Inspection Reports for Garden Courte Memory Care

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to reporting abuse and neglect.

The follow-up inspection found no deficiencies, confirming that the facility corrected the previously cited failure to report allegations of abuse as required by licensing laws and regulations.

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 allegation to the Department, which was identified as a failed provider practice and resulted in citations.

A follow-up visit was conducted to assess compliance after previous deficiencies related to resident falls and injuries. The document serves as formal notice of a civil fine imposed due to uncorrected violations.

The facility failed to take appropriate actions after falls occurred, resulting in injuries to two residents and placing other high fall-risk residents at risk for repeated falls and injury. This deficiency was previously cited and remains uncorrected.

The Department of Social and Health Services completed a complaint investigation at the assisted living facility to assess allegations related to abuse or neglect.

The licensee failed to document and determine investigative findings to rule out the possibility of abuse or neglect and failed to document preventative measures to prevent recurrence for two residents, placing residents at risk for ongoing or unidentified abuse or neglect. This deficiency is recurring from previous citations.

Complaint investigation conducted on December 4, 2024; deficiencies related to failure to properly investigate and document abuse or neglect; recurring deficiency previously cited on August 4, 2023, and June 14, 2022.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.

The follow-up inspection found no deficiencies, indicating the facility meets the Assisted Living Facility licensing requirements.

The inspection was conducted as an unannounced on-site complaint investigation regarding a resident entering a staff office and ingesting another resident's medications.

The facility failed to follow policies and properly store medications, resulting in a resident ingesting another resident's medication. This failure was identified as a failed provider practice with citations written.

The complaint involved allegations of quality of care/treatment and physical environment related to medication storage and safety. The complaint was substantiated with failed provider practice identified and citations written.

The Department of Social and Health Services conducted a follow-up visit to the Garden Courte Alzheimer Community to address previously cited deficiencies and to impose a civil fine for noncompliance.

The facility failed to ensure fire safety doors were not propped open, placing residents, staff, and visitors at risk. This deficiency was uncorrected and recurring, leading to a civil fine of $1,200.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.

The follow-up inspection on 06/27/2024 found no deficiencies and confirmed the facility meets Assisted Living Facility licensing requirements.

The Department of Social and Health Services conducted a follow-up visit to the Garden Courte Alzheimer Community assisted living facility to assess compliance and enforce corrective actions related to previously cited deficiencies.

The facility was found to have an uncorrected deficiency involving failure to ensure staff locked the wheels on a resident's wheelchair during transfer, placing the resident at risk of avoidable injury. This violation resulted in a civil fine of $300.

The Department of Social and Health Services conducted a follow-up visit to the Garden Courte Alzheimer Community to verify correction of previously cited deficiencies related to infection control and respiratory protection policies.

The licensee failed to update and implement their infection control and respiratory protection policy, placing all residents and staff at risk of exposure to infectious diseases. This deficiency was uncorrected and recurring, previously cited on March 20, 2024, and August 4, 2023.

The Department of Social and Health Services conducted a follow-up visit to the Garden Courte Alzheimer Community to assess correction of previously cited deficiencies and to impose civil fines based on uncorrected violations.

The facility was found to have multiple uncorrected and recurring deficiencies including fire safety doors being propped open, improper food storage and hand hygiene, failure to post recent inspection results, and poor maintenance and housekeeping, all placing residents at risk.

The Department of Social and Health Services conducted a follow-up visit to the Garden Courte Alzheimer Community to enforce compliance and impose a civil fine based on unresolved violations.

The facility failed to update and implement their policy for infection control and respiratory protection, placing all residents and staff at risk of exposure to infectious diseases. This was an uncorrected citation previously cited on August 4, 2023.

The Department of Social and Health Services conducted a follow-up visit to impose civil fines based on uncorrected and recurring deficiencies previously cited, related to safety, care planning, sanitation, staff training, and other regulatory violations at the assisted living facility.

Multiple uncorrected deficiencies were found, including unsafe oxygen tank storage, fire safety violations, incomplete service plan agreements, food sanitation issues, lack of tuberculosis screening for staff, maintenance and housekeeping failures, and inadequate staff training. These deficiencies placed residents, staff, and visitors at risk and resulted in civil fines totaling $4,600.

The Department completed a full inspection and complaint investigation of the Assisted Living Facility to assess compliance with licensing laws and regulations.

The facility was found not in compliance with multiple licensing requirements including fire safety, medication administration, staff training, resident rights, infection control, and maintenance. Specific issues included propped open fire doors, unsecured oxygen tanks, expired medications administered, incomplete nurse delegation documentation, unsafe hot water temperatures, lack of resident access to rooms without staff assistance, incomplete staff orientation and training, unsecured hazardous supplies, and failure to maintain confidentiality of resident records.

The Department of Social and Health Services completed a Full and Complaint Investigation at the assisted living facility to assess compliance with regulations and address alleged deficiencies.

The investigation identified multiple recurring deficiencies including failure to timely service fire extinguishers, improper infection control practices, medication management errors leading to resident harm, and failure to implement disaster policies during a gas leak, placing residents at risk.

The visit was triggered by a complaint and was a full complaint investigation conducted on January 11, 2024.

The inspection was conducted as an unannounced complaint investigation based on allegations of physical and psychological abuse towards residents at Garden Courte Alzheimer Community.

The facility failed to follow policies and procedures related to suspected abuse, failed to verify staff references prior to hiring, failed to ensure required dementia training for staff, and failed to prevent abuse and improper restraint of residents. These failures placed residents at risk of harm, including one resident who sustained a fractured femur during care.

The complaint investigation was triggered by allegations of physical and psychological abuse towards residents. The investigation included interviews, observations, and record reviews. The complaint was substantiated with findings of failed practices and citations issued.

The Department of Social and Health Services conducted a complaint investigation at Garden Courte Alzheimer’s Community on January 5, 2024, due to allegations of resident abuse and restraint violations.

The investigation found that staff failed to ensure residents were not abused or improperly restrained, resulting in one resident being restrained, injured, and hospitalized, and placing other residents at risk of harm and abuse.

The complaint investigation substantiated that staff abused or restrained three residents, with one resident injured and hospitalized, and all 80 residents placed at risk of abuse.

The inspection was conducted as an unannounced on-site complaint investigation regarding allegations of physical and psychological abuse towards residents at Garden Courte Alzheimer Community.

The facility failed to follow policies and procedures related to suspected and alleged abuse, failed to verify staff references prior to employment, failed to ensure required dementia care training for staff, and failed to protect residents from abuse and improper restraint. Multiple incidents of abuse and neglect were documented, including a resident sustaining a fractured femur during care.

The complaint investigation was triggered by allegations of physical and psychological abuse towards residents. The investigation substantiated failures in abuse prevention, staff reference verification, staff training, and resident safety. Multiple staff were implicated in abusive behavior and failure to follow protocols.

The inspection was a follow-up to complaint investigations regarding allegations of residents not being changed on night shift, infection control issues, and a resident fall involving a wheelchair.

The facility was found to have failed infection control practices by not washing hands or changing gloves between residents, and failed to follow policy regarding supportive devices, resulting in harm to a resident who had multiple falls and facial injuries. The follow-up inspection found no deficiencies.

The complaint investigation included allegations that residents were not being changed on night shift, infection control issues with dried bowel movement on linens, and a resident fall from a wheelchair resulting in facial injuries. The infection control allegation was substantiated with failed practices observed. The fall investigation found failure to assess and obtain consent for supportive device use contributing to harm.

The Office of the State Fire Marshal conducted a fire safety inspection at the Garden Courte Alzheimer Community facility to assess compliance with fire safety codes and regulations.

The inspection identified multiple fire safety deficiencies including missing elements in the fire evacuation plan, failure to maintain electrical outlets and microwave, missing fire-resistant construction, fire doors held open, lack of documentation for fire/smoke damper inspections, sprinkler system documentation deficiencies, missing certification for fire-extinguishing system personnel, failure to service fire extinguishers, blocked means of egress, missing exit signs, and inadequate emergency lighting and generator documentation.

The Department of Social and Health Services conducted a complaint investigation at Garden Courte Alzheimer Community on April 3, 2023, resulting in a civil fine due to a violation related to the implementation of a negotiated service agreement.

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 was recurring, having been previously cited in 2020 and 2022.

Complaint investigation conducted on April 3, 2023, substantiated by the finding of failure to provide a chair alarm as agreed in the service agreement.

The inspection was conducted in response to a complaint regarding a facility-reported resident fall.

The investigation found a failed provider practice where a resident was not utilizing a chair alarm as required by the negotiated service agreement, placing the resident at increased risk of falls and injury.

Complaint related to a facility-reported fall. Failed provider practice was identified and citation(s) were written.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to infection control.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. The prior deficiencies related to infection control were corrected.

The original complaint investigation was triggered by a reported outbreak of COVID-19 and found that the facility failed to ensure staff caring for positive residents were fit-tested for N95 masks and failed to maintain employee fit-testing records. The complaint was substantiated with citations written.

This letter serves as formal notice that the conditions placed on the facility's license on January 20, 2023, are lifted effective March 2, 2023.

The conditions that were previously imposed on the facility's license have been officially lifted as of March 2, 2023.

The notice was issued to impose conditions on the facility's license based on a prior Statement of Deficiencies dated January 5, 2023, requiring the hiring of a Registered Nurse Consultant to assist with infection control compliance.

The facility must comply with infection control requirements including fit testing of N95 respirators, staff training on PPE, and documentation of these activities, with oversight by the Department of Social and Health Services.

The Department of Social and Health Services completed a Complaint Investigation at the Garden Courte Alzheimer Community assisted living facility on January 5, 2023, due to concerns related to infection control measures.

The licensee failed to follow infection control measures to prevent the spread of COVID-19 by not fit testing all staff for N95 respirators, affecting three staff reviewed and placing all 81 residents, staff, and visitors at risk. This was a recurring deficiency previously cited in 2020 and 2021.

The visit was complaint-related, resulting in the imposition of conditions on the facility's license due to infection control violations. The deficiency was substantiated as it led to formal license conditions.

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