Jackson Gardens Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Jackson Gardens Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF689May 7, 2026

  Based on observations, interviews and records reviewed, the facility failed to maintain an environment free of accident hazards in two (fourth floor and second floor) out of three air conditioning unit rooms which could be locked from the inside and were found unlocked, presenting a risk that residents might enter and become trapped. There were 111 residents residing in the facility at the time of survey. The findings included: On 05/04/2026 during an observational tour conducted at 11:10 AM on the fourth floor and at 11:32 AM on the second floor the Air Conditioning (AC) unit room doors were found unlocked, further inspection of the doors revealed the doors were lockable from the inside. (Photographic evidence). No staff members were observed near to these rooms. […]

• No harm, potential for more than minimal, patternF761May 7, 2026

  Based on observations, records reviewed and interviews, the facility did not store medications and biologics correctly on two out of three medication carts (fourth floor carts 1 and 2) and in one out of two medication rooms (second floor medication room) selected for checking medication labeling and storage. Expired, unlabeled, and mislabeled eye drops and insulins were found in fourth floor medication carts 1 and 2. The refrigerator in the second-floor medication room was above the recommended temperature for storing medications. At the time of the survey, the facility had six medication carts and three medication rooms. […]

• No harm, potential for more than minimal, patternF880Sep 26, 2024

  Based on observations, interviews and record review the facility failed to ensure infection control standards were followed for two Residents (Resident #101 and Resident #92) out of two of the nine sampled residents as evidenced by observations a tube feeding syringe not labeled, a staff member not wearing a gown while providing hygiene care for a resident receiving tube feeding and an observation of no sign posted for Enhanced Barrier Precaution (EBP) for a Resident with an IV (intravenous)site. There were 122 residents residing in facility at the time of survey. The findings included: Observation on 09/23/24 at 10:15 AM, Resident #92 was asleep in bed; next to the bed was a tube feeding pole with an unlabeled plastic bag containing an enteral feeding syringe hanging on it. […]

• No harm, potential for more than minimal, patternF725May 19, 2022

  Based on observation, record review and interviews, the facility failed to ensure 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 and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice has the potential to affect 106 residents residing in the facility at the time of this survey. The findings included: Observation of the 4th floor posted nursing staff on 5/15/22 at 6:26 AM, 11 PM-7 AM shift revealed the following: The staffing board was dated 5/13/22. 4th floor: Census-36; 2 Nurses and 4 Certified Nursing Assistants (CNA). […]

• No harm, potential for more than minimal, isolatedF561May 7, 2026

  Based on observations, record review and interviews, the facility failed to accommodate a resident's choice for food preferences for one resident (Resident number 22) out of one resident reviewed for choices and preferences. There were a total of 111 residents residing in the facility at the time of this survey. The findings included:Record review of the Resident Rights Policy and Procedure (Revised January 2022, Reviewed January 2026) documented: Policy Statement-Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation-1) Federal and state laws guarantee certain basic rights to all residents of this facility. […]