Gardens Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Gardens Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF623Dec 10, 2024

  Based on record review, interviews, and facility Transfer and Discharge policy review, the facility failed to provide a 30-day notice of discharge for one (Resident #1) of 2 residents reviewed for facility-initiated discharges, from a total of 4 residents sampled. As a result of the swift discharge from what had become Resident #1's home, he experienced sadness, loss and regret, and had insufficient time to plan for discharge to another location that would meet his physical, emotional and psychosocial needs. The findings include: A closed record review for Resident #1 revealed he was admitted to the facility on [DATE] and was [AGE] years old. He was discharged on [DATE]. […]

• Actual harm, isolatedF626Dec 10, 2024

  Based on record review, interviews, and facility Resident Return to Facility document review, the facility failed to permit one resident who was admitted for long-term care (Resident #1) to return to the facility following a [NAME] Act transfer to the hospital from a total of two residents reviewed for transfer/discharge. The abrupt discharge for Resident #1 caused him to experience sadness, loss and regret, and gave insufficient time to plan for discharge to another location of his choice that would meet his physical, emotional and psychosocial needs. The findings include: A closed record review for Resident #1 revealed he was admitted to the facility on [DATE] and was [AGE] years old. He was discharged on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2024

  Based on observations, interviews with staff, and a review of the 2022 Food Code, the facility failed to store and distribute ice in accordance with professional standards for food service safety in two of three ice machines inspected. This had the potential to affect all 103 residents who ate and drank by mouth from a total of 104 residents in the facility. Failure to ensure ice machines are clean and draining properly poses a risk of contamination with mold or bacteria, which could lead to waterborne illness. The findings include: During an initial tour of the kitchen on 1/22/24 at 10:25 AM, the ice machine was inspected. Standing water was pooled at the base of the opening where the ice machine lid closed and came to rest. […]

• No harm, potential for more than minimal, isolatedF806Dec 10, 2025

  Based on interviews and record reviews, the facility failed to obtain food preferences for two of three residents (#63 and #119) reviewed for food in a total of 39 sampled residents. Failure obtain food preferences placed residents at risk of inadequate nutritional interventions and non-compliance. During the initial tour of the facility on 12/07/2025 at 12:30 PM, Resident 119 stated food is always cold and at times does not taste good. He explained that he was not aware if the facility had a substitution menu.On 12/08/2025 at 12:40 PM, Resident 119 was observed in his room with the food tray on the bedside table and the rice serving was untouched. He ate green beans and fish. He stated that the fish was warm. He added that he did not touch the rice because he hated rice. […]

• No harm, potential for more than minimal, isolatedF677Jan 25, 2024

  Based on observations, resident and facility record reviews, and interviews with staff, the facility failed to provide appropriate assistance with nail care for one (Resident #60) of four residents (Resident #60) reviewed for activities of daily living (ADLs), from a total of 29 residents in the sample. The findings include: An observation of Resident #60 was made on 01/23/24 at 9:34 AM. The fingernails on both of her hands were elongated and an unknown dark brown substance was observed under the nail tips. The tips of her nails were jagged and in need of filing. (Photographic evidence obtained) On 1/24/24 at 1:43 PM, Resident #60's fingernails on both hands were observed still in the same condition and with the unknown brown substance under the tips. […]