Garden Care Center

In the surveyor’s words

From the most serious findings on record at Garden Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 13, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF725Mar 4, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF686Aug 30, 2024

  Based 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. […]

• No harm, potential for more than minimal, isolatedF761Mar 4, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF880Mar 4, 2026

  Based 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. […]