Park Gardens Rehabilitation & Nursing Center LLC

Inspectors wroteNumber of residents sampled: 2Number of residents cited:1 Based on observation and staff interviews, the facility did not ensure a resident was cared for in a manner that maintained or enhanced their dignity. This was evident for one (1) of two (2) residents (Resident #28) reviewed for Urinary Catheter out of a total sample of 38 residents. Specifically, Resident #28's urinary catheter tubing was noted to be exposed and visible in the hallway during multiple observations.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1 Based on observations, interviews, and record review, facility did not ensure that services provided meet professional standards of quality. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, Licensed Practical Nurse #2 and Registered Nurse 2 failed to hold and continued to administer Midodrine 8mg to Resident #22 on several occasions, despite having received in-service regarding the protocol to hold Midodrine if systolic blood pressure is greater than 115mm/hg

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1 Based on observation, record reviews and interviews, the facility did not ensure each resident receives treatment and care in accordance with professional standards of practice. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, 1). Resident #22 continued to receive Midodrine 8mg 1 tablet on several occasions when the blood pressure was higher than the required parameters as per the physician's order. The Midodrine protocol was to hold medication if the systolic blood pressure is greater than 115mm/hg and yet, Midodrine was not held on different occasions despite in-services received by medication nurses (blood pressure ranges from 120mm/hg to 142mm/hg), and 2). [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1 Based on record reviews and staff interviews, the facility did not ensure the attending physician reviewed the resident's total program of care, including medications and treatments, at each visit. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, there was no documented evidence that the attending physician evaluated Resident #22's medication regimen and addressed irregularities as identified by the pharmacist.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1 Based on observations, record review, and staff the facility did not ensure that Medication Regimen Reviews performed by the Pharmacist were reviewed and acted upon by the attending physician in a timely manner. This was evident for one (1) of five (5) residents (Resident #22) reviewed for Unnecessary Medications out of a total sample of 38 residents. Specifically, the attending physician did not act upon the pharmacist's recommendations dated 09/17/2025,10/30/2025, 11/28/2025,12/29/2025 and 01/31/2026 to address Midodrine that was not held for Resident #22 when systolic blood pressure was greater than 115mm/hg (millimeters of mercury) as per physician's order.

Inspectors wroteBased on record review and staff interviews conducted during a Recertification Survey from 7/19/23 through 7/26/23, the facility did not ensure that the residents and their representatives received a written summary of the Baseline Care Plan (BCP). This was evident for 3 of 3 residents reviewed for the Baseline Care Plan out of 38 sampled residents. (Residents #177, #235, and #382).

Inspectors wroteBased on record review and staff interviews conducted during a Recertification Survey from 7/19/23 through 7/26/23, the facility did not ensure that Comprehensive Care Plans (CCP) were developed and implemented to meet resident needs. This was evident for 1 (Resident #235 and #382) of 38 sampled residents. Specifically,1) Resident #235 did not have a CCP related to leg fracture and pain management developed, and 2) Resident #382 did not have a CCP related to bacteriuria, Urinary Tract Infection (UTI) developed.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. This was evident for 2 (Resident #84 and #6) of 38 total sampled residents. Specifically, 1) Resident #84's CCP related to dementia was not reviewed upon each assessment and 2) Resident #6's CCPs related to Advance Directives and cognitive loss/dementia were not reviewed and revised.

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure all drugs and biologicals were stored in accordance with State and Federal laws. This was evident for 2 (Unit 4 and 6) of 5 units observed for medication storage. Specifically, 1) narcotics medications were not stored in a double-locked compartment in the medication cart on the 6th Floor, and 2) the Patient Narcotic's Log (PNL) did not match the narcotics medication count for Resident #5 on the 4th Floor.

Inspectors wroteBased on observations, record review, and staff interviews conducted during a recertification survey 04/14/2021-04/21/2021, the facility did not ensure that notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public was posted. Specifically, the survey results were located in unlabeled wall-mounted racks in or near the day rooms and in the building lobby but there was no notice about the availability of results in these locations. This was observed on 4 of 5 resident units and in the facility lobby.

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification survey from 04/14/2021 to 04/21/2021, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, resident rooms were not maintained in good repair and in a homelike manner. This was observed during Environmental Observations on 1 of 5 resident units. (Unit 4)

Inspectors wroteBased on observation, record review and staff interview, conducted during the Recertification survey, the facility did not ensure that infection control practices were maintained to control and help prevent the development and transmission of communicable diseases and infections. Specifically, (1). The Licensed Practical Nurse (LPN) did not clean and sanitize a glucometer after uses and (2). An LPN did not clean and sanitize a pulse oximeter before and after each use, and prior to using it on another resident. This was observed during the Medication Administration Task. The facility policy and procedure titled Cleaning and Disinfection of Equipment dated 03/24/2020 documented resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. [...]

Inspectors wroteBased on observations and interviews conducted during a Recertification survey from 04/14/2021 to 04/21/2021, the facility did not ensure that a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and the public. Specifically, the staff bathrooms were observed to be dusty and in disrepair. This was evident on 4 of 5 units observed during Environmental Rounds. (Units 2, 3, 4, and 5) During multiple observations conducted in the facility between 4/15/21 at 1:30 PM and 4/21/21 at 1:00 PM the following was observed: Staff bathroom on 1st Floor had mismatched paint on walls, rusted inner lower door area, black scuff marks on wall near toilet, and air vent was dusty. Staff bathroom located between room [ROOM NUMBER] and 203 had a discolored peeling toilet seat, mismatched paint on walls above paper dispenser and next to soap dispenser. [...]

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the Minimum Data Set (MDS) did not accurately code a resident who was receiving dialysis services. This was evident for 1 of 1 resident reviewed for Dialysis out of a sample of 35 residents. (Resident 172)

Inspectors wroteBased on observation, record review and staff interview, the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, a resident was observed on more than one occasion over 2 days to have fingernails approximately half an inch from the tip of the fingers. The fingernails were observed with a black substance imbedded underneath them. This was evident for 1 of 2 residents reviewed for Activities of Daily Living out of a sample of 35 residents. (Resident # 87) The facility policy on Resident Grooming dated 09/08/2020 documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve ability to carry out activities of daily living. [...]

Inspectors wroteBased on observations, record review and interviews conducted during a Recertification survey, the facility did not ensure that all medications and biologicals used in the facility were stored and labeled properly and included the expiration date when applicable. Specifically, one opened and undated vial of insulin was observed. This was evident on 1 of 5 units during the Medication Storage Task. (Unit 4)

Inspectors wroteBased on observations, interviews and record review conducted during a Recertification survey, the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident was noted to have orders for supportive devices which Certified Nurse's Aides (CNA'S) consistently documented were applied however, the resident was observed on multiple occasions to not have any of the devices in place. This was evident for 1 of 2 residents reviewed for Limited Range of Motion out of a sample of 35 residents. (Resident #28.)