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Gardens on University: Falls, Trauma Care Failures - WA
Critical documentation gaps emerged during the investigation....
Latest reports, citations, and penalties from CMS data
Critical documentation gaps emerged during the investigation....
Both medications are formulated as extended-release to provide steady therapeutic levels throughout the day....
This verbal-only policy structure represents a significant oversight in resident protection protocols....
According to the inspection report, the resident received three doses of the long-acting medication between December 21 and December 29, 2024....
The resident, identified as Resident 36, experienced a measurable decline in activities of daily living capabilities between October 2024 and January 2025....
Additionally, four nursing assistants lacked training in PTSD, SUD, GDR, trauma informed care, and fall management....
The original plan included only basic interventions: a physical therapy evaluation and following the facility's fall protocol....
This staffing gap represents a fundamental breakdown in infection control infrastructure....
The violations were classified as "immediate jeopardy" - the most serious level indicating potential for serious injury or death....
During interviews, nursing staff described the impact of these shortages....
The incident exposed multiple breakdowns in the nursing home's drug security protocols and raised questions about patient safety oversight....
During the three-day inspection period from January 15-17, 2025, surveyors observed the resident with cigars within arm's reach on multiple occasions....
The allegations prompted immediate action from facility administrators, who suspended the accused employee pending a full investigation....
Despite being on this high-risk medication class for over a year, facility staff failed to implement proper monitoring procedures....
The excessive temperatures were found in every area tested during the inspection period from 10:57 AM to 12:47 PM on July 23, 2024....
Inspectors documented multiple instances where meals failed to meet established safety standards for serving temperatures....
The CNA eventually returned to the facility around 9:00 AM and reported the incident to the charge nurse, who then notified the Director of Nursing....
The first documented incident occurred February 16, 2025, when the resident opened a dining room window and climbed out into the courtyard....
Advance directives serve as a resident's voice when they cannot speak for themselves during medical emergencies....
The resident required emergency department treatment for these injuries....