Gardner Rehabilitation And Nursing Center
GARDNER REHABILITATION AND NURSING CENTER in GARDNER, MA — inspection on September 9, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on records reviewed and interviews for one of three sampled residents (Resident #1), the facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aide (CNA) documentation related to positioning was either incomplete and/or inaccurate.Findings include:Review of the Facility policy titled, Documentation in Medical Record, revised January 2025, indicated the following:-Staff shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. -Documentation shall be accurate, relevant, and complete, containing sufficient details about the residents' care and/or responses to care. Resident #1 was admitted to the Facility July 2025, with diagnoses including but not limited to; cerebral infarct (blood clot blocks an artery in the brain, cutting off blood flow to a specific area), end-stage kidney disease, and pressure ulcers.Review of Resident #1's Minimum Data Set (MDS) admission Assessment, dated 08/05/25, indicated he/she was dependent on staff assistance for bed positioning.Review of Resident #1's ADL Flow Sheet (CNA documentation) dated 08/01/25 through 08/14/25 indicated for the following shifts, documentation was inaccurate or incomplete for positioning:-08/02/25 at 6:00 A.M, 10:00 A.M., 12:00 P.M., and 2:00 P.M. left blank.-08/03/25 at 8:00 A.M, 10:00 A.M., and 2:00 P.M. documented NA (not applicable).-08/05/25 at 6:00 A.M., left blank, 10:00 A.M., 12:00 P.M., and 2:00 P.M. documented NA.-08/08/25 at 8:00 A.M. and 10:00 A.M. documented NA.-08/10/25 at 10:00 A.M. documented NA.During an interview on 09/09/25 at 4:00 P.M., the Director of Nursing (DON) said the CNA assigned the resident is responsible for completing the CNA flow sheet.
The DON said the CNA flow sheet documentation on 08/02/25, 08/03/25, 08/05/25, 08/09/25 and 08/10/25 should not be blank or documented as NA.
The DON said Resident #1's CNA flow sheet was not complete or accurate.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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