The Gardens Rehab & Care Center

In the surveyor’s words

From the most serious findings on record at The Gardens Rehab & Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 21, 2021

  Based on clinical record review, facility documentation, staff interviews, personnel file review, and policies and procedures, the facility failed to ensure one sampled resident (#158) was free from staff to resident abuse, which resulted in psychosocial harm as evidenced by increased yelling, screaming, agitation, and the resident being afraid of the staff member. The census was 55. The deficient practice could result in other residents being abused. Findings include: Resident #158 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF727Jan 8, 2026

  Based on documentation, staff interviews, and the facility's policy and procedures, the facility failed to ensure a registered nurse was scheduled for 8 consecutive hours, or the DON (Director of Nursing) to serve as a charge nurse when the facility has an average daily occupancy of 60 or fewer residents on May 26, 2025. The deficient practice could impact the quality of care provided to residents and support for the staff scheduled.Findings include:Review of the daily staff posting dated May 26, 2025, revealed that a Registered Nurse (RN) was not scheduled to work on the day shift, 6 AM to 6:30 PM, or on the night shift, 6 PM to 6:30 AM.Review of the daily assignment sheet dated May 26, 2025, revealed that there were two Licensed Practical Nurses (LPNs) scheduled for the day shift, 6 AM… […]

• No harm, potential for more than minimal, patternF645Jan 8, 2026

  Based on clinical record review, staff interview and policy review, the facility failed to ensure that 3 residents (#5, #15 and #4) out of 13 sampled had a PASARR (Preadmission Screening and Resident Review) level 2 completed and submitted to the state for review. The universe was 44. The deficient practice could impact the resident's ability to receive the care and services in the most integrated setting appropriate to their needs.Findings include:-Regarding Resident #5Resident #5 was admitted on [DATE] with diagnosis including schizophrenia, encephalopathy, unspecified psychosis, hallucinations, recurrent bipolar disorder, anxiety disorder and other depressive episodes.A review of the quarterly MDS (minimum data set) dated October 25, 2025 revealed a BIMS (brief interview of mental… […]

• No harm, potential for more than minimal, patternF926Jan 8, 2026

  Based on clinical record review, staff interviews, observation of current practice, and review of facility policy, the facility failed to ensure the smoking policy was followed for 7 out of 7 residents (Resident #8, #30, #21, #20, #40, #52, #38). The sample Size was 44. The deficient practice could result in injury to residents.Findings include:-Regarding resident #8:Resident #8 was admitted on [DATE], with diagnoses including end stage renal disease, hypotension of dialysis, hypertension, and atrioventricular block.A review of the care plan initiated on August 29, 2023 revealed no initial identified risk of smoking.Further review of the care plan revealed an identified smoking risk dated November 30, no year noted. […]

• No harm, potential for more than minimal, patternF580Oct 21, 2021

  Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident's (#51) provider was consulted of a change in status regarding blood pressure. The sample size was 18. The deficient practice could result in providers not being notified of changes in residents' conditions. Findings include: Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if pulse is less than 60 or systolic blood pressure (SBP) is less than 100. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]