Gardens Nursing and Rehab Center

Inspectors wroteBased on observations, interviews, and record reviews it was determined that the facility did not ensure the resident call system functioned properly, nor did it maintain a reliable communication system for residents to request staff assistance from their rooms (including bathrooms) to a centralized staff work area on one (third) of the three floors where residents resided. Four residents (Resident #46, Resident #12, Resident #16, and Resident #52) out of the fifty-three residing on the third floor reported that the call system was not working.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility did not adequately protect one of two sampled residents from sexual abuse. According to a Federal report, on 03/17/2026, vulnerable Resident #32 was sexually assaulted by Resident # 6, who has a documented history of sexually inappropriate conduct toward staff and other residents. At the time of the survey, 112 residents resided in the facility.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed maintain an environment free from accidents and hazards in potentially hazardous or unsafe areas on all three floors where residents resided. Observations included unlocked doors leading to soiled utility and biohazard rooms, laundry chutes, janitor closets, and the clean utility room containing stored oxygen tanks, which posed significant risks to residents' safety. At the time of the survey, 112 residents lived in the facility.

Inspectors wroteBased on observations, records reviewed and interviews, the facility did not protect residents' information on one of four medication carts (West side cart) and one of two vital signs machines. Staff left an unattended computer screen on the west side medication cart and a vital signs machine open and unattended on the second floor, both displaying residents' information. At the time of the survey, 112 residents lived in the facility.

Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to honor one (Resident # 92) of two sampled residents' rights to be free from restraints. On two separate occasions, it was noted that the left side of Resident # 92's bed was positioned against the wall, which restricted Resident # 92's ability to exit the bed safely. At the time of the survey 112 residents were residing in the facilityThe

Inspectors wroteBased on observations records reviewed and interviews it was determined that the facility did not accurately complete Level I Preadmission Screening and Resident Review (PASRR) forms for two out of three sampled residents diagnosed with a Serious Mental Illness (SMI). Resident # 5's diagnosis of Schizophrenia was omitted on the Level I PASRR form despite being admitted to the facility with this diagnosis. 2. The Level I PASRR for Resident # 6 did not include documentation of exhibited behaviors posing potential risks to others. At the time of the survey, there were 112 residents residing in the facility.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility did not uphold the residents' right to adequate and appropriate health care for one (Resident #32) out of two sampled residents who returned to the facility after hospitalization with medication orders to continue post-discharge. Resident # 32 was transferred to the hospital after being sexually assaulted in the facility. The hospital's medical provider ordered and instructed the continuation of prophylactic medications for Resident # 32 upon discharge; however, the facility failed to implement this order. This omission increased Resident # 32's risk of an untreated sexually transmitted infection. At the time of the survey, 112 residents resided in the facility.

Inspectors wroteBased on observations, record reviews and interviews the facility failed to store medications and biologics properly for one (Resident #84) out of seven sampled residents. Resident # 84 had an over-the-counter topical medication used to relieve oral pain a medicated lotion at bedside. There were 112 residents residing in the facility at the time of survey.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to demonstrate effective plans of action were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F689 Free of Accident Hazards and Supervision and Devices, F761 Label and Store Drugs and Biologicals, F880 Infection Prevention and Control and F919 Resident Call System. These repeated deficiencies had the potential to affect 112 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record reviews, and interviews, the facility did not adhere to proper infection prevention and control protocols. Specifically, Staff C, a Wound Care Registered Nurse (RN), failed to perform hand hygiene during wound care procedures. At the time of the survey, there were 112 residents living in the facility.

Inspectors wroteBased on observations records reviewed and interviews the facility failed to ensure a safe bathing environment for one resident (Resident #100) out of two sampled. Resident #100 sustained a cut on the bottom of his right foot in the shower from a protruding metal screw, which secured the metal grate drain cover. This deficient practice increased Resident #100's risk for serious chronic wound complications such as an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food under sanitary condition in two out of two snack/nourishment refrigerator on the resident's unit. as evidenced by residents' foods brought to the facility by visitors and family were observed unlabeled and not appropriately dated. This deficient practice has the potential to affect residents receiving food brought in from outside sources.

Inspectors wroteBased on record reviews and interviews facility failed to notify one (Resident #1) out of three sampled residents' representative of a change in condition. As evidenced by Resident #1 with a clinical diagnosis of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) left the facility Against Medical Advise (AMA) and the responsible party was not notified.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure one (Resident #1 out of three (Resident #1) safely and appropriately discharged to a safe location where ongoing clinical care could be provided, as evidence by on 05/05/2025 Resident #1 a vulnerable resident with clinical diagnoses of Disorganized Schizophrenia (a mental condition that cause an individual to have trouble organizing their thoughts, which can lead to behaviors that seem random) insisted on leaving the facility was presented with an Against Medical Advise (AMA) form which he refused to sign. The facility did not obtain a valid address for Resident #1's next place of residence and did not inform the resident's advocate/representative about the AMA discharge. At the time of this survey Resident #1's location is unknown.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor their policy for Foods brought in by family/visitors for one (Resident #13) out of three sampled residents as evidenced by the facility's staff refuse to warm Resident #13's food brought in by family.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement a discharge care plan for one (Resident # 1) out of three resident whose discharge care plans were reviewed. There were 106 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure indwelling catheters are secure for two (Residents #7, and Resident #8) out of two residents reviewed for indwelling urinary catheter. As evidenced by Resident #7's was observed in the hallway carry his catheter bag in his hand and at times placing it on the floor. Resident # 8 was observed with the catheter's drainage bag on his lap and the tubing on the wheelchair's wheels. These deficient practices increases the risk for catheter related urological trauma if the indwelling urinary catheter is unintentionally pulled resulting in dislodgement.

Inspectors wroteBased on observations records reviewed and interviews; the facility failed to ensure Drug Regimen Reviews were completed for one (Resident # 13) out of three residents reviewed as evidenced by Resident #13 who was admitted to the facility has been receiving a combination of antidepressant, blood pressure medication, muscle relaxer, and atypical antipsychotic medication that has the potential to cause serious interactions and side effects has not received the Drug Regimen Review within the required time frame.

Inspectors wroteBased on record reviews and interviews; the facility's Administrator failed to follow up on reported rodent sightings in a timely manner and address them immediately, failed to ensure the designated Infection Preventionist who is responsible for the facility's Infection, Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control. The facility's administrative staff failed to ensure that their policies for pest control services were followed, coordinate with other department heads, failed to contact the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately implement an effective pest control program to eradicate and contain the rodents identified in residents' areas had the potential to spread diseases to residents and potentially affect 111 residents residing in this 120 bed facility. [...]

Inspectors wroteBased on record review, observations, interviews, the Administrator failed to follow up on reported rodent sightings in a timely manner and address them immediately, the administrative staff failed to follow infection preventions and control techniques and CDC (Centers for Disease Control) guidelines for How to Control Wild Rodent Infestations, the facility's administration staff failed to ensure that their policies for pest control services were followed, coordinate with other department heads; failed to contact the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately implement an effective pest control program to eradicate and contain the rodents. The facility's failure to properly inspect, clean and remove food sources identified in 2 of 17 Residents' rooms (Resident #9 and Resident #36). Rats and mice are known to carry many diseases. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility's administrative staff failed to implement, maintain, and measure an effective pest control program to eradicate and contain rodent infestation. Facility administrative staff was unable to address rodent sightings in a timely manner. The facility's administrative staff failed to follow their own policy for pest control and educate staff members appropriately. These diseases can spread to people directly through the handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or rodent bites. This had the potential to affect 111 residents residing in this 120-bed capacity facilities. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to follow the doctor's orders for tube feeding administration, complete a nutritional assessment, and identify a severe weight loss for 1 of 1 resident reviewed for tube feeding (Resident #210).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for potentially 107 facility residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility designated Infection preventionist who is responsible for the facility's Infection Prevention and Control Program (IPCP) had completed specialized training in infection prevention and control.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provided 6 non-sampled resident's and 1 of 1 (Resident #62) residents reasonable access to the use of a phone and in a place in the facility where calls can be made without being overheard.

Inspectors wroteBased on interviews and record review the facility failed to ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment observation period of the Minimum Data Set (MDS), the observation period (also known as the Look-back period) is the time period over which the resident's condition or status is captured by the MDS for 3 of 3 residents sampled for resident assessment (Residents #48, #100, and #59).

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a comprehensive care plan for smoking was revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 1 residents sampled for smoking (Resident #59).

Inspectors wroteBased on record review interviews and observations, the facility failed to ensure minimum nursing staff was provide daily related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population affecting resident census of 111 out of 120 bed facility . 1) Review of the facility's State Minimum Nursing Staffing from 06/23/24 to 08/24/24 revealed on 06/30/24 the daily average for nursing (Registered Nurses and Licensed Practical Nurses) was 0.9899 (below the minimum 1.0). On 08/30/24 at 3:00 PM the administrator provided updated Minimum Nurse Staffing forms. [...]

Inspectors wroteBased on observations and interviews the facility failed to post Nurse Staffing Data daily with current date and in a prominent place readily accessible to residents and visitors.

Inspectors wroteBased onrecord reviews and the facility failed to administer medications in a timely manner for 1 of 5 residents sampled for medication administration (Resident #70) and failed to ensure medications administered as ordered for 1 of 6 residents sampled for medication reconciliation (Resident #52) and failed to ensure drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 4 of 6 residents sampled for medication reconciliation (Residents #52, #54, #16, #42).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure behaviors were adequately monitored for residents on psychotropic medications for 4 of 5 residents reviewed for unnecessary medications (Resident #76, Resident #306, Resident #307, and Resident #56).

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure medications were secured at bedside for 1 of 43 sampled residents (Resident #28), failed to secure medications in 1 of 1 clean linen closet located on 2nd floor, and failed to secure wound treatment cart for 2 of 2 wound treatment carts.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide 107 of 111 facility residents with a nourishing, palatable, well-balanced diet that meet dietary needs and taking into consideration of food preferences of the residents.

Inspectors wroteBased on record review, observation and interview, it was determined that the facility failed to prepare in advance and follow the approved menu menu for 107 of the facility's 111 residents.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to prepare foods by the use of standardized recipes to ensure nutritive value, flavor, appearance, and food that is attractive and appetizing for 107 of the facility's 111 residents.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F584 Safe/clean/comfortable/homelike environment, F755 Pharmacy Srvcs/Procedures/pharmacist/records, F867 Qapi/qaa Improvement Activities, and F925 Maintains Effective Pest Control Program. These deficiencies have the potential to affect 111 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents have functioning communication system to call for staff assistance from their room (including bathroom) to a centralized staff work area for 5 of 43 residents reviewed for call lights (Resident #6, Resident #9, Resident #19, Resident #83, and Resident #88).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that the call lights were within reach for 4 of 43 sampled residents (Resident #88, Resident #11, Resident #15 and Resident #306).

Inspectors wroteBased on interviews, and record review, the facility failed to implement a Comprehensive Care Plan for antipsychotic medications for 3 of 43 sampled residents (Resident #56, Resident #306, and Resident #94) and a Comprehensive Care Plan for an Advance Directive for 1 of 43 sampled residents (Resident #100).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide necessary services to maintain good nutrition for 1 (Resident #45) of 6 sampled residents that are unable to eat without staff assistance.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure it was free from accident/hazard as evidenced by not providing direct supervision for 1 of 23 residents who smoke (Resident #59), paper trash observed in 1 of 1 red smolder cigarette butt bin on the smoking patio and excess lint in 1 of 2 dryers in the laundry room.

Inspectors wroteBased on record review and interviews the facility failed to ensure a performance review of every Certified Nursing Assistant (CNA) was completed at least every 12 months.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents are free of any significant medication errors for high-risk medications for 1 of 4 residents reviewed for medication administration (Resident #9).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to prepare food in a form designed to meet individual needs that included; Thickened Liquids for 1 of 1 sampled resident (Resident #45) and Purred Diet for 10 facility residents that included 5 sampled residents (Resident #17, #45, #211, #193, and #301).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow the diet orders as per Physicians' orders for one of 7 residents reviewed for nutrition (Resident #84).

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide special eating equipment (Divided Plate) 5 of (Resident's #16, #30, #34, #42, and #45) sampled residents who need them when consuming meals.

Inspectors wroteBased on observation , interview, it was determined that the facility failed to dispose of garbage and refuse properly.

Inspectors wroteBased on interviews, and record review, the facility failed to offer influenza and pneumococcal vaccinations for Resident #72 and to properly document immunization records for 3 of 5 residents reviewed for immunizations (Resident #72, Resident #89, and Resident #210).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide each resident with individual closet space in the resident room and ensure closets had privacy doors for 5 out of 43 sampled residents (Resident #79, Resident#20, Resident #15, Resident #212 and Resident #90).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included observation of 2 of 2 residential room areas (second floor and third floor), 1 of 2 dining room (second floor) areas, 1 of I elevators, and 4 of 4 wheelchairs Resident's #7, #9, #17, and #54.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to initiate and resolve grievances for 4 of 43 residents reviewed for grievances (Resident #6, Resident #9, Resident #19, and Resident #206).

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents reviewed for closed record (Resident #104).

Inspectors wroteBased on observations and interviews, the facility failed to ensure handrails are securly affixed to wall on 1 of 3 floors (3rd floor hallway).

Inspectors wroteBased on record reviews, observation,and interviews, the facility failed to prevent the neglect of one (Resident #1) out of six residents sampled documented for elopement risk. The facility's failure in ensuring an adequate alert monitoring system was in place and staff's negligence in ensuring supervision and failure in implementing measure to prevent the elopement of Resident #1 who was care planned as an elopement risk. Resident #1's exited the facility undetected on 07/17/2024 through the facility's laundry room door that was not latched by staff. Resident #1 who was last seen between 7:00 PM and 7:30 PM was located at approximately 2:30 AM by local law enforcement at the county dump site one and a half miles (1.5) from the facility). The facility is a three-story building with residents rooms on the second and third floor; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for second floor resident rooms.

Inspectors wroteBased on observations, interviews, and record review. The facility failed to maintain an effective pest control program so that the facility is free of pests as evidenced by live roaches, dead roaches and small black bugs observed in eleven different locations in the facility.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure dignity during dining for one (Resident #81) out of 28 residents who need assistance with eating. As evidenced by one facility staff member standing while feeding the resident.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate and appropriate health care, related to restorative therapy services for one (Resident # 7) out of one resident who needs to have splints on both hands. This practice has the potential to increase the risk of negative resident outcomes and to affect all in-house residents residing in the facility who need to wear splint devices.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pharmaceutical procedures were followed during medication administration and medication storage observation for two (3) out of four (4) medication carts observed and 3 residents observed for medication administration with 28 opportunities. This affected Residents #22, #32 and #73. There were 81 residents residing in the facility at the time of this survey. The Findings Included: During medication administration observation on 05/17/2023 at 8:30 AM with Registered Nurse (Staff I) on unit two (2) west medication cart, the medication Calcitriol Capsule 0.25 Microgram (MCG)-one (1) capsule by mouth once daily was not available to be given to Resident #73, the medication was last signed out in the Medication Administration Record (MAR) as given on 05/16/2023 at 9AM. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a Graduate Practical Nurse met the qualifications required for the job title. There were 81 residents residing in the facility at the time of this survey. The Findings Included: On 5/17/23 at 9:06AM, prior to the medication administration observation, the surveyor introduced herself to Graduate Nurse (Staff E) at the medication cart, Staff E stated, her name and title as a graduate nurse. Staff E stated, there is a program here in the facility for graduate nurses. On 05/18/23 at 02:32 PM, the Nursing Home Administrator (NHA) was asked about Staff E's graduate nurse qualifications, it stated Staff E was hired as a Certified Nursing Assistant (CNAs), I am aware that she has a certificate stating she can sit for the nursing state boards as a Licensed Practical Nurse (LPN). [...]

Inspectors wroteBased on record Review and interview, the facility failed to demonstrate effective plans of action were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F550 Resident Rights/Exercise of Rights and F688 Increased/Prevent Decrease in Range of Motion/Mobility. This practice has the potential to increase the risk of negative resident outcomes that could affect all 81 residents residing in the facility at the time of this survey.