The Gardens Care Homes - Memorial Park Assisted Living 1

“Based on observations, record review, and interview, the residence failed to maintain sufficient staffing to help residents needing or potentially needing assistance, affecting 12 current residents.Findings include:1. ObservationsOn 7/29/25 from 7:00 a.m. to 3:00 p.m., two staff members were present from 7:00 a.m. until approximately 10:00 a.m., when the support staff ' s shift ended. The administrator designee (AD) arrived at approximately 8:00 a.m. and floated between the assisted living residence and a sister residence (SR). The AD floated between the residence and the SR approximately every hour, alerting Staff #1 each time she was leaving the residence.2. Record Reviewa. Resident Agreement and CensusThe residence template resident agreement, undated, read in part: The residence employed sufficient staff to ensure the provision of services necessary to meet the needs of the residents. This included trained staff members for both the assisted living and memory care secured environments. Staffing considerations included: services to meet the residents' needs, services to be provided under the care plan, and services to be provided under the resident agreement.A resident roster, dated 7/16/25, revealed that 12 residents resided in the residence.b. Staff ScheduleA staff schedule for 7/27/25 through 8/2/25 revealed the following staffing pattern:On 7/27/25, from 6:00 a.m. to 6:00 p.m., one assisted living (AL) staff member (Staff #5) was scheduled.On 7/27/25, from 7:00 a.m. to 3:00 p.m., Staff #6 was scheduled to float between the residence and the SR.On 7/27/25, the residence scheduled only one staff member from 6:00 a.m. to 7:00 a.m., and from 3:00 p.m. to 6:00 p.m., and intermittently had only one staff member on-site from 7:00 a.m. to 3:00 p.m.On 7/28/25, from 6:00 a.m. to 6:00 p.m., Staff #1 was scheduled.On 7/28/25, from 6:00 a.m. to 9:00 a.m., Staff #3 was scheduled to float between the residence and the SR.On 7/28/25, from 8:00 a.m. to 4:00 p.m., the AD was scheduled to manage both the residence and the SR.On 7/28/25, the residence scheduled only one staff member from 4:00 p.m. to 6:00 p.m., and intermittently had only one staff member on-site from 6:00 a.m. to 8:00 a.m., and from 9:00 a.m. to 9:00 p.m.On 7/29/25, from 6:00 a.m. to 2:00 p.m., Staff #1 was scheduled.On 7/29/25, from 2:00 p.m. to 10:00 p.m., Staff #7 was scheduled.On 7/29/25, from 6:00 a.m. to 9:00 a.m., Staff #3 was scheduled to float between the residence and the SR.On 7/29/25, from 7:00 a.m. to 3:00 p.m., Staff #8 was scheduled to float between the residence and the SR.On 7/29/25, from 8:00 a.m. to 4:00 p.m., the AD was scheduled to manage both the residence and the SR.On 7/29/25, the residence scheduled only one staff member from 4:00 p.m. to 10:00 p.m., and intermittently had only one staff member on-site from 6:00 a.m. to 7:00 a.m., 9:00 a.m. to 4:00 p.m.c. Sample ResidentsResident #1 was admitted to the residence on 3/14/24 with a diagnosis of dementia.A care plan, dated 7/29/25, read in part: Resident #1 had a diminished safety awareness due to the progression of her dementia. Staff were required to monitor and prompt as needed for safety. Additionally, Resident #1 required monitoring and cues for ambulation. Staff were required to monitor the resident daily at 6:00 a.m., 10:00 a.m., 2:00 p.m., and 6:00 p.m. Furthermore, Resident #1 required supervision and physical assistance to evacuate the building. Staff were required to provide physical assistance as needed in the event of an emergency.Resident #2 was admitted to the residence on 6/18/25 with a diagnosis of Alzheimer's disease.A care plan, dated 7/29/25, read in part: Resident #2 had a diminished safety awareness due to the progression of Alzheimer's disease. Staff were required to monitor and prompt as needed for safety. Additionally, Resident #2 required staff monitoring and verbal prompts while eating. Staff were required to monitor and provide verbal cues to the resident while eating. Furthermore, Resident #2 required supervision and physical assistance to evacuate the building. Staff were required to provide physical assistance as needed in the event of an emergency.Resident #3 was admitted to the residence on 10/31/25 with diagnoses of hemiplegia, unspecified affecting left nondominant side; age-related osteoporosis without current pathological fracture; and osteomyelitis of the vertebra, lumbar region.A care plan, dated 7/29/25, read in part: Resident #3 required full assistance with bathing, dressing, and undressing. Staff were required to provide full assistance with changing daily and showering twice weekly. Additionally, Resident #3 required monitoring for ambulating. Staff were required to monitor and provide cues as needed. Furthermore, Resident #3 required supervision and physical assistance to evacuate the building. Staff were required to provide physical assistance as needed in the event of an emergency.3. InterviewsOn 7/29/25 at 8:45 a.m., Staff #1 confirmed that 12 residents resided at the residence and that she was the only staff assigned to the residence. She explained that there was only ever one staff member assigned to the residence on each shift. She explained that Staff #3 was the activities staff and that he was usually at the residence from 5:00 a.m. to 10:00 a.m. Monday through Saturday, but throughout this time, he frequently left the residence to assist the SR during that time.On 7/29/25 at 8:50 a.m., Staff #3 stated that he was the activities staff and supported the residence and the SR during his shifts Monday through Saturday from approximately 5:00 a.m. to approximately 10:00 a.m. On 7/29/25 at 8:55 a.m., Staff #1 stated that she attempted to provide the required care for every resident; however, it often took quite a while. She stated that when she was providing personal care to residents, and Staff #3 or the AD were present, they monitored the other residents. She explained that when neither of these staff members was on site, she requested staff assistance from the SR; however, they often could not assist due to their staffing constraints. She stated that she felt unsafe when she was alone with all the residents and needed to provide care to a resident. She explained that it was because she could not safely monitor the other residents or respond in a timely manner if an emergency occurred. Staff #1 stated that approximately two to three times per week, she had to request assistance from support staff or staff from the SR. She stated that she felt the residence would benefit from additional care staff during the day.On 7/29/25 at 9:15 a.m., Confidential Resident #6 stated that she felt as though one staff member became overwhelmed by residents who had higher care needs. She stated that staff had not assisted her with making her bed regularly. She explained that other residents who required more assistance got staff support in making their bed and getting dressed; however, when she requested assistance with bed-making, staff often stated that they would return to assist her, but did not consistently follow through. Confidential Resident #6 stated that she liked to wake up around 5:00 a.m. and wanted to have her bed made in the morning. She stated that she understood that other residents had higher needs, but felt left out when she did not get assistance with making her bed. She explained that it was "a thing for her" to have her bed made in the morning, but that if staff did not get to it before the afternoon, there would be no point because she took a nap in the afternoon. Confidential Resident #6 also stated that there were not enough staff to be consistent with taking out her trash; she often requested multiple times, but the staff still could not do it.On 7/29/25 at approximately 12:40 p.m., Confidential Staff #4 stated that today was the most support she had gotten from support staff and the AD since she had been employed with the residence. She stated that she believed they were helping out more because of the state surveyor being present.On 7/29/25 at 2:35 p.m., Resident #5 reported that the residence does not have sufficient staffing. She stated that there is only one staff member assigned to the assisted living residence on each shift, and she believed that there should be two for safety. She explained that staff could not keep up with cooking, cleaning, care, and safely monitor the residents by themselves. She stated that if the staff is assisting another resident, she and other residents often assist those who are remaining with what they can. She expressed that she does not mind assisting, but does not think it should be this way. "We have had to help each other out when staff are busy."On 7/29/25 at 2:45 p.m., Resident #3 stated that she believed that there should be two staff members on each shift. She explained that one staff member could focus on medication and food while the other could assist residents with other care needs and maintain safety. On 7/29/25 at 2:50 p.m., Resident #4 stated that she believed there is "not quite enough staff". She explained that the staff seem very overwhelmed.On 7/29/25 at 3:30 p.m., the AD confirmed there were 12 residents and one staff member assigned per shift. She stated an activities staff member was assigned to float between the residence and SR Wednesday through Thursday from 6:00 a.m. to 9:00 a.m. and Friday and Saturday from 7:00 a.m. to 3:00 p.m. The AD added that she was also managing the residence and SR Monday through Friday from 8:00 a.m. to 4:00 p.m. She stated that she agreed that the activities and other support staff, including herself, were assigned to both the residence and SR, and that the second staff member was not consistently assigned to the residence. The AD stated that she was aware of the required one-to-10 ratio for staff to residents during the day time, and she felt the residence was meeting that standard. She agreed that the residence and SR were separate entities. The AD clarified that she felt the residence was sufficiently staffed and that staff were only alone with the residents from 6:00 p.m. to 6:00 a.m., Sundays and Mondays, and from 10:00 p.m. to 6:00 a.m., Tuesday through Saturday. She stated that the support staff and activities staff watched the residents when they were present, and staff could always request assistance from the staff assigned to the SR if needed. The AD stated that the residents were never unattended.”

“Based on observations, records review, and interviews, the facility (residence) failed to meet a minimum of one staff to 10 members (residents) during daytime, affecting 12 current members.Findings include:1. ObservationsOn 7/29/25 from 7:00 a.m. to 3:00 p.m., two staff members were present from 7:00 a.m. until approximately 10:00 a.m., when the support staff ' s shift ended. The administrator designee (AD) arrived at approximately 8:00 a.m. and floated between the assisted living residence and a sister residence (SR). The AD floated between the residence and the SR approximately every hour, alerting Staff #1 each time she was leaving the residence.2. Record Reviewa. Resident Agreement and CensusThe residence template resident agreement, undated, read in part: The residence employed sufficient staff to ensure the provision of services necessary to meet the needs of the residents. This included trained staff members for both the assisted living and memory care secured environments. Staffing considerations included: services to meet the residents' needs, services to be provided under the care plan, and services to be provided under the resident agreement.A resident roster, dated 7/16/25, revealed that 12 residents resided in the residence.b. Staff ScheduleA staff schedule for 7/27/25 through 8/2/25 revealed the following staffing pattern:On 7/27/25, from 6:00 a.m. to 6:00 p.m., one assisted living (AL) staff member (Staff #5) was scheduled.On 7/27/25, from 7:00 a.m. to 3:00 p.m., Staff #6 was scheduled to float between the residence and the SR.On 7/27/25, the residence scheduled only one staff member from 6:00 a.m. to 7:00 a.m., and from 3:00 p.m. to 6:00 p.m., and intermittently had only one staff member on-site from 7:00 a.m. to 3:00 p.m.On 7/28/25, from 6:00 a.m. to 6:00 p.m., Staff #1 was scheduled.On 7/28/25, from 6:00 a.m. to 9:00 a.m., Staff #3 was scheduled to float between the residence and the SR.On 7/28/25, from 8:00 a.m. to 4:00 p.m., the AD was scheduled to manage both the residence and the SR.On 7/28/25, the residence scheduled only one staff member from 4:00 p.m. to 6:00 p.m., and intermittently had only one staff member on-site from 6:00 a.m. to 8:00 a.m., and from 9:00 a.m. to 9:00 p.m.On 7/29/25, from 6:00 a.m. to 2:00 p.m., Staff #1 was scheduled.On 7/29/25, from 2:00 p.m. to 10:00 p.m., Staff #7 was scheduled.On 7/29/25, from 6:00 a.m. to 9:00 a.m., Staff #3 was scheduled to float between the residence and the SR.On 7/29/25, from 7:00 a.m. to 3:00 p.m., Staff #8 was scheduled to float between the residence and the SR.On 7/29/25, from 8:00 a.m. to 4:00 p.m., the AD was scheduled to manage both the residence and the SR.On 7/29/25, the residence scheduled only one staff member from 4:00 p.m. to 10:00 p.m., and intermittently had only one staff member on-site from 6:00 a.m. to 7:00 a.m., 9:00 a.m. to 4:00 p.m.c. Sample ResidentsResident #1 was admitted to the residence on 3/14/24 with a diagnosis of dementia.A care plan, dated 7/29/25, read in part: Resident #1 had a diminished safety awareness due to the progression of her dementia. Staff were required to monitor and prompt as needed for safety. Additionally, Resident #1 required monitoring and cues for ambulation. Staff were required to monitor the resident daily at 6:00 a.m., 10:00 a.m., 2:00 p.m., and 6:00 p.m. Furthermore, Resident #1 required supervision and physical assistance to evacuate the building. Staff were required to provide physical assistance as needed in the event of an emergency.Resident #2 was admitted to the residence on 6/18/25 with a diagnosis of Alzheimer's disease.A care plan, dated 7/29/25, read in part: Resident #2 had a diminished safety awareness due to the progression of Alzheimer's disease. Staff were required to monitor and prompt as needed for safety. Additionally, Resident #2 required staff monitoring and verbal prompts while eating. Staff were required to monitor and provide verbal cues to the resident while eating. Furthermore, Resident #2 required supervision and physical assistance to evacuate the building. Staff were required to provide physical assistance as needed in the event of an emergency.Resident #3 was admitted to the residence on 10/31/25 with diagnoses of hemiplegia, unspecified affecting left nondominant side; age-related osteoporosis without current pathological fracture; and osteomyelitis of the vertebra, lumbar region.A care plan, dated 7/29/25, read in part: Resident #3 required full assistance with bathing, dressing, and undressing. Staff were required to provide full assistance with changing daily and showering twice weekly. Additionally, Resident #3 required monitoring for ambulating. Staff were required to monitor and provide cues as needed. Furthermore, Resident #3 required supervision and physical assistance to evacuate the building. Staff were required to provide physical assistance as needed in the event of an emergency.3. InterviewsOn 7/29/25 at 8:45 a.m., Staff #1 confirmed that 12 residents resided at the residence and that she was the only staff assigned to the residence. She explained that there was only ever one staff member assigned to the residence on each shift. She explained that Staff #3 was the activities staff and that he was usually at the residence from 5:00 a.m. to 10:00 a.m. Monday through Saturday, but throughout this time, he frequently left the residence to assist the SR during that time.On 7/29/25 at 8:50 a.m., Staff #3 stated that he was the activities staff and supported the residence and the SR during his shifts Monday through Saturday from approximately 5:00 a.m. to approximately 10:00 a.m. On 7/29/25 at 8:55 a.m., Staff #1 stated that she attempted to provide the required care for every resident; however, it often took quite a while. She stated that when she was providing personal care to residents, and Staff #3 or the AD were present, they monitored the other residents. She explained that when neither of these staff members was on site, she requested staff assistance from the SR; however, they often could not assist due to their staffing constraints. She stated that she felt unsafe when she was alone with all the residents and needed to provide care to a resident. She explained that it was because she could not safely monitor the other residents or respond in a timely manner if an emergency occurred. Staff #1 stated that approximately two to three times per week, she had to request assistance from support staff or staff from the SR. She stated that she felt the residence would benefit from additional care staff during the day.On 7/29/25 at 9:15 a.m., Confidential Resident #6 stated that she felt as though one staff member became overwhelmed by residents who had higher care needs. She stated that staff had not assisted her with making her bed regularly. She explained that other residents who required more assistance got staff support in making their bed and getting dressed; however, when she requested assistance with bed-making, staff often stated that they would return to assist her, but did not consistently follow through. Confidential Resident #6 stated that she liked to wake up around 5:00 a.m. and wanted to have her bed made in the morning. She stated that she understood that other residents had higher needs, but felt left out when she did not get assistance with making her bed. She explained that it was "a thing for her" to have her bed made in the morning, but that if staff did not get to it before the afternoon, there would be no point because she took a nap in the afternoon. Confidential Resident #6 also stated that there were not enough staff to be consistent with taking out her trash; she often requested multiple times, but the staff still could not do it.On 7/29/25 at approximately 12:40 p.m., Confidential Staff #4 stated that today was the most support she had gotten from support staff and the AD since she had been employed with the residence. She stated that she believed they were helping out more because of the state surveyor being present.On 7/29/25 at 2:35 p.m., Resident #5 reported that the residence does not have sufficient staffing. She stated that there is only one staff member assigned to the assisted living residence on each shift, and she believed that there should be two for safety. She explained that staff could not keep up with cooking, cleaning, care, and safely monitor the residents by themselves. She stated that if the staff is assisting another resident, she and other residents often assist those who are remaining with what they can. She expressed that she does not mind assisting, but does not think it should be this way. "We have had to help each other out when staff are busy."On 7/29/25 at 2:45 p.m., Resident #3 stated that she believed that there should be two staff members on each shift. She explained that one staff member could focus on medication and food while the other could assist residents with other care needs and maintain safety. On 7/29/25 at 2:50 p.m., Resident #4 stated that she believed there is "not quite enough staff". She explained that the staff seem very overwhelmed.On 7/29/25 at 3:30 p.m., the AD confirmed there were 12 residents and one staff member assigned per shift. She stated an activities staff member was assigned to float between the residence and SR Wednesday through Thursday from 6:00 a.m. to 9:00 a.m. and Friday and Saturday from 7:00 a.m. to 3:00 p.m. The AD added that she was also managing the residence and SR Monday through Friday from 8:00 a.m. to 4:00 p.m. She stated that she agreed that the activities and other support staff, including herself, were assigned to both the residence and SR, and that the second staff member was not consistently assigned to the residence. She agreed that the residence and SR were separate entities. The AD clarified that she felt the residence was sufficiently staffed and that staff were only alone with the residents from 6:00 p.m. to 6:00 a.m., Sundays and Mondays, and from 10:00 p.m. to 6:00 a.m., Tuesday through Saturday. She stated that the support staff and activities staff watched the residents when they were present, and staff could always request assistance from the staff assigned to the SR if needed. The AD stated that the residents were never unattended.”