Inspection·October 3, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for second floor resident rooms. The findings included: Observation on the Second Floor 10/03/2023 from 8:02am to 9:15am revealed: Rooms #221 - Under the sink a container, the toilet paper holder was on the floor, the shower floor was dirty, and on the ceiling a water marks. The cover sheet under air conditioner (AC) unit was collecting the moisture and was wet. Water was running from the shower head on the bathroom floor. room [ROOM NUMBER] - At the entrance there was a dead roach, bathroom walls were in disrepair, the shower was observed to rusty and dirty. In the hallway across from room [ROOM NUMBER] another roach was observed. Room#223 - Under the Air Conditioner unit, there was a blanket to collect the moisture. In the bathroom a live roach was observed and the wall was in disrepair. Room#229 - At the entrance of the room, a dead roach was observed, on the wall next to the AC unit, there were 2 dead roaches and a large hole on the wall. Room#225 - The bathroom walls needed painting, and appeared dirty. Room#226 - The bathroom walls were dirty, the floor base tiles were missing, some were dirty. Room#227 - The bathroom walls were dirty, floor base tiles were missing and some were dirty, there was a hole on the wall, and painting was needed. Room#229 - A dead roach was on the floor, a paper to catch roaches was under the table with several roaches on it and there were dead roaches in the lamp cover. Room#230 - The room wall needed painting, there was one dead roach at the entrance and another a live roach was under the night table. Room#231 - The base board was peeling off the wall, and there was a hole. (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 3 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 10/03/2023 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)