Garden Spring Rehab and Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Nov 5, 2025

  Based on facility policy review, review of manufacturer's instructions, clinical record review, observation, and staff interview, it was determined that the facility failed to implement proper infection control procedures regarding the use and disinfection of a multi-use blood glucose meter (BGM) for four of 21 residents that utilized one of two medication carts on the nursing unit. This resulted in an Immediate Jeopardy situation due to an increased likelihood of transmitting bloodborne pathogens between residents who required fingerstick blood glucose testing. […]

• Actual harm, isolatedF689Oct 19, 2022

  Based on facility policy and documentation review, clinical record review, observation, and staff interview, it was determined that the facility failed to provide an environment and adequate supervision to prevent accidents related to elopement (unauthorized departure from the facility), resulting in actual harm that required transfer to the hospital for treatment of a head wound and failed to conduct a thorough incident investigation for one of five sampled residents. (Resident 1) Findings include: Review of the facility policy entitiled, Accidents and Incidents - Investigating and Reporting, revealed that all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. […]

• No harm, potential for more than minimal, widespreadF812Dec 2, 2022

  Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department. Findings include: Review of the facility's policy entitled, Food Storage, dated [DATE], revealed that all food must be labelled with the name of the item and that if opened, the date it was opened and use by date should be on the food item. Observation during the tour of the dietary department on [DATE], at 10:22 a.m., revealed the following: There was an opened bag of beef patties in the freezer with no date on it and two aluminum pans of a food item that the Food Service Director (FSD) identified as churros that were not dated and labelled. […]

• No harm, potential for more than minimal, widespreadF880Dec 2, 2022

  Based on a review of facility policy, observation, review of facility documentation, and staff interview, it was determined that the facility staff failed to wash hands during the medication pass in accordance with facility infection control policy on two of four nursing units(Units 2 and 3) and failed to perform infection surveillance in accordance with facility policy. Findings include: Review of the facility policy entitled, Administering Oral Medication, last reviewed September 29, 2022, revealed that staff was to wash or sanitize hands before and after giving medications to residents. On November 30, 2022, between 9:30 and 10:30 a.m., LPN 1 was observed giving medication to Residents 62 and 105 without washing or sanitizing her hands between residents. […]

• No harm, potential for more than minimal, widespreadF812Jun 8, 2022

  Based on facility policy review, observation, and staff interview, it was determined that the facility failed to store food under safe conditions. Findings include: Review of the facility policy entitled, Food Storage, dated October 15, 2021, revealed that the Food Service Director and/or Cook would ensure that all food items were stored properly. Cold foods must be in covered containers (airtight or wrapped tightly and sealed) and labeled and dated with the food name and two date system (prepared date and use by date). Dry foods must be labeled (if not in the original package) and dated with received date, then opened , and use by dates. Observation during a tour of the kitchen begun on June 8, 2022, at 10:25 a.m. […]