Gardens Health and Rehab, the

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, sanitary, and comfortable environment by failing to maintain shower rooms in a safe and sanitary condition and failing to prevent persistent objectionable odors in the facility. These deficient practices had the ability to affect all residents. The facility census was 88. The facility did not provide a policy regarding environmental sanitation and maintenance. 1. Observation on 07/09/26 at 8:40 A.M. of shower room A-6 showed: - A facial tissue and plastic bag in the sink; - An opened one-gallon bottle of bodywash/shampoo sat on the shower room floor with no lid; - An approximate one inch by one inch gauze pad containing a brownish-red substance on the shower room floor; - An adhesive bandage containing a reddish substance on the shower room floor; - No handrail adjacent to the shower head. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the required members attended Quality Assurance & Performance Improvement (QAPI) meetings at least quarterly. The facility's census was 87. The facility did not provide a policy. 1. Review of the monthly QAPI Meeting sign in sheets, dated August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, and February 2025, provided by the Administrator, showed the following required members attended each meeting: - Administrator; - Director of Nursing; - Infection Preventionist; - At least two other staff members; - No record of the Medical Director attending any meetings. During an interview on 03/12/25 at 4:36 P.M., the Director of Nursing (DON) said the Medical Director is invited, but he does not come to the meetings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility's census was 87. Review of the facility's policy titled, Shower Room, undated, showed: - Maintaining a clean and sanitary shower room in skilled nursing facilities is crucial for infection control and resident safety; - Shower rooms should be cleaned and disinfected daily, with increased frequency based on usage and facility needs; - High-touch surfaces and any visibly soiled areas should be cleaned and disinfected immediately after each use; - Remove any waste or disposable items from the area; - Apply detergent to all surfaces, including walls, floors, fixtures, and equipment; - Scrub surfaces to remove dirt and biofilm. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman of all transfers to the hospital and failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for four residents (Resident #29, #57, #76, #83) out of 18 sampled residents and one resident (Resident #87) outside the sample. The facility's census was 87. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer; - Hospital transfer on 01/30/25 not included on the monthly list sent to the ombudsman. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for five residents (Resident #29, #36, #57, #76, #83) out of 18 sampled residents and one resident (Resident #87) outside the sample. The facility's census was 87. Review of the facility's policy, Bed Holds and Returns, revised March 2017, showed: - Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed hold and return policy; - Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: the rights and limitations of the resident regarding bed holds; the reserve bed payment policy as indicated by the state plan (Medicaid residents); [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility) within the required time frames for seven residents (Resident #29, #31, #36, #49, #52, #68, and #83) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on completion of MDS assessments. Record review of the Resident Assessment Instrument (RAI) Manual showed: - For the admission assessment, the MDS Completion Date (Z0500B) must be no later than 13 days after the Entry Date (A1600); - The ARD (Assessment Reference Date) of an assessment drives the due date of the next assessment. The next comprehensive assessment is due within 366 days after the ARD of the most recent comprehensive assessment; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility) assessment for two residents (Resident #52 and #56) out of 18 sampled residents and one resident (Resident #33) outside the sample. The facility's census was 87. The facility did not provide a policy that addressed the timely completion of significant change MDS assessments. Review of the Resident Assessment Instrument (RAI) Manual, revised October 2024, showed: - A significant change in status (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for one resident (Resident #52) out of 18 sampled residents and one resident (Resident #86) outside the sample. The facility's census was 87. Review of the facility's policy, Certifying Accuracy of the Resident Assessment, revised December 2009, showed all personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section O0110K1, Hospice care: [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an accurate baseline care plan (the minimum healthcare information necessary to properly care for a resident) upon admission with specific interventions for two residents (Residents #138 and #289) out of 18 sampled residents. The facility's census was 87. Review of the facility's policy, Care Plans-Baseline, undated, showed: - A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; - The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medication, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs, including but not limited to: initial goals based on admission orders; physician orders; dietary orders; therapy services; social services; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions to meet the highest practicable physical, mental, and psychosocial well-being for four residents (Residents #29, #47, #49, and #79) out of 18 sampled residents and one resident (Resident #86) outside the sample. The facility's census was 87. The facility did not provide a policy. 1. Review of Resident #29's medical record showed: - admission date of 11/15/24; - Diagnoses of muscle weakness, morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), pain, and osteoarthritis of both hips (a chronic, degenerative joint disease that causes pain, stiffness, and loss of function in the affected joints); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #29) out of one sampled resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility's census was 87. Review of the facility's policy, Pain Assessment and Management, revised March 2015, showed: - The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; - The pain management program is based on a facility-wide commitment to resident comfort; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately assess residents for the use of side rails prior to installation or use, the facility failed to obtain informed consent from the resident or resident's representative, and the facility failed to provide on-going monitoring, supervision, and routine maintenance of the beds with side rails in use for two residents (Resident #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on side rails. 1. Review of Resident #29's medical record showed: - admission date of 11/15/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that three nursing assistants (NAs) completed a nursing assistant training program within four months of his/her employment at the facility. This deficient practice had the potential to affect all residents. The facility's census was 87. Review of the facility's policy, Nurse Aide Training Program, Purpose of, last revised December 2006, showed: - The primary purpose of the nurse aide training program is to prepare the individual for employment in a long-term care facility; - Provide each individual presently employed in the long-term care facility with an in-depth training program; - Provide each student with instructions on how to perform basic long-term care nursing procedures; - The policy did not address time frame in which NAs must become certified. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement procedures to ensure medications were accurately administered, documented, and reconciled for one resident (Resident #29) of 18 sampled residents and failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation of controlled medications to ensure nursing staff signed at the beginning and end of each shift. The facility failed to document the total number of narcotic drug cards counted for two of three narcotic count books checked. The facility's census was 87. Review of the facility's policy titled, Controlled Substances, revised December 2012, showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. This had the potential to affect all residents. The facility's census was 87. Review of the facility's policy titled, Cleaning Rotation, dated 2011, showed: - Equipment and utensils will be cleaned according to the following guidelines or manufacturer's instructions; - Items cleaned daily: stove top, grill, exterior and large appliances, kitchen and dining room floors; - Items cleaned weekly: hoods, filters, storerooms. Review of the facility's policy titled, Steam Table Serving Temperatures for Hot and Cold Foods, dated 2011, showed: - Staff will follow the guidelines below when serving hot and cold beverages and food; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection for ten residents (Resident #6, #14, #19, #37, #38, #57, #70, #72, #78, and #79) out of the 14 sampled residents. The facility's census was 87. Review of the facility's policy titled, Hand Hygiene Policy and Procedure, dated 2025, showed: - The purpose is to establish clear and standardized hand hygiene practices for all staff to prevent the spread of infections, maintain a safe environment, and comply with CMS (Centers for Medicare and Medicaid Services, CDC (Centers for Disease Control), and state infection control guidelines. [...]

Inspectors wroteBased on interview and record review, the facility failed to document pertinent education provided to the resident or the resident's representative regarding benefits, side effects, or warnings of the influenza (a viral respiratory infection) and/or the pneumococcal (an infectious lung disease) vaccine for two residents (Residents #36 and #47) out of five sampled residents. The facility's census was 87. The facility did not provide a policy regarding influenza or pneumococcal vaccination. 1. Review of Resident #36's medical record showed: - admission date of 04/24/20; - No documentation the facility provided information and education for influenza or pneumococcal vaccinations; - No documentation of consent or refusal; - No documentation the influenza or the pneumococcal vaccinations had been administered. 2. Review of Resident #47's medical record showed: - admission date of 06/17/24; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Covid-19 (an infectious disease caused by a virus that could cause some people to become seriously ill and require medical attention) vaccination was offered, administered, or refused by the resident and/or resident's representative for three residents (Resident #36, #47 and #56) out of five sampled residents. The facility's census was 87. Review of the facility's Immunization Policy, undated, showed: - The Centers for Medicare and Medicaid Services (CMS) mandates that all long term care facilities develop and implement policies to ensure that all staff are fully vaccinated against Covid-19. This includes educating residents and staff about benefits and potential side effects of the Covid-19 vaccine and offering the vaccine to them; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for two residents (Residents #29 and #47) out of 18 sampled residents. The facility's census was 87. The facility did not provide a policy on inspection of side rails. 1. Review of Resident #29's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: - On 03/09/25 at 12:54 P.M., half rails up on both sides and resident leaning to the right against bed rail; - On 03/11/25 at 2:00 P.M., half rails up on both sides and resident leaning to the right against bed rail. 2. Review of Resident #47's medical record showed no maintenance inspection for the side rails. Observations of the resident showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the required annual competency training for dementia care (care of a resident with an impaired ability to remember, think, or make decisions) and/or have staff attend at least twelve hours of in-service education per year for two of three sampled Certified Nursing Assistants (CNAs). This deficient practice had the potential to affect all residents. The facility's census was 87. The facility did not provide a policy. 1. Review of CNA E's in-service record showed: - A hire date of 07/12/89; - A total of twelve hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. 2. Review of CNA F's in-service record showed: - A hire date of 03/28/23; - A total of four hours of annual in-services for March 2024 through February 2025; - No documented annual dementia care training. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care in a sterile manner for one resident (Resident #4) of 11 sampled residents and did not assess or notify the physician when the peripherally inserted central catheter (PICC), (a long, flexible tube that is inserted into a vein in the arm and threaded into a large vein near the heart, used to deliver fluids, blood transfusions, medications, and nutrition intravenously, and to draw blood samples) line was cut during a dressing treatment and subsequently removed without a physician's order, placing the resident at risk for possible complication of a catheter-related bloodstream infection (CRBSI), which can occur when bacteria enter the bloodstream through the catheter site due to improper sterile technique, potentially leading to serious systemic infection. The facility census was 88. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1) out of five sampled residents was free of misappropriation of his/her property when Housekeeper A utilized the resident's bank card for his/her own personal use. The facility census was 62. The administrator was notified of the Past Non-Compliance (PNC) on 08/23/24. The PNC started on 07/28/24 and was removed on 07/30/24, when the incident was reported to the Administrator who immediately began an investigation and removed the housekeeper from the facility then completed the facility policy and procedure on misapprorpiation, reporting and retraining staff The PNC was removed on 07/30/24. Review of the facility's policy titled, Standards of Conduct, dated May 2023, showed violation of the Conduct Standards include, but are not limited to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 65. Review of the facility's policy titled, Quality of Life - Homelike Environment, undated, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary and orderly environment. Observations of room [ROOM NUMBER] showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) (a federally mandated assessment to be completed by the facility staff) for three residents (Resident #23, #45 and #48) out of 16 sampled residents. The facility census was 65. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, undated, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan with specific interventions tailored to meet individual needs of three residents (Resident #15, #45, and #48) out of 16 sampled residents and one resident (Resident #35) outside the sample. The facility census was 65. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, undated, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain physician's orders for one resident (Resident #2) out 16 sampled residents. The facility census was 65. Review of the facility's policy titled, Physician's Orders, undated, showed: - Our facility shall promptly obtain physician orders for accident, discovery of injuries of an unknown source, an incident involving the resident and specific instruction to notify the physician of changes in the resident's condition; - Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider; - The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices during incontinent care for one resident (Resident #38) out of six sampled residents, and for the disinfection of a glucometer (a device for measuring the concentration of glucose in the blood) used for glucose (the main type of sugar in the blood) monitoring for three residents (Resident #24, #30, and #47) out of three sampled residents. The facility census was 65. Review of the facility's policy, titled, Handwashing/Hand Hygiene, dated 10/11/22 showed: - The facility considers hand hygiene the primary means to prevent the spread of infection; - All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections; [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one resident's (Resident #1) right to be free from verbal abuse when Registered Nurse (RN) C yelled, cursed, and threatened to withhold cigarettes from the resident in order to force the resident's compliance with incontinence care. The facility census was 64. The Administration was notified on 09/12/23 of the Past Non-Compliance citation on 09/06/23. On 09/06/23, facility staff took appropriate corrective actions as confirmed by survey staff during the onsite visit. The facility started an investigation, and assessed Resident #1. The facility started an in-service that covered abuse and neglect. The deficiency was corrected on 09/06/23. Review of the facility's policy titled, Resident Freedom from Misappropriation of Property and Exploitation and Procedure, not dated, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update and revise care plans with specific interventions tailored to meet individualized needs for three residents (Residents #33, #51, and #40) out of 16 sampled residents. The facility census was 64. 1. Record review of Resident #33's Face sheet, showed: - admission date 4/14/2015; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) a group of lung diseases that block air flow making it difficult to breathe, tracheostomy (trach, tube surgically inserted into the trachea for breathing) . Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed: - Section O, special treatment for tracheostomy care while a resident marked. Review of Resident #33's Physician's Order Sheet (POS), dated November 2021, showed: [...]

Inspectors wroteBased on interview, and record review the facility failed to follow physician orders for two residents (Resident #22 and #214) out 16 sampled residents. The facility census was 64. 1. Record review of Resident #22's medical record, showed: -An admission face sheet, admission date of 2/22/17; -Diagnoses included morbid obesity due to excess calories and major depression (a serious medical illness that negatively affects how you feel, the way you think and how you act). Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/13/21, showed: -Alert and oriented; -No behaviors for rejection of care; -Required extensive to total assistance from one to two staff for activities of daily living (ADLs); -Non-ambulatory; -No impaired range of motion affecting upper/lower extremities. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain adequate grooming, bathing and nail care had been completed for three residents (Resident #21, #22, and #38) out of 16 sampled residents. The facility census was 64. 1. Record review of the facility's Shower/Tub Bath Policy/Procedure, dated October 2020, showed: -Purpose: The purposes of this procedure are to promote cleanliness, provide comfort to the residents and to observe the condition of the resident's skin; -Documentation: The following information should be recorded in the resident's ADL record and/or in the resident's medical record; 1. The date and time the shower/tub bath was performed. 2. The name and title of the individuals who assisted the resident with the shower/tub bath; 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize, evaluate and address the nutritional needs of one resident (Resident #3) out of 16 sampled residents. The facility's census was 64. Record review of the facility's policy titled Weight Assessment and Intervention, dated September 2008, showed: - The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter; - Each weight will be recorded in each unit's Weight Record chart; - Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing; - The Dietician will respond within 24 hours of receipt of notification; [...]

Inspectors wroteBased on interview, and record review the facility failed to provide tracheostomy (trach, tube surgically inserted into the trachea for breathing) care consistent with professional standards of practice by failing to change the inner cannula (IC) every other day as ordered by the physician for one resident (Resident #33) out of one sampled resident. The facility census was 64. 1. Record review of Resident #33's Face sheet, showed: - admission date 4/14/2015; - Diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (a group of lung diseases that block air flow making it difficult to breathe) and Tracheostomy. Record review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/10/21 showed: - Section O, special treatment for tracheostomy care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide thorough assessments, orders, monitoring and on-going communication with dialysis (process for removal of waste and excess water from the blood due to kidney failure) center for one resident (Resident #40) out of a sample of two residents receiving dialysis treatments. The facility census was 64. Review of the facility's Dialysis-General Guidelines and Management Policy/Procedure, dated May 2017, showed: -Policy: -It is the policy of this home that dialysis residents will receive services as per physician's orders and will be monitored accordingly; -Hemo-Dialysis involves shunting the resident's blood from the body through a dialyzer (machine used in dialysis treatments) in which diffusion and ultrafiltration occur and back into the resident's circulation. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff dated insulin vials and Flexpens (prefilled injectable insulin) once they were opened and discard outdated insulin vials for two of two medication carts checked and failed to store all drugs under proper temperature controls in the medication refrigerator on the B hall. The facility census was 64. 1. Review of the facility's Insulin Administration Policy, dated September 2014, showed: -Purpose: To provide guidelines for the safe administration of insulin to residents with diabetes mellitus (DM, condition that affects the way the body processes blood sugar); -Preparation: The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to use; -Steps in the procedure (insulin injections); [...]