Inspection Reports for
Garden Courte Memory Care

This complaint investigation involved multiple allegations including quality of care/treatment, injury of unknown origin, restraints/seclusion, falsification of records, neglect, and death. The investigation found failed practices in monitoring, documentation, and care plan adherence. Citations were written for identified deficiencies. Some allegations such as restraint administration and death process were unable to be substantiated.

The facility failed to follow residents' care plans and safety checks, resulting in multiple failed practices including inadequate monitoring, documentation, and follow-up on physician orders. Citations were written for these deficiencies.

The licensee failed to take appropriate actions after falls occurred, resulting in injuries to two residents and placing other high fall risk residents at risk. This deficiency was uncorrected from a prior citation and resulted in a $400 civil fine.

This was a complaint investigation completed on December 4, 2024. The deficiency involved failure to properly investigate and document abuse or neglect allegations affecting two residents. The deficiency was recurring from prior citations in 2023 and 2022.

The investigation found failures to document and determine investigative findings to rule out abuse or neglect and to document preventative measures for two residents. These deficiencies placed residents at risk and resulted in a civil fine.

The complaint investigation involved allegations of physical and psychological abuse towards residents. The investigation found failed practices including abuse, neglect, failure to verify staff references, and inadequate dementia training. Multiple residents were affected, including one who sustained a fracture due to improper restraint and care. The facility was cited for these deficiencies.

The facility was found to have failed in multiple areas including implementing policies and procedures related to abuse, verifying staff references prior to hiring, ensuring staff had not abused or restrained residents, and providing specialized dementia training. Resident 3 sustained a fracture due to improper care and restraint. The follow-up inspection found all cited deficiencies corrected.

The complaint investigation involved a public allegation of sexual abuse towards a resident by facility staff. The facility started an investigation but failed to report the allegations to the Department. Interviews and record reviews confirmed the failure to report. The complaint was substantiated with citations issued. The deficiency was recurring from a prior citation dated 11/29/2021.

The investigation found that the facility failed to report allegations of sexual abuse to the Department, constituting a failed provider practice. Citations were written for noncompliance with reporting abuse and neglect regulations. A follow-up inspection on 01/17/2025 found all deficiencies corrected.

An investigation was conducted related to a complaint alleging a named resident sustained an injury to her leg during a transfer. The facility failed to ensure staff locked the wheels on residents’ wheelchairs during transfers to prevent avoidable injuries. Additional residents reviewed had no concerns. Citations were written.

The follow-up inspection on 09/26/2024 found no deficiencies and the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The complaint involved allegations of quality of care and physical environment related to medication storage and administration. The investigation confirmed the facility failed to secure medications properly, leading to a resident ingesting another resident's medication. Citations were issued.

The facility failed to follow policies and properly store medications, resulting in a resident ingesting another resident's medication. The investigation identified failed practices and citations were written.

The facility was cited for failing to ensure fire safety doors were not propped open, placing residents, staff, and visitors at risk. This deficiency was uncorrected and recurring, resulting in a $1,200 civil fine.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The facility failed to ensure staff locked the wheels on a resident's wheelchair during transfer, placing the resident at risk of avoidable injury. This deficiency was previously cited and remained uncorrected, resulting in a $300 civil fine.

The inspection found multiple uncorrected and recurring deficiencies placing residents at risk, including propped open fire safety doors, improper food storage and hand hygiene, failure to post inspection results, and poor facility maintenance. Civil fines totaling $2,600 were imposed based on these violations.

The facility failed to update and implement their infection control and respiratory protection policies, placing residents and staff at risk. This violation was previously cited and remains uncorrected, resulting in a $400 civil fine.

The report details multiple uncorrected deficiencies related to safety, care planning, sanitation, staff training, and facility maintenance, all previously cited and now resulting in civil fines totaling $4,600. All deficiencies remain uncorrected as of the inspection date.

The complaint alleged medication errors including a medication technician administering medication prescribed for another resident to a different resident, resulting in a resident's change of condition and emergency room visit. The investigation confirmed the medication error but could not substantiate that it caused the change of condition.

The facility was found noncompliant with multiple licensing requirements including fire safety, medication administration, staff training, resident rights, infection control, and maintenance. Several deficiencies were recurring and some posed risks to resident safety and quality of life. The facility failed to secure hazardous materials, maintain safe water temperatures, ensure proper medication management, and provide adequate staff training and documentation. The facility also failed to ensure resident privacy and access to rooms without staff assistance.

The visit was a Full and Complaint Investigation triggered by specific allegations regarding fire safety, infection control, medication management, and emergency procedures. Multiple deficiencies were found and civil fines imposed.

The investigation identified multiple violations related to fire safety, infection control, medication services, and disaster policy implementation. Civil fines totaling $2,400 were imposed due to these deficiencies, which placed residents at risk. The violations are recurring and have resulted in enforcement actions.

Complaint investigation conducted due to allegations of abuse and restraint involving three residents. The allegations were substantiated, resulting in citations and a civil fine.

The investigation found that staff had abused or restrained three residents, resulting in one resident being injured and hospitalized, and placing all 80 residents at risk of abuse. A civil fine of $1,500 was imposed based on these violations.

The complaint investigation involved multiple allegations of physical and psychological abuse towards residents, including taunting, yelling, rough care, and improper restraint. Specific incidents involved Staff B and Staff C taunting residents and causing injury to Resident 3 during care. The investigation included interviews, record reviews, and policy assessments. The complaint numbers referenced include 101047, 99320, 99595, 101823, 99931, 102395, and 104783.

The investigation found multiple failures including inadequate implementation of abuse policies, failure to verify staff references prior to hiring, failure to ensure required dementia training for staff, and incidents of staff abusing and restraining residents. These failures placed all 80 residents at risk of harm. Several residents were directly affected, including one who sustained a fractured femur due to rough care and improper restraint.

The investigation was complaint-related, triggered by a facility-reported fall. The complaint involved failure to utilize bed and chair alarms as required. A failed provider practice was identified and citations were written.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The facility was found to have multiple fire safety deficiencies including missing fire evacuation plan elements, unmaintained fire doors, lack of required documentation for fire and suppression systems, and blocked egress paths. The overall approval status was Disapproved due to these unresolved violations.

This was a complaint investigation resulting in a civil fine for failure to implement a negotiated service agreement. The deficiency was recurring and substantiated.

The investigation found that the licensee failed to provide a chair alarm as agreed upon in the negotiated service agreement for one resident, placing the resident at increased risk of falls and injury. This deficiency is recurring and resulted in the imposition of a $300 civil fine.

The complaint investigation was triggered by a reported COVID-19 outbreak. The investigation found that staff were not fit-tested for N95 respirators and that the facility lacked documentation of fit-testing. Multiple interviews and record reviews were conducted. The deficiency was cited and later corrected as confirmed by the follow-up inspection.

The follow-up inspection on 03/02/2023 found no deficiencies and confirmed that previously cited deficiencies related to infection control were corrected. The facility meets the Assisted Living Facility licensing requirements.

The conditions previously imposed on the assisted living facility license have been officially lifted as of March 2, 2023.

The complaint investigation included allegations that residents were not being changed on night shift, infection control lapses with dried bowel movement on linens, and a resident fall resulting in facial injuries. The investigation substantiated infection control failures and failure to follow supportive device policies, resulting in citations.

The investigation found infection control deficiencies related to staff not changing gloves or washing hands between residents, and failure to follow policy for supportive devices resulting in a resident fall and facial injuries. The facility was cited for these deficiencies and required to take corrective action.

The notice mandates hiring a Registered Nurse Consultant to develop and implement infection control policies, ensure staff fit testing and training on PPE, and provide documentation to the Department. These conditions remain in effect until formally lifted.

This report is based on a complaint investigation completed on January 5, 2023. The investigation found the licensee failed to comply with infection control requirements, resulting in conditions imposed on the license.

The licensee failed to follow infection control measures by not fit testing all staff for N95 respirators, placing all 81 residents, staff, and visitors at risk of COVID-19 spread. This recurring deficiency led to conditions being placed on the license.