Garden Crest Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF689Nov 16, 2023

  Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 3, Resident 31 and Resident 48), received services to prevent accidents. a.For Resident 3, who was diagnosed with left above the knee amputation (AKA- surgical removal of a person's leg above the knee) and end stage renal disease (ESRD - the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), the facility failed to ensure Resident 3 received two or more-person physical assistance when transferring Resident 3 from wheelchair to car per the comprehensive assessment and the facility failed to develop care plan interventions regarding Resident 3's need for two-person… […]

• Actual harm, isolatedF689Aug 23, 2023

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (trouble remembering, learning new things, concentrating,), identified as a high fall risk, and had a history of falls, the facility failed to: - Identify interventions related to Resident 1's specific risks and causes to try and prevent the resident from falling, per facility policy Falls and Fall Risk, Managing, -Ensure the interdisciplinary team (IDT - a group of healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.] that provide care for the residents) meets to assess the appropriate level and number of staff required to supervise Resident 1 and identify interventions and means of mitigating the… […]

• Actual harm, isolatedF600May 12, 2023

  Based on interview and record review, the facility failed to ensure one of three sampled residents was free from verbal abuse, when Licensed Vocational Nurse 1 (LVN1) yelled and spoke loudly to Resident 1. This deficient practice resulted in Resident 1 suffered emotional distress which affected her psychosocial well-being resulting in Resident 1 losing sleep, crying, feeling fearful and unsafe, and feeling like a child. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty or discomfort swallowing) following cerebral infarction (damage to the brain due to a loss of oxygen to the area), and a gastrostomy (a tube inserted through the wall of the abdomen to the stomach, which may be… […]

• No harm, potential for more than minimal, widespreadF851Nov 15, 2024

  Based on interview and record review, the facility failed to ensure to report the Payroll-Based Journal (PBJ - a method to collect staffing data from nursing facilities) for the 3rd quarter (April 1-June 30). This deficiency resulted in the inaccurate data reporting of direct care staff, providers, and vendors potentially placing the facility at risk of not implementing their policy. Findings: A review of the Certification and Survey Provider Enhanced Reports (CASPER) for the PBJ Staffing Data Report Fiscal Year Quarter 3 2024 (April 1 - June 30) indicated the metric was triggered for Failed to Submit Data for the Quarter. During an interview on 11/15/2024 at 12:28 p.m. with the Administrator (ADM) and payroll (Staff 1), Staff 1 stated she had been employed at the facility since 9/16/2024. […]

• No harm, potential for more than minimal, patternF759Dec 17, 2025

  Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate (observed or identified preparation or administration of medications or biologicals which is not in accordance with the physician's order, manufacturer's specifications for the preparation and administration of the medication or biological, and professional standards of practice) was not five percent (5%) or greater. On 12/16/2025 at 9:31 AM, Licensed Vocational Nurse 1 (LVN 1) failed to administer Simethicone (an anti-gas medication used to relieve symptoms like pressure, bloating, and fullness caused by excess gas in the stomach and intestines) and Aspirin (makes blood less sticky, preventing platelets from clumping and forming dangerous clots that cause heart attacks,… […]