69) of five residents reviewed for immunizations out of 35 sample residents. Specifically, the facility failed to follow up with a resident and/or the resident' s representative to offer and administer COVID-19 vaccination for Resident #69. Findings include:I. Professional referenceAccordin.. Based on record review and interviews, the facility failed to ensure that three (#57, #10 and #51) of five residents out of 35 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Residents #57, #10 and #51, the facility failed to:-Adequately identify and monitor target behaviors for psychotropic medications; -Identify resident specific interventions for behaviors; and,-Provide adequat.. Based on record review and interviews, the facility failed to ensure three (#86, #48 and #93) of six residents reviewed for abuse out of 35 sample residents were free from abuse. Specially, the facility failed to:-Protect Resident #48 from physical abuse by Resident #86;-Protect Resident #86 from physical abuse by Resident #48; and, -Protect Resident #93 from physical abuse by Resident #84. Findings include: I. Facility policy and procedure&nb.. Based on record review, observations and interviews, the facility failed to ensure that one (#79) of three residents out of 35 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #79, residing on the secure locked unit, had the required documentation to justify such restrictions including a consent from the resident' s responsible party for placement, do..