Country Gardens Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Country Gardens Health and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jun 23, 2025

  Based on record review and interview, the facility failed to electronically submit direct care staffing data to Centers for Medicare and Medicaid Services (CMS) for the entire reporting period, Fiscal Year (FY) Quarter 2 2025 (January 1 -March 31) in accordance with the schedule specified by CMS. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Report, CASPER Report 1705D, FY Quarter 2 2025 (January 1 - March 31), indicated the facility triggered for: -Failed to Submit Data for the Quarter (No Data Submitted for Quarter) -One Star Staffing Rating (Staff Staffing Rating Equals 1) During an interview on 6/18/25 at 9:37 A.M., the Director of Operations said the company had a change in the corporate Human resource position at the time of PBJ submission for Quarter 2 and… […]

• No harm, potential for more than minimal, widespreadF880Jun 23, 2025

  3. Review of the facility's policy titled Administering Medications, last revised August 2024, indicated but was not limited to: -Staff shall follow established facility infection control procedures for the administration of medications. On 6/16/25 at 8:25 A.M., the surveyor observed Nurse #4 prepare 10 medications for Resident #8. Nurse #4 dropped one pill on to the top of the medication cart, picked up the pill, placed it into the medication cup and administered it to Resident #8. During an interview on 6/16/25 at 8:43 A.M., Nurse #4 said she had cleaned the top the of the medication cart at the beginning of her shift at 7:00 A.M. […]

• No harm, potential for more than minimal, widespreadF680Jul 1, 2024

  Based on interviews and review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include: During an interview on 6/25/24 at 11:13 A.M., the Activity Director (AD) said she used to be the First [NAME] at the facility and picked up hours every other week as an Activity Assistant for a while. She said she was hired as the AD for the facility in July 2023 when the former AD left. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2024

  Based on observation, policy review, and interview, the facility failed to follow their policy and professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to properly label and date food products and maintain safe and clean equipment in two of two nourishment kitchenettes. Findings include: Review of the facility's policy titled Food: Safe Handling for Foods from Visitors, revised ,d+[DATE], indicated but was not limited to: - Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. […]

• No harm, potential for more than minimal, widespreadF868Jul 1, 2024

  Based on interview, policy review, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Infection Preventionist failed to attend the last two quarterly QAPI meetings. Findings include: Review of the facility's policy titled Quality Assurance and Performance Improvement (QAPI), dated as revised 3/4/24, indicated but was not limited to: - The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan. […]