The Gardens Care Homes - Meadow Hills Memory Care

“Based on record review and interviews, the residence failed to ensure the administrator managed the day-to-day delivery of services including completing, maintaining and submitting all reports and records required by the department, affecting 12 current residents.Findings included:On 1/7/26 at approximately 10:30 a.m., during a record review of the sampled residents, no documentation, including progress notes, incident reports, or any other records, indicated that the residents were left without any staff members onsite for approximately 30 minutes.On 1/7/26 at 10:29 a.m., the administrator designee (AD) stated that he did not know he was required to complete an occurrence report and further stated that he did not submit any documentation to the department for the incident in which Staff #2 abandoned her shift and left the residents alone for approximately 30 minutes.On 1/7/26 at approximately 2:00 p.m., the administrator stated that she did not submit any documentation regarding the incident on 11/3/25 to the department. She also questioned the administrator designee and confirmed that he had not submitted any documentation.”

“Based on record review and interviews, the residence failed to ensure the administrator managed the day-to-day delivery of services including completing, maintaining and submitting all reports and records required by the department, affecting 12 current residents.Findings included:On 1/7/26 at approximately 10:30 a.m., during a record review of the sampled residents, no documentation, including progress notes, incident reports, or any other records, indicated that the residents were left without any staff members onsite for approximately 30 minutes.On 1/7/26 at 10:29 a.m., the administrator designee (AD) stated that he did not know he was required to complete an occurrence report and further stated that he did not submit any documentation to the department for the incident in which Staff #2 abandoned her shift and left the residents alone for approximately 30 minutes.On 1/7/26 at approximately 2:00 p.m., the administrator stated that she did not submit any documentation regarding the incident on 11/3/25 to the department. She also questioned the administrator designee and confirmed that he had not submitted any documentation.”

“Based on record review and interview, the residence failed to comply with occurrence report requirements required by state law, affecting 12 current residents.Findings include:On 1/7/26 at approximately 10:30 a.m., during record and documentation reviews, neither the administrator nor the administrator designee submitted an occurrence report for the incident on 11/3/25, when Staff #2 abandoned her shift and left 12 residents alone without any staff members present. As of 1/7/26 there was not an occurrence report submitted to the department.On 1/7/26 at 11:19 a.m., the administrator designee stated that he did not submit an occurrence report and was unsure that he was required to do so.”

“Based on record review and interviews, the residence failed to ensure the residents were free from neglect, affecting 12 current residents.Findings Include:An undated admission agreement, in part, stated that the residence shall provide, either directly or indirectly, a physically safe environment with protective oversight, including ensuring that at all times at least one trained staff member is present in the secure environment, with zero tolerance for abuse and neglect.On 1/7/26 at 11:33 a.m., the administrator designee submitted to the human resources representative (HRR) a text message he received from Staff #2 stating, in part, that on 11/3/25, Staff #2 left the residence without any other staff onsite, abandoned her shift, and acted in a neglectful manner.On 1/7/26 at approximately 9:00 a.m., Staff #1 reported that on 11/3/25, Staff #2 left her shift before Staff #3 arrived, leaving 12 residents unattended without another staff member onsite.On 1/7/26 at 10:29 a.m., the administrator designee (AD) stated that at 6:15 a.m., Staff #2 notified him that she had left the residence, a secured environment, and that no other staff were present. He said he did not see the text message from Staff #2 until approximately 6:25 a.m. He stated that the residents were left unattended for approximately 30 minutes, acknowledged that this was unacceptable, and confirmed that the residents had been neglected.”

“Based on record review and interviews, the residence failed to ensure the residents were free from neglect, affecting 12 current residents.Findings Include:An undated admission agreement, in part, stated that the residence shall provide, either directly or indirectly, a physically safe environment with protective oversight, including ensuring that at all times at least one trained staff member is present in the secure environment, with zero tolerance for abuse and neglect.On 1/7/26 at 11:33 a.m., the administrator designee submitted to the human resources representative (HRR) a text message he received from Staff #2 stating, in part, that on 11/3/25, Staff #2 left the residence without any other staff onsite, abandoned her shift, and acted in a neglectful manner.On 1/7/26 at approximately 9:00 a.m., Staff #1 reported that on 11/3/25, Staff #2 left her shift before Staff #3 arrived, leaving 12 residents unattended without another staff member onsite.On 1/7/26 at 10:29 a.m., the administrator designee (AD) stated that at 6:15 a.m., Staff #2 notified him that she had left the residence, a secured environment, and that no other staff were present. He said he did not see the text message from Staff #2 until approximately 6:25 a.m. He stated that the residents were left unattended for approximately 30 minutes, acknowledged that this was unacceptable, and confirmed that the residents had been neglected.”

“Based on record review and interviews, the residence failed to conduct a thorough investigation of an allegation of neglect, including outlining the investigative process and ongoing monitoring, and failed to provide documented findings of the abuse investigation to the department upon request, affecting 12 current residents.Findings Include:On 1/7/26 at approximately 10:30 a.m., all internal investigation documents related to the incident that occurred on 11/3/25 were requested; however, the residence failed to provide a comprehensive investigation of any aspect of the abuse and neglect incident, including documentation that the legal representative was notified within 24 hours, the investigative process used, how the investigation was documented to evidence required reporting and thoroughness, or any corrective actions taken if the neglect or abuse was verified.On 1/7/26 at approximately 10:45 a.m., the administrator designee (AD) stated that Adult Protective Services (APS) and law enforcement were notified; however, he did not conduct an internal investigation. He further stated that he notified most families or powers of attorney but was unable to provide documentation of those notifications, and acknowledged that he did not know what actions were required when an incident of negligence occurs.On 1/7/26 at approximately 1:00 p.m., the human resources representative (HHR) stated that no internal investigation documents were completed regarding the incident of neglect on 11/3/25.On 1/7/26 at 2:11 p.m., the administrator designee (AD) acknowledged that the residence did not conduct an internal investigation of the incident on 11/3/25 and stated that negligence occurred.”