Gardner Rehabilitation and Nursing Center

In the surveyor’s words

From the most serious findings on record at Gardner Rehabilitation and Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 15, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a wheelchair for mobility, the Facility failed to ensure his/her safety was maintained to prevent incidents resulting in an injury. On 1/04/21, Certified Nurse Aide (CNA) #1 was propelling Resident #1 in his/her wheelchair, Resident #1 fell forward out of the wheelchair onto the floor. Resident #1 was transferred to the Hospital Emergency Department for evaluation, he/she required 11 staples to close a 10 centimeter laceration to his/her forehead, and was diagnosed with an acute fracture of his/her second Cervical (C2) spine (neck fracture). […]

• No harm, potential for more than minimal, patternF658Feb 2, 2026

  Based on observations, interviews, and record reviews the facility failed to ensure that professional standards of practice in delivery of care and services were being met for seven Resident's (#3, #5, #32, #15, #113, #108, and #2) out of a total sample size of 24 residents. Specifically, 1.For Resident #3, the facility failed to ensure that a Physician's order for CBC (Complete Blood Count) and BMP (Basic Metabolic Panel) laboratory testing was obtained as ordered, placing Resident #3 at risk for worsening medical conditions. 2. […]

• No harm, potential for more than minimal, patternF761Feb 2, 2026

  Based on observation and interviews, the facility failed to store all medications in a safe and secure manner in one central supply room (South Two Unit), out of two central supply rooms in the facility, and one Nursing Unit (East One). Specifically, the facility failed to ensure that the central supply room on the South Two Unit was locked on 1/28/26, allowing residents, visitors, and unauthorized staff ready access to over-the-counter medications. 2.the facility failed to ensure that two plastic bags containing muscle relaxant, diuretic, and psychotropic medications were appropriately stored on the East One Unit, placing unauthorized staff, visitors and facility residents at risk for accessing the medications. […]

• No harm, potential for more than minimal, patternF689Oct 18, 2024

  Based on observation, interview, record and policy review, the facility failed to maintain an environment that is free of accidents and hazards for two Resident (#103 and #45) out of a total sample of 23 Residents. Specifically, the facility staff failed to: 1. For Resident #103, ensure potentially hazardous smoking materials were stored in a secure area, putting the facility Residents at risk for injury due to inappropriate usage when the Resident was smoking in his/her room. 2. For Resident #45, ensure that an elopement assessment was completed timely and safety interventions were implemented when the Resident demonstrated exit seeking behaviors, resulting in the Resident eloping from the secure (locked) unit via a door that was malfunctioning. Findings include: 1. […]

• No harm, potential for more than minimal, patternF812Oct 18, 2024

  Based on observation, interview, and policy review, the facility failed to adhere to safe food practices to prevent contamination of food and beverage items intended for resident consumption in the facility's main kitchen. Specifically, the facility failed to implement safe food practices in the main kitchen relative to: -labeling/dating, storage guidelines. -use of hair restraints in order to reduce the risk of cross contamination/spoilage of food items. -maintaining the facility kitchen in a clean, sanitary, and free of dust and debris manner. Findings include: Review of the facility policy titled Dietary Rules, dated July 2020, included the following: -Personal items: should be stored in the office. […]