The Gardens Rehab & Care Center

Based on observation and interview, the facility failed to provide corridor doors in accordance with the requirements of NFPA 101 - 2012 edition, Sections 19.3.6, 19.3.6.3, and 19.3.6.3.10. This deficient practice could affect approximately 8 of 46 residents plus staff in the affected area.Â

Based on record review and staff interview, the facility failed to conduct fire drills in accordance with the requirements of NFPA 101 - 2012 edition, Section 19.7.1. This deficient practice could affect all 46 residents and all staff.Â

Based on observation, interviews, review of documentation, and review of facility policies, the facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for one resident (#54). -Regarding Resident # 54: Resident # 54 was admitted to the facility on December 26 2024 and discharged January 7, 2025, with diagnoses that included displaced transverse fracture of right patella, subsequent encounter for closed fracture with routine healing, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, altered mental status, unspecified, mild cognitive impairment of uncertain or unknown etiology. The Medicare 5-day Minimum Data Set (MDS) assessment dated January 2, 2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating the resident had severe cognitive impairment. A nursing progress note dated January 05, 2025, revealed that at approximately 5:53 PM, revealed the following note "residents' spouse at the. Resident was in w/c in commons area and spouse pushed resident towards door of room. This writer was sitting at nurses station an overheard spouse talking to resident and stated, "You fucking idiot, I can't take you home. You're so stupid, why can't you listen to me? You're fucking worthless." Nurse intervened and stepped between resident and spouse, and removed spouses' hands from w/c. Spouse continued to attempt to talk to resident stating, "I can't take care of you, I'm not taking you home." This writer had another staff member stay with resident and escorted spouse out of facility and informed him that he isn't allowed to talk to resident in that way or tone. Administration updated per night supervisor A Communication Note- with family/NOK/POA dated January 6, 2025 at 1:18 PM, Administrator in Training ((AIT/Staff # 12) revealed "Assistant Administrator spoke with husband this morning regarding the interaction between resident's spouse and wife Toni yesterday afternoon. Resident's spouse told Assistant Administrator that his dog is very sick and having seizures. He was upset about the dogs' condition and then shared that information with resident #54 (he admitted to this being a mistake). Resident #54 then got very agitated and was wanting to leave. Resident's spouse said he got frustrated with everything going on and lost his temper. He was apologetic and said it won't happen again. He also told the Assistant Administrator that she had been calling him this morning wanting him to come in. Assistant Administrator and DON interviewed the resident. Resident doesn't recall the incident therefore resident did not seem negatively affected by the incident with her husband on 1/5/25. Resident stated she felt comfortable with her husband and doesn't feel uncomfortable with him at all." A Psychiatry/Mental Health note dated January 7, 2025 at 5:15 PM reve

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to report an allegation of verbal abuse to the state agency based on the regulatory timeframe for one resident (#30). Findings include: Resident #30 was admitted to the facility on January 21, 2023 with diagnoses that included cerebral infarction, chronic kidney disease, encephalopathy, and hypertension. The minimum data set (MDS) dated January 30, 2024 included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. A progress note dated January 30, 2024 revealed that residents were interviewed and notified appropriate agencies as per protocol. Resident #30 made an allegation of abuse to his therapist. The therapist alerted administration and this nurse at 3:10 p.m. and an investigation was started immediately. The responsible party, the resident's mother, was present when the resident was interviewed at 3:15 p.m. A psych consult was ordered for psychosocial well-being. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. A skin assessment dated February 1, 2023 did not reveal any injuries. -Resident #2 was admitted to the facility on January 6, 2023 with diagnoses that included acute kidney failure, post traumatic stress disorder, and Rhabdomyolysis. The minimum data set (MDS) dated January 13, 2023 included a brief interview for mental status score of 5 indicating the resident had a severe cognitive impairment. The care plan dated January 6, 2023 did not reveal a plan for behaviors or PTSD. The progress note dated January 27, 2023 revealed that the resident had a verbal altercation with his roommate. The resident was moved to room #11. The power of attorney is aware. A progress note dated January 30, 2023 revealed that the resident was involved in an allegation of abuse. Administration and this nurse were notified at 3:10 p.m. and an investigation was started immediately. The appropriate parties were notified and a psych consult was ordered. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. The progress note dated January 30, 2023 revealed that the resident was moved to another room per his request. A skin assessment dated January 31, 2023 did not reveal any injuries. Review of the 5-day investigation dated Review of the 5-day investigation dated February 3, 2023 revealed: -a physical therapy assistant (staff #21) informed the nurse that resident #30 was inquiring about the altercation that took place with him and his roommate. The staff informed the administrator on January 30, 2023 and started an investigation immediately by interviewing the two residents. - a certified nursing assistant (CNA/staff #9). Staff #9's sta

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that resident (#30) was not abused by resident (#2). Findings include: Resident #30 was admitted to the facility on January 21, 2023 with diagnoses that included cerebral infarction, chronic kidney disease, encephalopathy, and hypertension. The minimum data set (MDS) dated January 30, 2024 included a brief interview for mental status score of 12 indicating the resident had a moderate cognitive impairment. A progress note dated January 30, 2024 revealed that residents were interviewed and notified appropriate agencies as per protocol. Resident #30 made an allegation of abuse to his therapist. The therapist alerted administration and this nurse at 3:10 p.m. and an investigation was started immediately. The responsible party, the resident's mother, was present when the resident was interviewed at 3:15 p.m. A psych consult was ordered for psychosocial well-being. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. A skin assessment dated February 1, 2023 did not reveal any injuries. -Resident #2 was admitted to the facility on January 6, 2023 with diagnoses that included acute kidney failure, post traumatic stress disorder, and Rhabdomyolysis. The minimum data set (MDS) dated January 13, 2023 included a brief interview for mental status score of 5 indicating the resident had a severe cognitive impairment. The care plan dated January 6, 2023 did not reveal a plan for behaviors or PTSD. The progress note dated January 27, 2023 revealed that the resident had a verbal altercation with his roommate. The resident was moved to room #11. The power of attorney is aware. A progress note dated January 30, 2023 revealed that the resident was involved in an allegation of abuse. Administration and this nurse were notified at 3:10 p.m. and an investigation was started immediately. The appropriate parties were notified and a psych consult was ordered. A care plan dated January 30, 2023 revealed that resident #2 was involved in an allegation of abuse. Interventions included to order a psych consultation related to psychosocial well-being. The progress note dated January 30, 2023 revealed that the resident was moved to another room per his request. A skin assessment dated January 31, 2023 did not reveal any injuries. Review of the 5-day investigation dated February 3, 2023 revealed: -a physical therapy assistant (staff #21) informed the nurse that resident #30 was inquiring about the altercation that took place him and his roommate. The staff informed the administrator on January 30, 2023 and started an investigation immediately by interviewing the two residents. - a certified nursing assistant (CNA/staff #9). Staff #9's statement revealed that on January 27, 2023, dietary staff (#62) reported to her that two residents wer

Based on clinical record reviews, facility documentation, staff interviews, policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure that a resident (resident #1) was free from verbal abuse from another resident (resident #2). Findings include: Regarding Resident #1: Resident #1 was admitted at the facility on July 22, 2020 with diagnoses of syncope and collapse, major depressive disorder, schizophrenia. Regarding Resident #2: Resident #2 was admitted at the facility on November 30, 2023 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, spastic hemiplegia affecting right nondominant side, major depressive disorder, anxiety disorder. Brief Interview Mental Status (BIMS) 15, cognitively intact. A review of resident #2's progress notes revealed on September 19, 2024 10:30 AM, staff member #5, was at the nursing station and heard cussing. The staff member went to Rose Hall and heard resident state, "She called me a psycho bitch". The staff member immediately spoke with both residents to deescalate and Resident #2 stated, "I know, I am sorry, I should not have said that, I am just so stressed". The staff member then immediately reported to Assistant Administrator and Administrator. The staff member de-escalated situation, ensured residents were safe. Contacted responsible parties. To prevent further disagreements, resident was presented with a room change. Resident agreed, signed advance notice of room change paperwork with Social Services director and moved rooms. Resident #2 was moved to another room in a different Hall. A review of documentation revealed that Resident #2 was served with a 30 day notice of discharge and said to staff member #5 that she should not of said that to resident #1 yesterday and was sorry. Documented on 09/20/2024 at 1133AM. An interview was conducted with Resident #1 on October 15, 2024 at 6:10PM. The resident stated that it was a big misunderstanding. Resident #2 wanted Resident #1 to wake them up at a certain time. I don't smoke so I did not pay attention. She was saying bad things and called me a "crazy bitch". She is no longer here (resident #2), she wanted me to wake her up. Resident concluded the interview with stating, feeling safe in the facility. Care plans were updated on 09/19/2024 for both residents regarding the verbal abuse. Resident #2 had a care plan in place for verbal behavior, makes loud verbal outbursts Manifested by: swearing and insults during meals and activities. Disturbs other individuals. Will yell out/curse at other when uncomfortable in current situation. Resident Rights policy reviewed and the policy states under Procedure 3: Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Abuse Prevention Program policy reviewed and states: It is the policy of this facility for our resident