Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews and interviews, the facility failed to ensure dignity during dining for one
(Resident #81) out of 28 residents who need assistance with eating. As evidenced by one facility staff
member standing while feeding the resident.
The findings included:
In an observation on 05/16/23 at 12:02 PM. In the dining room, there were 12 residents and 2 staff sitting
down while assisting residents to eat lunch. Staff I, a Registered Nurse was seen pulling resident up in the
chair. Staff I, fed resident #81 from his regular diet tray, while standing and resident #81 was observed
feeding himself at times.
On 05/16/23 at 02:35 PM, during an interview with Staff I, Registered Nurse, when asked, How was lunch
for resident #81 and the reason for standing while feeding the resident? Staff I stated, The resident was
sliding down in the chair. I'm supposed to be sitting when I'm feeding a resident. When asked, The reason
for not sitting down? Staff I stated, I'm an active person, I walk around, I feel more comfortable standing. I
want to see everyone, and I don't want my back turned. I like to be aware of the environment and what is
going on with other residents in the dining room. When asked, What is your facility's policy regarding
dining? Staff I stated, I'm usually tending to residents in the room for 1 to 1. Usually, it's one certified
nursing assistant (C.N.A.) that supervises everyone in the dining room. Today, I was to supervise and see
residents being fed properly. When asked, Does the facility allow you to stand while feeding the resident?
Staff I stated, I usually sit down to feed residents. Today, the resident was lying limp, I pulled him up to sit
him properly to feed him. I was stimulating him so that he could eat for himself. When asked, Where can
you get chairs to be able to sit? Staff I stated, I can pull one from nursing station and from other rooms.
Record review of resident #81's medical records documented a readmission on [DATE]. The current
admission was on 12/7/22. The Minimum Data Set, dated [DATE] for a Quarterly assessment documented,
Brief interview of mental status was not completed. Cognitive skills for daily decision making were severely
impaired. Eating was supervision with one-person physical assist. No swallowing disorders. No weight loss
or weight gained. No speech therapies. During review of the residents care plan, dated 1/3/23 revealed, the
Resident's activities of daily living self-care deficit documented, Supervision to extensive assist related to
functional decline and depression. The goal was the resident will receive the level of assistance required to
maintain or improve present level. Interventions/Approaches ensure all needs are met. Target date is
6/16/23.
In the facility's Policy titled, Assistance with Meals. In Section 1, C it is documented, Residents
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 11
Event ID:
105765
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (C1)
documented, Not Standing over residents while assisting them with meals.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 2 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to provide adequate and appropriate health care,
related to restorative therapy services for one (Resident # 7) out of one resident who needs to have splints
on both hands. This practice has the potential to increase the risk of negative resident outcomes and to
affect all in-house residents residing in the facility who need to wear splint devices.
The findings included:
Observation of Resident # 7 on 05/16/2023 at 09:03 AM. The resident was observed with both hands
contracted and not wearing splints or hand rolls.
Observation of Resident # 7 on 05/17/2023 at 10:15 AM. The resident was observed lying in his bed. The
resident was not wearing splints or hands rolls in his contracted hands.
Observation of Resident # 7 on 05/18/23 at 10:31 AM. The resident was observed lying in his bed. The
resident was observed with both hands contracted. The resident was not wearing any splint or devices. The
resident was not able to respond to questions asked.
Observation of Resident on 05/18/23 at 02:20 PM. The resident was observed wearing splints in both
hands.
Observation of Resident #7 on 05/19/23 at 12:12 PM. The resident was observed wearing the splint in both
hands.
Record review of the clinical records for Resident #7 revealed, the resident was admitted to the facility on
[DATE] and readmitted on [DATE]. Clinical diagnoses included but were not limited to, Chronic Respiratory
Failure, Unspecified whether with Hypoxia or Hypercapnia; Encounter for Attention to Tracheostomy;
Encounter for Attention to Gastronomy; Contracture, Right Hand; Contracture, Left Hand; Contracture of
Muscle, Right Hand; Contracture of Muscle, Left Hand.
Record review of Physician Orders dated 03/16/2023 revealed, the resident had an order for Right and Left
Resting Hand Wrist Hand Finger Orthosis (BMI-WHFO) splint to be donned during AM, removed during
PM. Check skin integrity prior to applying splint and after removing splint.
Record review of Quarterly Minimum Data Set (MDS) Section C, Cognitive Patterns dated 03/18/2023
revealed, the residents Brief Interview for Mental Status (BIMS) summary score was 00 out of 15. Review of
the Quarterly MDS Section G, Functional Status dated 03/18/2023 the resident needed total dependence
with two-persons physical assistance for bed mobility, transfer, and toilet use. The resident needed total
dependence with one-person physical assistance for locomotion, dressing, eating and personal hygiene.
Review of the Quarterly MDS Section O, Special Treatments, Procedures and Programs dated 03/18/2023
revealed, the resident had physical/occupational therapy from 01/17/2023 through 03/16/2023.
Record review of the Care Plan initiated on 10/15/2020 and the next review date 06/18/2023 revealed, the
resident wascare planned for Activities of Daily Living (ADL) self-care deficit related to Dementia/Post
Status Cerebrovascular/Dementia-Contractures. Goal: Resident will be kept clean and with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 3 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
neat appearance; and will have needs met daily through the next review date. Approach: Assist with ADLs
daily and encourage participation in simple tasks if able. Praise all attempts. Reorient to the environment as
needed. Keep call light within easy reach and encourage use of call light. Document and report any
deterioration/changes in status to physician/rehabilitation and restorative nursing. Rehabilitation to screen
treatment if ordered. Position in wheelchair properly, provide assistive device as per rehabilitation
recommendation.
Interview with Staff A, a Registered Nurse (RN) on 05/18/2023 at 10:40 AM. She stated, the resident had to
wear splints in both hands, after care in the morning to care in the afternoon. She stated, that she does not
know why the resident was not wearing splints on both hands.
Interview with Staff B, a Certified Nursing Assistant (CNA) on 05/19/2023 at 12:25 PM. She stated, that
CNAs were the ones in charge of putting the splints in both hands of the resident after care in the morning
and removed after care in the afternoon. She stated, that she did today after finishing the morning care to
the resident.
Interview with Staff C, a Physical Therapy Assistant (PTA) on 05/19/2023 at 1:49 PM. She stated, the facility
had no restorative department. The CNAs were responsible for putting the devices on the residents. She
stated, the resident had physical/occupational therapy started on 01/17/2023 and finished on 03/16/2023.
The splints for the resident were ordered for CNAs to put on after morning care.
Record review of the Policies and Procedures for Resident Mobility and Range of Motion not dated,
revealed Policy Statement: 1-Residents will not experience an avoidable reduction in range of motion
(ROM). 2-Residents with limited range of motion will receive treatment and services to increase and/or
prevent a further decrease in ROM. 3-Residents with limited mobility will receive appropriate services,
equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.
Policy Interpretation and Implementation 2-e) Contractures. 3-d) Conditions that limit or immobilize
movement of limbs or digits (e.g., splints)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 4 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure pharmaceutical procedures were
followed during medication administration and medication storage observation for two (3) out of four (4)
medication carts observed and 3 residents observed for medication administration with 28 opportunities.
This affected Residents #22, #32 and #73. There were 81 residents residing in the facility at the time of this
survey.
The Findings Included:
During medication administration observation on 05/17/2023 at 8:30 AM with Registered Nurse (Staff I) on
unit two (2) west medication cart, the medication Calcitriol Capsule 0.25 Microgram (MCG)-one (1) capsule
by mouth once daily was not available to be given to Resident #73, the medication was last signed out in
the Medication Administration Record (MAR) as given on 05/16/2023 at 9AM.
Interview on 05/17/2023 at 8:30AM with Registered Nurse, Staff I, when asked about the policy on
reordering the medication for resident's Staff I stated, I reordered the medication yesterday, it is just not
here.
Review of the medical records for Resident #73 revealed, the resident was admitted to the facility on
[DATE]. Clinical diagnoses included but were not limited to: End Stage Renal Disease (ESRD).
Review of the Physician's Orders Sheet for May 2023 revealed, Resident #73 had orders that included but
were not limited to: Calcitriol Capsule 0.25 Microgram (MCG)-one (1) capsule by mouth once daily related
to ESRD.
Record review of Resident # 73's Comprehensive Minimum Data Set (MDS) dated [DATE] revealed:
Section C for Cognitive Patterns documented Brief Interview for Mental Status Score is 12 on a 0-15 scale,
indicating the resident is moderately impaired cognitively.
Record review of Resident #73 's Care Plans with a Reference Date of 01/31/2020 revealed: Resident
requires Hemodialysis. Interventions up to and including -Administer medications as ordered, and monitor
labs as ordered.
During the Medication Administration Observation on 05/17/2023 at 9:06AM with Graduate Nurse (Staff E)
on unit three (3) east/west cart, Staff E signed out all medications in the Medication Administration Record
by writing her initials on each medication prescribed for 9AM for Resident #32 before administering the
medications to Resident # 32. Staff E left the East/West medication cart unlocked in the hallway close to
resident #32's room while administering the medications in the resident's room.
Interview on 5/17/23 at 9:06AM with Graduate Nurse, Staff E, when asked why she signed off on the
medications before administering to the resident, Staff E stated, I know the resident is going to take the
medications when asked, what the facility's policy is on signing off on medications, Staff E stated, we are
supposed to sign off on the medications after they are given to the resident. Staff E was shown that her
medication cart was left unlocked, Staff E stated, I forgot to lock the cart.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 5 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During the Medication storage observation on 05/18/23 at 11:19 AM on Unit two (2) East Cart with
Registered Nurse (Staff F), two (2) white round pills were found on the bottom of the shelf in the second
drawer of the cart. Staff E acknowledged the location of the pills when they were found by the surveyor and
disposed of the two (2) pills in the sharps container attached to the cart.
Interview on 05/18/2023 at 11:19AM with Registered Nurse, Staff F, Staff F stated the carts are cleaned
daily on every shift and the facility's policy is to clean the medication carts daily on every shift. When asked
how the nurses are supposed to dispose of loose medications, Staff F stated, we place the loose
medications in the sharps containers.
Interview on 05/19/23 at 09:38 AM with the Assistant Director of Nursing (ADON) it was stated, after being
told by surveyor about the issues observed during the medication administration and medication storage
observations, the ADON stated when Resident #73's medication arrived from the pharmacy, it was given to
the resident, the resident's physician gave an order for the medication to be administered on arrival. The
medication was given on 5/17/23 at 12pm. The nurse (Staff I) said she ordered the medication for the
resident that was missing his medications the day before. We are going to in-service our nurses concerning
all the information you gave me on loose pills on the cart, the medication cart being unlocked, signing off on
medications before giving to the resident, medication disposal and making sure we order medications on
time to make sure we do not run out.
Review of the facility's policy and procedures titled, Medication Administration-General Guidelines dated
May 2022 states: Medications are administered as prescribed in accordance with good nursing principles
and practices and only by persons legally authorized to do so. Personnel authorized to administer
medications do so only after they have been properly oriented to the facility's medication distribution system
(procurement, storage, handling, and administration).
Review of the facility's policy and procedures titled, Storage of Medications dated May 2022 states:
Medications and biologicals are stored safely, securely, and properly, following manufacturers
recommendations or those of the supplier. Procedure except for those requiring refrigeration or freezing,
medication intended for internal use are stored in a medication cart or other designated area.
Review of the facility's policy and procedures titled, Ordering and Receiving non-controlled Medications
from the Dispensing Pharmacy dated May 2022 states: Procedure 2-Reordering of medications is done in
accordance with the order and delivery schedule developed by the pharmacy provider(s). Reorder
medication in advance of need, as directed by the pharmacy order and delivery schedule, to assure an
adequate supply is on hand.
Review of the facility's policy and procedures titled, Discarding and Destroying Medications. Revision date
April 2022 states: Medications will be disposed of in accordance with federal, state, and local regulations
governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances.
On 05/18/23 at 02:25 PM, during an observation of the third floor's west medication cart with Staff A,
Registered Nurse (R.N). A blue and [NAME] green capsule determined to be Fluoxetine 20 mg and a
broken piece of a white pill was found on the bottom of the medication cart drawer. Staff A placed the pills
in a drug buster.
On 05/18/23 at 03:54 PM, when asked to Staff A, R.N, What is the facility's policy regarding cleaning carts?
Staff A R.N stated, We are to clean the cart after our shift.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 6 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Record review of Resident #22's recent minimum data set. In Section C for Cognitive Pattern documents,
unable to complete brief interview of mental status interview. In Section I, for Active Diagnosis documented,
includes Depression and Schizophrenia. Section N for medications stated, Resident #22 received
antipsychotic and antidepressant in the last 7 days.
Review of the physician orders for Resident #22 revealed, orders for Fluoxetine 20mg capsule - give one (1)
capsule by mouth once daily for Depression.
Event ID:
Facility ID:
105765
If continuation sheet
Page 7 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0839
Employ staff that are licensed, certified, or registered in accordance with state laws.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review and interview, the facility failed to ensure a Graduate Practical Nurse
met the qualifications required for the job title. There were 81 residents residing in the facility at the time of
this survey.
Residents Affected - Few
The Findings Included:
On 5/17/23 at 9:06AM, prior to the medication administration observation, the surveyor introduced herself
to Graduate Nurse (Staff E) at the medication cart, Staff E stated, her name and title as a graduate nurse.
Staff E stated, there is a program here in the facility for graduate nurses.
On 05/18/23 at 02:32 PM, the Nursing Home Administrator (NHA) was asked about Staff E's graduate
nurse qualifications, it stated Staff E was hired as a Certified Nursing Assistant (CNAs), I am aware that
she has a certificate stating she can sit for the nursing state boards as a Licensed Practical Nurse (LPN). I
will find out from Human Resources (HR) when Staff E graduated from nursing school and if she has a
Graduate Practical Nurse letter from the State of Florida.
On 05/18/23 at 04:00 PM, received from the NHA, Staff E's Authorization to test form with a date range of
February 8, 2023-August 7, 2023.
On 05/19/23 at 08:21 AM, received from NHA, Staff E's Graduation certificate dated June 18, 2016.
On 05/19/23 at 08:56 AM, the NHA administrator stated, Staff E stated, she will be taking her test in June
2023 and she had never taken the Licensed Practical Nurse (LPN) nursing exam before. The NHA stated, I
was unaware of Staff E nursing school graduation date. The NHA stated, Staff E asked on 2/20/23 if she
could work as a graduate nurse, I told her she needed to provide proof that she could take the exam and
that she did not already take the exam and failed. She provided the test date and told me she had never
taken the exam. Since 2/20/23 she has worked as a graduate LPN periodically, she also has her CNA
license and works as a CNA. Based on the information I received about the graduate nurse job description
from HR yesterday, I will sit down with her (Staff E), the Director of Nursing (DON) or Assistant Director of
Nursing (ADON) and HR and let her know if we cannot get the necessary information needed she can no
longer work as a graduate nurse and she can continue to work as a CNA at the facility.
Review of the facility's Graduate nurse job description documented: The Graduate Nurse Position is time
limited. A person may remain in the Graduate Nurse position until one of the following occurs:
1) They become an LPN, licensed in the state of Florida, at which time they will be transferred to the LPN
position, OR
2) They receive a failing score on the nurse licensure exam, at which time they will no l longer be able to
work as an LPN, OR
3) They failed to become an LPN in the state of Florida within the required timeframe, at which time their
employment will be terminated.
Record review of the facility's Agency for Healthcare Administration (AHCA) roster documented Staff E was
hired as a CNA on 09/06/2012.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 8 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0839
Record review of Staff E's Human Resources (HR) documentation revealed, Staff E Graduated Nursing
School on June 18, 2016.
Level of Harm - Minimal harm
or potential for actual harm
Florida Board of Nursing Authorization to practice as Graduate Practical Nurse PN-Not available.
Residents Affected - Few
Previous Test Dates-Unknown
Staff E Will be taking LPN exam -7/2023.
Graduate Nurse Competency Training completed-03/10/2023 facilitated by DON.
CNA License Status-Clear/Active, Expiration 05/31/2024
Authorization to Test the National Council Licensure Examination for Practical Nurses (NCLEX-PN)
NCSBN ID: .
Authorization Number:
Test Validity: February 8, 2023-August 7, 2023
Nursing Regulatory Body: North Carolina Board of Nursing
Program: T College, B ., N., US
Review of the facility's policy and procedures titled, Job Description revision date October 2010 states: Our
facility has developed a written description for each position within our facility. A written job description has
been developed for each position within our facility. Job descriptions are criteria based and reflect the skills
required for each position. Each job description defines the following categories:
a. Duties and responsibilities
b. Working conditions
c. Educational requirements
d. Experience
e. Specific requirements
f. Physical and sensory requirements
g. Acknowledgements: and
h. Job description analysis information
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 9 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based on record Review and interview, the facility failed to demonstrate effective plans of action were
implemented to correctly identify quality deficiencies in the problem area related to repeated deficient
practices for F550 Resident Rights/Exercise of Rights and F688 Increased/Prevent Decrease in Range of
Motion/Mobility. This practice has the potential to increase the risk of negative resident outcomes that could
affect all 81 residents residing in the facility at the time of this survey.
The finding included:
Record review of the facility's survey history revealed, during a recertification survey with exit 3/10/2022,
Resident Rights/Exercise of Rights was cited related to the facility failed to treat
1 out of 24 sampled residents in a dignified manner. Moreover, Increase/Prevent Decrease in ROM/Mobility
was cited related to the facility failed to provide adequate care and treatment for one resident with a
contracture as evidenced by the facility's failure to apply elbow extension and splint devices as per
physician's order.
During record review of the quarterly meeting sign-in sheet, it was revealed that the facility's Quality
Assessment and Assurance Committee (QAA) is comprised of the following: Administrator, Risk Manager,
Medical Director, Director of Nursing, Dietary Director, Social Service Director, Minimum Data Set Director,
Care Plan Coordinator, and Director of Therapy.
During an interview on 05/19/2023 at 04:11 PM, the Nursing Home Administrator revealed that the facility
has the following Performance Improvements Plans (PIPs) open: Care Plan due to turn over in the
Minimum Data Set department, documentation and omissions on residents' charts, labs and missed
appointments as labs were not transcribed correctly and missed appointment for the residents refusing to
not go to their appointments were not documented in charts, Wheelchairs identified as being dirty and
missing parts to be replaced, furniture and privacy curtains needed to be replaced, pest in the facility and
around the facility, missing physical Minimum Data Set copies from file cabinet as we found that some
residents had only three assessments, and some had 15 months of assessments, Resident finger and
toenail clipping, and Missing clothing.
Review of the facility document titled, THE QUALITY ASSURANCE PERFORMANCE IMPROVEMENT
PLAN revealed,
I.
Goals
Our organization's overall goal of the Quality Assurance Performance Improvement Program is to have an
ongoing internal review of our care and service practices as a way of assessing the quality of the care and
services provided.
We will seek and assess how to implement evidence-based best practices and explore the use of
technology to improve quality of care and services.
Quality Assurance Performance Improvement activities will be used to assess, gather data, and use
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 10 of 11
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105765
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gardens Nursing and Rehab Center
190 NE 191st Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
the best available evidence to define and measure goals.
Level of Harm - Minimal harm
or potential for actual harm
II.
Scope
Residents Affected - Few
Practice areas assessed as needing improvement or change will be addressed in a performance
improvement action plan using a SMART formula for setting the goal of the plan, root cause analysis to find
the systemic cause of why the practice area is in need of improvement or change and feed back from all
stakeholders to ensure the safety and high quality of all clinical interventions emphasize autonomy and
choice in the daily life of residents.
III.
Feedback, Data Systems, and Monitoring
Our organization will be using data from the following sources to monitor care and services:
a.
Survey results
b.
Results of QIS Comparative Activities
Information from the above sources will be reviewed at least monthly at the Quality Assurance Performance
Improvement meetings and at any other time that an issue arises and needs to be addressed.
Information will be analyzed against benchmarks/absolute thresholds that have been established by QIS
Survey protocols and accepted by the organization.
The information on the outcomes of the Performance Improvement projects will be disseminated to the
Quality Assurance Performance Improvement leadership, Resident Council and employees, through written
reports and meeting groups.
IV.
Guidelines for Performance Improvement Projects
Topics for Performance Improvement Projects will be identified through deficient practices that impact the
quality of services delivered to our residents.
Our organization will develop projects on an as needed basis or as soon as an area of concern is identified.
The project will be assembled by the project manager and include at least three members from affected
and unaffected departments to ensure that an interdisciplinary approach.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F839 - Staff qualifications
Employ staff that are licensed, certified, or registered in accordance with state laws.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
FAQ · About this visit
Common questions about this visit
What happened during the May 19, 2023 survey of GARDENS NURSING AND REHAB CENTER?
This was a inspection survey of GARDENS NURSING AND REHAB CENTER on May 19, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS NURSING AND REHAB CENTER on May 19, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.