Inspection Reports for
Lewis &Amp; Clark Gardens

The complaint involved allegations by Resident #1 that a staff member (CNA A) squeezed his/her face and yelled at him/her. The facility initially did not report the allegation to the state agency because the resident denied the abuse when interviewed with the alleged staff present. The investigation was incomplete with no interviews of the alleged perpetrator or witnesses. The Administrator acknowledged the failure to report and incomplete investigation.

The facility failed to timely report allegations of abuse to the state survey agency and did not conduct a thorough investigation of the abuse allegations involving Resident #1. The resident alleged that a staff member squeezed his/her face and yelled at him/her, but the facility did not report the incident because the resident later denied the allegation during an interview with staff present. The investigation lacked interviews or statements from the alleged perpetrator or other witnesses.

The facility failed to provide residents with meals served at proper temperatures and palatability. Multiple residents reported food being cold, undercooked, bland, or unappetizing. Observations confirmed food items served at temperatures below required standards and issues with food preparation and serving practices.

Complaint #2610531 regarding failure to provide bathing assistance to residents on the COVID isolation unit. The complaint was substantiated with findings of missed showers and inadequate bathing care.

The facility failed to provide bathing for four residents who required assistance during their stay on the COVID isolation unit. Shower schedules were not followed, and documentation of showers was missing for multiple days. Staff cited issues such as a broken shower drain and staffing shortages. Hospice aides were not allowed on the COVID unit, and facility staff did not consistently provide showers or bed baths as required.

The complaint investigation revealed that Resident #1 was subjected to neglect and abuse by staff, including a fall caused by a CNA who pushed the resident and failed to assist or assess him. Resident #2 reported that a staff member threatened to hit him with a closed fist and was fearful of retaliation. The facility failed to report this allegation timely. Both residents have diagnoses affecting mobility and cognition.

The facility failed to maintain a clean and safe environment for Resident #1, failed to prevent abuse and neglect by staff including a fall caused by a CNA, failed to timely report an allegation of abuse involving Resident #2, and failed to develop a comprehensive care plan addressing the needs of Resident #1 with Huntington's disease. Staff lacked understanding of Huntington's disease and did not communicate properly with the resident.

The complaint was substantiated. Resident #1 reported verbal abuse by CMT B, who yelled and used inappropriate language. Witnesses and staff statements confirmed the incident. The facility suspended and terminated CMT B and notified appropriate parties including the police.

The facility failed to ensure Resident #1 was free from verbal abuse when CMT B yelled, used vulgar language, and told the resident to shut up during care refusal. The facility investigated, suspended, and terminated the staff member, educated staff on abuse policies, and corrected the deficiency.

The complaint investigation found that Resident #1, who was at risk for wandering and elopement, exited the facility through an alarmed fire exit door without staff knowledge. Staff did not hear the alarm promptly, and 15-minute checks were not completed as required. The resident was found outside with severe injuries. The immediate jeopardy was corrected on 4/18/25.

The facility failed to respond timely to a door alarm when Resident #1, assessed at risk for elopement, exited through an alarmed door unnoticed by staff. The resident was not monitored with required 15-minute checks and subsequently fell outside the facility, sustaining multiple facial fractures and a subdural hemorrhage. The facility implemented corrective actions including staff education, alarm volume adjustment, and ongoing audits.

The complaint was substantiated. The resident reported unauthorized use of their debit card by CNA A, who withdrew cash and paid bills without permission. Law enforcement was involved, and the resident filed a police report.

The facility failed to protect one resident from misappropriation of property when CNA A used the resident's debit card without permission to withdraw cash and pay bills totaling $1,369.69. CNA A was suspended, investigated, and terminated. The facility educated staff on misappropriation policies and took corrective actions.

The facility failed to ensure staff followed physician's orders for wound care for two residents, resulting in improper wound treatment and lack of order reconciliation after hospital readmission. Additionally, the facility failed to provide an ongoing activities program meeting individual interests, especially lacking activities in the evenings and on weekends for multiple residents.

The facility was found deficient in multiple areas including failure to accommodate resident needs for oxygen and mobility aids, failure to follow physician orders for wound care, inadequate activities programming, unsecured hazardous materials, improper respiratory care, food safety and preparation issues, infection control lapses, and incomplete pneumococcal vaccination administration.

The visit was complaint-related, focusing on allegations that the facility failed to provide adequate personal hygiene care and failed to apply prescribed therapeutic devices for residents.

The facility failed to ensure staff provided adequate personal hygiene care including nail care and shaving for two residents, and failed to apply hand splints and palm protectors as directed for one resident with hand contractures. The deficiencies were observed in a sample of nine residents.

The complaint investigation was triggered by an incident where two residents engaged in sexual intercourse without documented capacity to consent. The investigation confirmed the incident and found failures in supervision and care planning. The immediate jeopardy was removed after corrective actions were implemented.

The facility failed to prevent sexual abuse between two residents with cognitive impairments. The investigation revealed inadequate supervision and failure to assess capacity to consent. The facility also failed to provide adequate personal hygiene care and failed to apply prescribed hand splints and palm protectors for a resident with contractures.

The facility was found deficient in multiple areas including failure to honor resident bathing preferences, failure to promptly address resident council grievances, inadequate cleanliness and odor control, failure to follow physician orders for medications and supplements, failure to provide adequate oral care and assistance with meals, and failure to properly assess and document pressure ulcers.

The complaint investigation revealed failure to honor a resident's DNR advance directive resulting in immediate jeopardy, failure to provide Medicare Part A non-coverage notices, inadequate abuse investigation procedures, failure to complete PASARR screening, and failure to provide scheduled bathing assistance.

The facility failed to honor a resident's advance directive resulting in immediate jeopardy, failed to provide required Medicare Part A non-coverage notifications, inadequately investigated an abuse allegation, failed to complete a PASARR Level 1 screening for a resident, and failed to provide adequate bathing assistance to a resident.

The facility was found deficient in multiple areas including resident dignity and respect, financial access, notification of condition changes, environmental cleanliness, abuse investigation, significant change assessments, care planning, medication administration, personal hygiene, resident transfers, catheter care, feeding tube care, pain management, medication storage and control, food service, and infection control.