Gardens Nursing And Rehab Center

During a telephone interview on 03/25/2026 at 1:59 PM, the Psychiatrist stated: I assessed [Resident # 32] with a Creole speaking nurse and found [Resident # 32] to be so demented that there was no recollection of the incident.

There has been no major change in [Resident # 32's] psychological state compared to before the incident.

Interview on 03/25/2026 at 5:25 PM about the incident that occurred on 3/17/2026, Staff D, RN stated: After dinner between 5:30 PM to 6:00 PM I was called to [Resident # 32's] room by Staff D, CNA and saw [Resident # 6] standing in the room. [Resident # 6] told me he was using the restroom. I informed the RN supervisor and was instructed to change [Resident # 6's] room to the 2nd floor and place [Resident # 6] on 1:1 monitoring.

Record review of the facility's Policies and Procedures titled Policies and Procedures titled, Abuse, Neglect, Exploitation & Misappropriation Effective Date: 11/30/2014 Revision Date: 11/28/2017 revealed POLICY: It is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property.

The management of the facility recognizes these rights and hereby establishes the following statements, policies, and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of occurrences of resident abuse.Employees of the center are charged with a continuing obligation to treat residents, so they are free from abuse, neglect, mistreatment, and/or misappropriation of property. No employee may at any time commit an act of physical, psychological, or emotional abuse, neglect, mistreatment, and/or misappropriation of property against any resident.

Violation of this standard will subject employees to disciplinary action, including dismissal, provided herein.

Sexual Abuse is non-consensual sexual contact of any type with a resident.

Sexual abuse includes but is not limited to: Unwanted intimate touching of any kind especially of breast or perineal area.

All types of sexual assault or battery, such as rape, sodomy and coerced nudity Forced observation of masturbation and/or pornography; and Taking sexually explicit photographs and/or audio/video recordings of a residents) and maintaining and/or distributing them (i.e. posting on social media).

This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident.Other examples of non-consensual sexual contact may include, but are not limited to, situations where a resident is sedated, is temporarily unconscious or is in a coma.

Generally, sexual contact is non-consensual if the resident either: Appears to want contact to occur but lacks the cognitive ability to consent; or does not want contact to occur.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

Observation on 03/25/2026 at 9:20 AM revealed Resident # 92 had bilateral side rails up and the left side of the bed was positioned against wall.

Photo evidence provided.

Record review of a demographic sheet revealed Resident #92 was admitted to the facility on [DATE] with diagnosis that included but not limited to: metabolic encephalopathy and transient alteration of awareness.Record review of the admission Minimum Data Set (MDS) reference dated 02/19/26 revealed Resident #92 had a Brief Interview for Mental Status (BIMS) score of 02 out of 15 indicating severe cognitive impairment.

The resident required substantial assistance for eating, toileting, showering, sit to lying and upper and lower body dressing and had impairment on both sides to the upper and lower extremities.

Record review of Resident # 92's Activities of Daily Living (ADLs) care plan revealed self-care performance deficit related to (r/t) Weakness, Encephalopathy, Fatigue, Chronic disease burden, Hospital deconditioning, Cognitive fluctuation.

Evidence: Total self-care deficit listed, Altered mental status (AMS) and Functional decline.

Interventions include: The resident is totally dependent on (1-2) staff for repositioning and turning in bed, the resident is totally dependent on (1) staff for personal hygiene and oral care and the resident requires mechanical lift with (2) staff assistance for transfers.

Interview on 03/25/2026 at 9:24 AM with Staff A, Registered Nurse (RN) stated I did not place the bed against the wall because it should remain in the middle to allow safe access from both sides.

Placing the bed against the wall is considered a restraint and is not permitted.

The resident is confused and frequently attempts to get out of bed.

The physician explained that this confusion is due to elevated ammonia levels, and the resident's lactulose has been increased to help manage this condition. I have also observed that the resident attempts to pull down the Percutaneous Endoscopic Gastrostomy (PEG) feeding pole, which increases his risk for injury and could interfere with his treatment.

Interview on 03/25/2026 at 9:53 AM with Staff B, Certified Nursing Assistant (CNA) stated I did not put the bed against the wall. I do not know how it was moved or if the resident tried to get out of bed.

During an interview on 03/25/2026 at 09:57 AM, the Director of Nursing (DON) stated I will educate the staff not to place the bed against the wall, as it is considered a restraint. I was not aware that this resident is confused or attempts to get out of bed.

Review of the facility's policy and procedure titled Resident Rights dated 10/18/2018 documented:Policy: It is the policy of the company to:1.

Make residents and their legal representatives aware of residents' rights.2.

Ensure that residents' rights are known to staff.3.

Ensure residents' rights are honored.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

30 days as part of a medically prescribed period of recovery.Those who are certified by a physician

Disease, Amyotrophic Lateral Sclerosis, CHF or COPD.d.

Those with a diagnosis of dementia or its

Intellectually Disabled (ID) screenings.If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services/designee to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results.Results of the screening evaluation will be placed in the appropriate section of the individual's medical records and any recommendations for services will be followed.Recommendations will be incorporated in the individual resident's plan of care and approaches/interventions developed to meet the identified needs of the individual.Social Services/designee will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency.

These results, along with the results from the previous years will be kept in the appropriate sections of the resident's records.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

minimum.A revision of the existing H & P that is 12 months old ONLY when the revision is considered

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

it. I usually have to enter a code to get in, but it was already open this time.

08/2025 revealed: Policy: Chemicals and hazardous materials shall be stored and handled in a manner

Procedure: Store and dispense chemicals/hazardous materials from originally marked containers or specifically label /marked dispensers.

The facility shall have available and maintain SDS's (safety data sheets) for chemicals used or stored Staff are to be trained upon hire and annually on handling and storage of chemicals/hazardous materials.

Chemical storage rooms and /or chemical storage cabinets are to be locked when not in direct site of a staff member.

Store full and partially empty containers in locked areas per the Life Safety Code and OSHA requirements.

Dispose of empty containers in accordance with SDS.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

Based on observations, record reviews and interviews the facility failed to store medications and

over-the-counter topical medication used to relieve oral pain a medicated lotion at bedside.

There were 112 residents residing in the facility at the time of survey.

The findings included:Observation on 03/23/2026 at 10:03 AM in Resident # 84's room revealed a container of [brand] over-the-counter topical medication used to temporarily relieve oral pain on the side table and a medicated lotion on the nightstand. (photo evidence). On 03/23/2026 at 10:19 AM Staff E, Registered Nurse (RN) was made aware of the identified concern and stated: Residents cannot have medications at the bedside without a physician's order.

During an interview with the Director of Nursing (DON) on 03/23/2026 at 10:46 AM it was revealed that Resident #84 did not have physician's order to keep over-the-counter topical medication used to temporarily relieve oral pain or medicated lotions at the bedside.

Record review of the facility's Policies and Procedures titled Subject: Medication Storage Effective Date: 12/08/2023 revealed Policy:The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Procedure:1.

Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received.Only the issuing pharmacy is authorized to transfer medications between containers.2.The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner.6.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.7.Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.

Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

improvement, evaluate progress towards goals, and ensure systems and actions are in place to

actions on medical errors and adverse events.

The center will monitor department performance

center utilizes performance improvement projects to improve a systemic problem or improve quality, and at a minimum must conduct one performance improvement project annually.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

gloves.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

During an interview conducted on 03/23/2026 at 10:30 AM, Staff N Registered Nurse revealed when a resident uses the call light to call for assistance, a light should go on outside the room, indicating that the resident needs help and also at the nurse 's station, indicating the room number that the call light was used.

On 03/23/2026 at 11:38 AM Staff L, Certified Nursing Assistant stated: We have a person checking the room every 15 minutes, a different person is assigned every day, I can't put a finger on how many months it's been, but there is a log where they record when they go into the rooms.

On 03/25/2026 at 1:41 AM, the Director of Environmental Services reported that before he started working in the facility seven months ago, there was an estimate for repairs to the call lights. He is aware that CNAs are supposed to do 15-minute rounds. He noted that the call lights for the bathroom and the entire third floor are not working and that he can call corporate to check when they will be fixed.

Currently, there is no set time for these repairs, including the bathroom call lights.

On 03/26/2026 at 9:21 AM the Director of Environmental Services revealed the call light estimate was given to corporate on the same day dated on estimate form, and they had not got back about that, and he believes administrator has called once or twice about it.

On 03/26/2026 at 5:50 PM the Administrator revealed the second floor currently operates on a wireless call bell system, with noted challenges related to internet reliability despite backup measures.

Plans include exploring repairs using existing system components or transitioning them into a more reliable solution.

The third floor is in the process of obtaining estimates and awaiting a few other companies to get back. We have a 15-minute rounds establish, and they are all documented in a log in the nurse station.

Review of the Policies and Procedures for call lights, Effective Date: 09/01/2024 Policy: The purpose of this policy is to ensure residents' requests and needs are responded to.

Procedure: Call light should be within reach of the resident Answer the residents' call as soon as possible Report malfunctioning call lights to Maintenance, ED, and/or DON promptly Offer stationary bells and/or round frequently on residents if the call light system is malfunctioning.

105765 03/26/2026

Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

Review of the comprehensive Minimum Data Set submitted 02/20/2026 cognitive section revealed a Brief Interview of Metal Status score of 14 out of 15 indicating the resident is cognitively intact.

The functional section revealed Resident #100 required set-up and clean up assistance for Activities of Daily Living.

Record review of a Skin/Wound Note with effective date: 03/25/2026 timestamped 16:14 (4:14 PM) completed by Staff N, Licensed Practical Nurse note text indicated: Resident evaluated by wound care nurse for wound under right plantar.

Treatment administered as standard order by wound care physician .

Record review of progress notes completed by the Director of Nursing (DON) dated 3/25/2026 time stamped 17:40 (5:40 PM) Note Text: Resident reported that he sustained a cut to his foot approximately two days ago while in the shower.

Resident stated he did not report the injury at the time.

Resident further stated that a nurse later inquired about his limping.

Wound care treatment was initiated, and the wound care nurse was notified MD (Medical Doctor was notified, and new order was received to transfer the resident to the hospital for further evaluation and treatment.

Resident was educated on the importance of hospital evaluation, including potential risks of untreated wounds such as infection and delayed healing .

Record review of physician order dated 03/25/2026 indicated standard order: Clean wound on right plantar foot with saline, pat dry.

Apply Med honey to wound bed, Cover with boarder dressing gauze and PRN (as needed), in the morning for wound care and as needed.

During an interview on 03/26/2026 2:24PM the Director of Maintenance/ Housekeeping and Laundry revealed he was informed on 3/25/2026 of a screw in Resident #100's shower posing a hazard and had received emails from the administration concerning the shower needing to be cleaned with picture attachments and further reported that Resident #100's shower was inspected on 3/8/2026 and 03/23/2026 and stated: I had not gotten around to getting the shower cleaned.Record review of the facility's Physical Environment - Room Repairs policy dated 09/26/2023 revealed, Maintenance Director or Designee will complete room rounds 2-4 time per month.

Findings from these rounds will be prioritized and the repairs made as indicated.

Apart from completing room rounds, a maintenance log is kept at the nurse's station for any repairs staff find need completed throughout the day.

Staff will put maintenance request into the log; maintenance department will check log throughout the day to complete tasks.

Any repairs requiring immediate attention are to be reported directly to the Maintenance Director or Administrator.

Record review of facility complete room procedure included: 3.) Scrub bathroom floor (if ceramic tile) 4.) Complete 8-step room cleaning procedure (20-25 min)