Health 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. Page 1 of 3 105765 105765 10/03/2023 Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

F 0584 Room#233 - The bathroom walls had holes and were dirty. Level of Harm - Minimal harm or potential for actual harm Room#234 - The toilet paper holder was broken, and the ceiling had a black substance on it. In the bathroom near the dining room there were two live roaches observed. Residents Affected - Some *For all these observations there is photographic evidence* Policies and Procedures-Physical Environment-Room Repairs Policy: The center will ensure the residents have a safe, homelike, environment free from physical hazards. Procedure: 1. To ensure a safe, homelike environment, the Maintenance Director, or Designee, will complete room rounds 2-4 times per month. Findings from these rounds will be prioritized and repair made as indicated. Apart from completing room rounds, a maintenance log is kept at the nurse's station for any repair staff find need to be completed throughout the day. Staff are to put the maintenance request in the log, the maintenance department will check the log throughout the day to complete those tasks. Any repairs requiring immediate attention are to be reported directly to the Maintenance Director or Administrator. On 10/3/23 at 10:44 AM, the bathroom near the dining room was locked. Staff A, Certified Nursing Assistant (C N A) was asked to observe the bathroom, Staff A, opened the door with a plastic utensil. Staff A was asked, the reason a plastic utensil was used and whether maintenance staff were notified. Staff A stated, There is no key and yes. Observation of the restroom revealed, there were two toilet paper rolls on top of the paper towel dispenser. There were metal and plastic eating utensils behind the sink knobs. A piece of the toilet seat was broken off. [See photo evidence] 105765 Page 2 of 3 105765 10/03/2023 Gardens Nursing and Rehab Center 190 NE 191st Street Miami, FL 33161

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review. The facility failed to maintain an effective pest control program so that the facility is free of pests as evidenced by live roaches, dead roaches and small black bugs observed in eleven different locations in the facility. Residents Affected - Some The findings included: On 10/3/23 at 8:02 AM to 9:15AM, during an observation of the facility's second floor the following was observed: The second-floor dining room: There were seven residents in total and five were in a wheelchairs. There was a live roach crawling on the wall. room [ROOM NUMBER]: A dead roach was near Bed A. [See photo evidence]. room [ROOM NUMBER]: A live roach was seen crawling in the bathroom. [See photo evidence]. room [ROOM NUMBER]: 2 dead roaches were seen and smashed into the wall. [See photo evidence]. room [ROOM NUMBER]: A dead roach was found in front of Bed B in the room. room [ROOM NUMBER]: One live roach was seen crawling on the wall. room [ROOM NUMBER]: Multiple roaches were found stuck to a glue traps underneath the window bed furniture. [See photo evidence]. room [ROOM NUMBER]: A live roach was seen near a yellow-stained sheet on the floor. On 10/3/23 at 09:17 A.M., the bathroom near the second-floor dining room had one live roach on the door frame and one on the wall. [See photo evidence] On 10/3/23 at 11:19 AM: A roach was observed crawling out of room [ROOM NUMBER] into the hallway. On 10/3/23 at 11:25 AM: At the nursing station, a flat body round insect walked on the counter. In review of Policy and procedures titled Maintenance - Plumbing, [Heating, Ventilation, and Air Conditioning] HVAC and related systems. The purpose of this procedure is to guide the sanitary handling of plumbing, heating, ventilation, air conditioning, and related systems within the facility. Under the section titled, general guidelines, 19. The pest control vendor should spray monthly (or as necessary) for insects and rodents. 105765 Page 3 of 3