Garden Care Center

Inspectors wroteBased on record review, and interviews, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on three (3) (Unit 1, Unit 2 and Unit 3) of three (3) resident units reviewed for the Sufficient Nursing Staffing Task. Specifically, the facility triggered for the low weekend staffing metric on the Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Quarter two, Quarter three, and Quarter four of Fiscal Year 2025. A random sampling of facility nursing staffing assignments did not reflect the staffing numbers as stipulated in the Facility Assessment for Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. [...]

Inspectors wroteBased on observation and interviews, the facility did not ensure that all drugs and biologicals were stored in locked compartments. This was identified for one (1) of three (3) medication storage rooms observed during the Medication Storage task. Specifically, two medication cabinets, inside the central supply room, containing over the counter medication supply were left unlocked. The central supply room door lock was malfunctioning causing the door to remain unlocked. The finding is:The facility policy and procedure for Labeling and Storage of Drugs and Biologicals, last reviewed/revised on July 2025 documented that over-the-counter medications maintained in Central Supply shall be secured to prevent unauthorized access. The room shall remain locked when unattended. Access is limited to authorized personnel, including nursing administration and designated staff. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure that it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This was identified for one (1) (Resident #124) of five (5) residents observed during medication administration. Specifically, during the medication pass observation on 02/26/2026, Licensed Practical Nurse #1 did not perform hand hygiene and administered the eye drops while wearing the same gloves they had used to administer the oral medications and respiratory treatment to the resident. The finding is:The facility policy titled Eye Drop Administration, dated 8/2025, documented eye medications will be administered in a safe and effective manner. The first step in the procedure is to put on examination gloves. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024 the facility did not ensure that each resident with Pressure Ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for three (Resident #38, Resident #5, and Resident #82) of eight residents reviewed for Pressure Ulcers. Specifically, 1) Resident #38 had multiple pressure ulcers and had a physician's order to use a low-air loss mattress for pressure relief. During multiple observations, the adjustable weight setting for the air mattress, which is meant to correspond to the resident's weight, was not set accurately. 2) Resident #5 had a history of Moisture Associated Skin Damage to the left buttock. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that a Pre-admission Screening and Resident Review (PASARR) was completed for each resident prior to their admission to the facility to determine that the individual requires the level of services provided by the nursing facility and whether the individual requires specialized services. This was identified for one (Resident #29) of 26 residents reviewed for Pre-admission Screening and Resident Review (PASARR). Specifically, Resident #29 was admitted to the facility in October 2023. There was no documented evidence that a Level 1 Pre-admission Screening and Resident Review (PASARR) was completed prior to Resident #29's admission. The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice. This was identified for one (Resident #1) of five residents reviewed for Unnecessary Medications. Specifically, Resident #1 with a diagnosis of Diabetes Mellitus had a physician's order to monitor the resident's blood glucose level as per the facility's protocol. The facility policy indicated reporting the findings to the Physician if the blood glucose levels were less than 100 milligrams/Deciliter or greater than 300 milligrams /Deciliter. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that each resident's environment remained as free of accident hazards as possible. This was identified for one (Third Floor) of three units observed during the initial tour. Specifically, a full oxygen E-Cylinder tank (portable oxygen tank) was observed in the third-floor day room that was not secured in a rolling safety stand or a metal rack. The finding is: The facility's policy and procedure titled Oxygen Therapy last revised on 5/2024 documented that safety devices in valves or cylinders shall never be tampered with. Cylinders shall not be chained to portable or movable apparatus such as beds and tables. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice. This was identified for two (Resident #5 and Resident #82) of two residents reviewed for Respiratory Care. Specifically, 1) Resident #5 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen therapy on 8/26/2024, 8/27/2024, and 8/28/2024. 2) Resident #82 had a physician's order to continuously receive oxygen therapy at 2 liters per minute. The resident was observed receiving an inaccurate amount of oxygen therapy on 8/26/2024, 8/27/2024, and 8/28/2024.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 8/26/2024 and completed on 8/30/2024 the facility did not ensure that it maintained an infection prevention and control program designed to help prevent the development and transmission of infectious diseases. This was identified for one (Resident #67) of three residents reviewed for tube feeding. Specifically, Resident #67 had a physician's order for Enhanced Barrier Precautions for the use of a gastrostomy tube (feeding tube inserted through the stomach for artificial feeding). During an observation, Registered Nurse Supervisor #2 was observed entering Resident #67's room without the use of Personal Protective Equipment (gown and gloves) and disconnected the tube feeding from the gastrostomy tube. The finding is: [...]

Inspectors wroteBased on record review and interview conducted during an abbreviated survey (NY00320341), the facility failed to protect one of three residents reviewed for Accidents (Resident #1). Specifically, Certified Nurse Assistant #1 (CNA #1) failed to follow the plan of care which required two people to assist for toileting and bed mobility. CNA #1 proceeded to provide incontinet care (in the bed) alone causing Resident #1's head to strike the bedside table resulting in a laceration. The laceration required Resident #1 to be transfer to the hospital and six sutures. This was evidenced by: Resident #1 Minimum Data Set (MDS) dated [DATE] documented resident is rarely/never understood. MDS documented resident requires extensive assistance of two person for bed mobility, transfer, and toilet use. [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00297184) initiated on 1/5/2023 and completed on 1/13/2023, the facility staff did not effectively implement interventions to prevent an avoidable accident. This was identified for 1 (Resident #47) of five residents reviewed for Accidents. Specifically, Resident #47 required two-person assistance for bed mobility as per the resident's assessments and care plans. On 6/8/2022, the assigned Certified Nursing Assistant (CNA) #2 provided incontinent care to Resident #47 independently and did not seek assistance from another staff member. Resident #47 rolled out of the bed and fell to the floor and sustained a Hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space) to the frontal lobe, and Ecchymotic (bruise) areas to the left eye, nose, and face. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00292723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that all alleged violations were thoroughly investigated for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. An x-ray of the right lower extremity was not ordered until 3/15/2022, upon which a fracture of the right tibia was identified. The accident and incident (A/I) investigation dated 3/18/2022 concluded that no abuse, neglect, or mistreatment had occurred; however, interviews with staff only went back to 3/14/2022, and not to when the pain and swelling initially started on 3/8/2022. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification Survey initiated on 1/05/2023 and completed on 1/13/2023, the facility must develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objective and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (Resident #54) of one resident reviewed for Communication and Sensory: Hearing/Vision. Specifically, Resident #54 utilized bilateral hearing aids. There was no CCP developed for the use of the hearing aids. The finding is: The facility Policy and Procedure for Comprehensive Care Plan dated 6/2017 documented that each resident must have an individualized interdisciplinary plan of care in place. Within 48 hours, there must be a baseline care plan in place. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00292723) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #21) of one resident reviewed for Change of Condition. Specifically, Resident #21 was identified with swelling and pain of the right lower extremity beginning on 3/8/2022. The resident continued to participate in Physical Therapy (PT), standing on both lower extremities, and was performing transfers from once surface to another (bed/chair) on the nursing unit daily. The resident was complaining of pain to the right lower extremity during the PT and during transfers. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00290705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that each resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in December 2021, which was not addressed by the Registered Dietitian (RD) until January 2022. The finding is: The facility's policy titled, Monthly Weight and Vital Sign Policy and Procedure last reviewed on 1/2021 documented that the Nurse would notify the Physician and Dietitian of any 5 pounds (lbs)/5% weight changes. The policy also documented that once weights are completed, they will be given to the Dietitian. [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY00290705) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not ensure that the medical care of each resident was supervised by the Physician including monitoring changes in the resident's medical status. This was identified for one (Resident #163) of two residents reviewed for Nutrition. Specifically, Resident #163 had a 14% significant weight loss in one month, identified in December 2021, which was not addressed by their Primary Care Physician (PCP). Resident #163 had an additional 5% significant weight loss in one month, identified in January 2022, and there was no documentation from the PCP addressing the resident's significant weight loss in a timely manner. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey initiated on 1/5/2023 and completed on 1/13/2023 the facility did not ensure for influenza vaccine that each resident's medical record indicated either the resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. This was identified for one (Resident #104) of five residents reviewed for influenza vaccine; and for Pneumococcal vaccine the facility did not ensure that each resident's medical record indicated either the resident received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for two (Resident #104 and #99) of five residents reviewed for pneumococcal vaccine.

Inspectors wroteBased on interview and record review during the Recertification Survey and Abbreviated Survey (NY00306893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not conduct COVID-19 testing individuals with known or suspected exposure to COVID-19. This was identified for one (Resident #263) of one resident reviewed for Infection Control. Specifically, Resident #263 was transferred to the hospital for low blood pressure, low heart rate and low oxygen saturation on 12/22/2022. At the hospital the resident was diagnosed with COVID-19 infection. The facility was notified of the resident's COVID-19 diagnosis by the hospital. The facility did not conduct contact tracing to identify staff that were in close contact with Resident #263 to identify transmission of COVID-19 infection and did not conduct COVID-19 testing. The finding is: [...]

Inspectors wroteBased on observation, interview and record review during the Recertification Survey and Abbreviated Survey (NY00306893) initiated on 1/5/2023 and completed on 1/13/2023, the facility did not provide a functional environment for one (Resident #263) of one Resident reviewed for Environment. Specifically, when Resident #263 resided on the second floor in a three bedded room. There was insufficient space in the room to accommodate a Mechanical (Hoyer) lift between Resident #44's bed and Resident #263 bed. Resident #263 was asked to get out of bed exit the room when Resident #44 needed to be transferred in and out of bed with Hoyer lift. The finding is: The facility policy entitled Safety Management Plan dated November 2017 documented that a safe and functional environment of care is essential for delivering high quality of care to all. [...]