Gardenia Garden, Inc

Based on observation and staff interview, LPA observed that the RCFE (Residential Care for the Elderly) “Let Us No” Complaint (PUB 475) poster was not posted at the facility which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, Resident #6 (R6’s) file did not have documentation of determination for ambulatory status which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observed that Resident #1 (R1), Resident #2 (R2), and Resident#4 (R4) to Resident #6 (R6) had half bed rails and R1, R2, and R4 to R6's file did not have physician's order for bed rails which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and staff interview, LPA observed that the Administrator’s file does not have a valid RCFE Administrator’s Certificate which poses a potential health, safety or personal rights risk to persons in care.

Based one record review and observation, LPA observed that Resident #3 (R3) had a full bed rail and R3's file did not have a hospice care plan specifying a need for a full bed rail which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA reviewed Staff #1 (S1’s) file did not have a Valid First Aid Training which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, LPA observed Resident #1 (R1’s) Medication Administration Record (MAR) for the month of February 2026 was not up to date as initials for three (3) medications were missing initials and was last initialed on 02/02/2026. LPA also observed for Resident #2 (R2’s) MAR for the month of February 2026 was not up to date and not accurate since one medication was initialed from 02/01/2026 to 02/31/2026. LPA observed that Resident #3 (R3) did not have a current MAR in file. This poses a potential health, safety or personal rights risk to persons in care.

Based on observation, record review, the Administrator did not comply with the section cited above in that the facility does not have the proper Medication Administration Record (MAR) to document the residents' medication which poses an immediate health, safety or personal rights risk to residents in care.

Based on observation, record review, the Administrator did not comply with the section cited above in that the facility currently has 2 bedridden residents but only has fire clearance approved for (1) bedridden resident which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on record review,, the Administrator did not comply with the section cited above in that the Administrator cannot provide proof of staff training on knowledge and use of the oxygen equipment which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on observation, the Administrator did not comply with the section cited above in that (3) Residents on hospice requiring oxygen on as need basis but facility did not have "No smoking-oxygen in use" signs posted on their rooms which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on interview, record review, the Administrator did not comply with the section cited above in that the Administrator has not reported to the local fire department that oxygen is in use at the facility which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on record review, the Administrator did not comply with the section cited above in that the facility did not have a current and complete medication record for all the residents for the month of April 2024 which poses/posed a potential health, safety or personal rights risk to residents in care.

Based on record review, the Administrator did not comply with the section cited above in that PRN medications for Resident #1 did not have written order from a physician which poses an immediate health, safety or personal rights risk to residents in care.

Based on record review, the Administrator did not comply with the section cited above in that the liability insurance policy expired on 03/01/2024 and the Administrator has not renewed the policy which poses/posed a potential health, safety or personal rights risk to residents in care.