Inspection visit
Inspection
43 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 43 deficiencies, 4 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
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 ensure that the call lights were within reach
for 4 of 43 sampled residents (Resident #88, Resident #11, Resident #15 and Resident #306).
Residents Affected - Few
The findings included:
A review of the facility's policy titled Call Lights dated 09/01/23 showed that the purpose of this policy is
ensuring residents' request and needs are responded to. The call light should be within reach of the
resident.
1. A chart review revealed that Resident #88 was admitted to the facility on [DATE] with diagnoses of
Cerebral infarction and Hyperlipidemia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that
Resident #88 had a Brief Interview of Mental Status (BIMS) score of 12, which was a slight cognitive
impairment.
In a phone interview conducted on 08/25/24 at 11:33 AM with Resident #88's family stated that Resident
#88 fell in the facility last week trying to go to the bathroom on his own with no assistance. The call light
was not within reach and Resident #88 was not able to call for help.
In an observation conducted on 08/26/24 at 7:30 AM, the call light cord was noted on the floor on the right
side of the bed.
In an observation conducted on 08/26/24 at 8:00 AM, the call light cord was noted on the floor on the right
side of the bed.
In an interview conducted on 08/26/24 at 8:30 AM, Resident #88 reported that the call light cord in his room
is never within reach and is always located on the right side of his bed. He had fallen last week and was not
able to call for help because the call light cord was on the floor. Resident #88 said that while attempting to
use the bathroom on his own, he fell and somehow managed to get back on the bed with lots of difficulties.
He is worried that the next time he has a fall, he will not be able to call for help. In this interview, Resident
#88's call light was noted on the floor on the right side of the bed.
In an interview conducted on 08/26/24 at 8:45 AM with Staff YY, a Certified Nursing Assistant stated that
when the call light is used, a light will go on outside the room and at the nurse's station, indicating the room
number of the resident who used the call light to call for assistance.
2)Record review for Resident #11 revealed that the resident was admitted to the facility on [DATE]
(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 70
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
08/30/2024
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 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
with the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left
Non-Dominant side; Lack of Coordination; Anxiety Disorder; Need for Assistance with Personal Care.
Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #11 had a Brief
Interview for Mental Status of 13, which indicated that he was cognitively intact. Review of Section GG of
the MDS revealed that Resident #11 was dependent on staff for toileting hygiene.
During an observation conducted on 08/26/24 at 10:24 AM, Resident #11's call light was wrapped around
the left bedside rail, hanging downward, and out of reach of the resident. When asked Resident 11 if he can
reach the call light he stated no, since he cannot move his left arm, photographic evidence obtained. Asked
resident to reach for the call light but was unable to reach it.
3) Record review for Resident #15 revealed that the resident was admitted to the facility on [DATE] with the
following diagnoses: Cerebral Palsy; Contraction of right wrist and hand; Need for Assistance with Personal
Care.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #15 had a Brief Interview for
Mental Status of 00, which indicated that he was rarely understood. Review of Section GG of the MDS
revealed that Resident #15 was dependent on staff for toileting hygiene.
During an observation conducted on 08/26/24 at 10:40 AM Resident #15 was in bed, call light was wrapped
around the bedrail and hanging downward, photographic evidence obtained. When asked Resident #15 if
he was able to reach the call light, he shook his head indicating no.
4) Record review for Resident #306 revealed that the resident was admitted to the facility on [DATE] with
the following diagnoses: Unspecified Fracture of the Right Femur; Shortness of Breath; History of Falling.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #306 had a Brief Interview for
Mental Status of 05, which indicated that he was cognitively impaired.
During an observation conducted on 08/26/24 at 10:35 AM, Resident #306 was in his wheelchair and was
holding an empty water cup. He stated that he was going to get water. When asked why he did not call for
staff to get him water, he looked confused and did not respond. Further observation revealed Resident
#306's call light was behind his bed on the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 2 of 70
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
08/30/2024
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 0576
Ensure residents have reasonable access to and privacy in their use of communication methods.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview, it was determined that the facility failed to provided 6 non-sampled
resident's and 1 of 1 (Resident #62) residents reasonable access to the use of a phone and in a place in
the facility where calls can be made without being overheard.
Residents Affected - Some
The findings included:
During the screening of residents on the second floor on 08/26/24 at 10:00 AM it was noted that 6 residents
who resided on the second floor were using the facility telephone located at the nurses station desk.
Further observation noted these residents just walking up to the phone and dialing without any staff
intervention to use a phone in a private area. The resident's conversations could be overheard by numerous
staff and residents located within the nurses station area. Random observations conducted on 08/8//27/24
noted residents again utilizing the facility nurses station phone, however in addition it was noted that
outside calls were being routed into the nurses station and residents were brought to the nurses station to
voice aloud in a non -private setting.
On 08/28/24 at 12:30 PM it was noted that Resident #62 was noted to walk up to the second floor nurses
station and began dialing the facility's phone. For the next 30 minutes it was noted the the resident put the
phone speaker on and was speaking with his local banking institution. It was noted no less than 4 times the
resident and bank could be clearly heard the baking account number and credit card numbers with
numerous staff, visitors, and residents in the area. At no time did staff intervene to bring Resident #62 to a
private area to use a phone. During the observation the surveyor requested to the Director of Nursing and
Registered Nurse (Staff G) of the situation. The surveyor asked the Director and Staff G why the residents'
are not being brought to a private area (room or office) to have private phone conversation, and if the
nurses station is equipped with a remote cordless phone for residents use in private areas/room. The staff
answered that they were unaware that residents conversations on phone should be conducted in a private
setting and that the nurses station not equipped with a private cordless phone. An interview with the
Corporate Maintenance Director conducted at the time of the staff interviews stated to the surveyor that the
nurses station has 2 private cordless phones available for resident's private phone calls. The Director
proceeded to open a desk drawer at the nurses station and it was noted a cordless phone inside, however
the the phone was not charged and the charging connection were not available.
On 08/29/24 at 7:30 AM it was noted that the cordless phone was located at the nurses station, however
the not charged for resident use and the charging cords were still not available. Continuous observation
conducted on the second floor Nurses Station on 08/29/24 from 7 AM - 3 PM noted numerous residents (5
non-sampled) using the station phone without staff intervention. Resident noted to be speaking loudly with
family and friends concerning various topics. Resident #62 noted to use the station telephone at least 4
times and was noted to have the phone speaker on while discussing medical condition with his personal
physician and his church.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 3 of 70
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
08/30/2024
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review the facility failed to ensure each resident receives an accurate assessment,
reflective of the resident's status at the time of the assessment observation period of the Minimum Data Set
(MDS), the observation period (also known as the Look-back period) is the time period over which the
resident's condition or status is captured by the MDS for 3 of 3 residents sampled for resident assessment
(Residents #48, #100, and #59).
Residents Affected - Some
The findings included:
1) Resident #48 was originally admitted to the facility on [DATE] with most recent readmission on [DATE]
with diagnoses that included in part: Cardiac Arrythmia Unspecified, Atherosclerotic Heart Disease of
Native Coronary Artery Without Angina Pectoris, Epilepsy, Cognitive Communication Deficit, and Dementia.
Review of the MDS for Resident #48 dated 07/13/24 documented in a Brief Interview of Mental Status
(BIMS) score of 7 indicating severe cognitive impairment. Documented in Section N under High-Risk Drug
Classes: Use and Indication 1. Is taking -Check if the resident is taking any medication by pharmacological
classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7
days; 2. Indication noted- If column 1 is checked, check if there is an indication noted for all medications in
the drug class. E. Anticoagulant documented in column 1 under is taking was marked and under column 2
marked indication noted. Antiplatelet was not documented as taking or indication noted. To summarize, this
indicated the resident was ordered/receiving anticoagulant and not ordered/receiving an antiplatelet.
Review of the Physician's Orders for Resident #48 revealed an order dated 03/07/24 for Aspirin EC (An
Antiplatelet) tablet Delayed Release 325mg, give 1 tablet by mouth one time a day for CAD/DVT (Coronary
Artery Disease/Deep Vein Thrombosis).
Review of the Physician's Orders for Resident #48 revealed an order dated 03/07/24 for Eliquis tablet 5mg
(Apixaban) (An Anticoagulant) give 1 tablet by mouth two times a day for AFIB (Atrial fibrillation).
2) Resident #100 was admitted to the facility on [DATE] with diagnoses included in part: Cerebral Infarction,
Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Transient
Cerebral Ischemic Attack, and Difficulty in Walking.
Review of the MDS for Resident #100 dated 06/03/24 documented a BIMS score of 15 indicating a
cognitive response. it was indicated in the high risk medications that the resident was receiving an
anticoagulant and not receiving an antiplatelet.
Review of the Physician's Orders for Resident #100 revealed an order dated 06/01/24 for Aspirin EC (An
Antiplatelet) Tablet Delayed Release 325mg give 1 tablet by mouth one time a day for HTN (Hypertension).
Review of the Physician's Orders for Resident #100 revealed an order dated 06/01/24 for Clopidogrel
Bisulfate (An Antiplatelet) tablet 75 mg give 1 tablet by mouth one time a day for blood clot prevention.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 4 of 70
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
08/30/2024
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 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of the Physician's Orders for Resident #100 revealed no order active or discontinued for an
anticoagulant.
3) Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with
diagnoses including in part: Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified
Angina Pectoris, Unspecified Atrial Fibrillation, and Nicotine Dependence Unspecified.
Review of the MDS for Resident #59 dated 06/10/24 documented a BIMS score of 15 indicating a cognitive
response. Documented in Section N for medications under High-Risk Drug indicated the resident was
receiving an anticoagulant and not receiving an antiplatelet.
Review of the Physician's Orders for Resident #59 revealed an order dated 03/02/24 for Aspirin (An
Antiplatelet) 81 mg Oral Tablet Chewable give 1 tablet y mouth one time a day for CAD (Coronary Artery
Disease).
Review of the Physician's Orders for Resident #59 revealed an order dated 03/02/24 for Clopidogrel
Bisulfate (An Antiplatelet) Oral Tablet 75 mg give 1 tablet by mouth one time a day for DVT (Deep Vein
Thrombosis).
Review of the Physician's Orders for Resident #59 revealed no order for an anticoagulant.
During a telephone interview conducted on 08/28/24 at 4:33 PM with Staff VV Minimum Data Set (MDS)
Coordinator who stated she has worked at the facility for over 1 year. When asked how she determines if a
medication is high risk what drug classification it is, Staff VV stated that she looks at the order for aspirin or
Plavix (Clopidogrel Bisulfate) and what the indication is on the order, if it is for something related to the
heart like CAD, she classifies it anticoagulant under high risk medications in Section D of the MDS.
During a telephone interview conducted on 08/28/24 05:25 PM with facility's Consultant Pharmacist (CP)
with Staff VV also on the telephone, the CP was asked if aspirin is antiplatelet, she stated it is antiplatelet
and inhibits coagulation. When asked if aspirin was an anticoagulant, the CP stated no it is not . When
asked about Clopidogrel she stated it is a reducing platelet activation and aggregation and is not
considered an anticoagulant. The CP does not look at aspirin and Clopidogrel, or Plavix as an
anticoagulant, because they work differently. The CP stated the mediations that would be classified as an
anticoagulant would be Warfarin, Eliquis, Heparin, etcetera. Staff VV stated that after listening to the CP
she acknowledged she had documented incorrectly the high class medications for anticoagulant and
antiplatelet for Residents #48, #100, and #59.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 5 of 70
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
08/30/2024
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Record
review for Resident #94 revealed that the resident was admitted to the facility on [DATE] with the following
diagnoses: Anxiety Disorder; Type 2 Diabetes Mellitus With Other Specified Complication; Altered Mental
Status.
Review of the Minimum Data Set (MDS) dated [DATE] Quarterly revealed that Resident #94 had a Brief
Interview for Mental Status (BIMS) of 02, which indicated that she was severely cognitively impaired.
Review of the Physician's Orders showed that Resident #94 had an order dated 05/08/24 for Insulin Lispro
Injection Solution, inject as per sliding scale: if 150 - 199 = 2 units ; 200 - 249 = 4 units; 250 - 299 = 6 units;
300 - 349 = 8 units; 350 - 399 = 10 units Blood glucose greater than 400 give 12 units and notify physician,
subcutaneously before meals and at bedtime for DM type 2. Clonazepam tablet 0.5 mg, give 1 tablet by
mouth three times a day for Anxiety.
Review of the Care Plan for Resident #94 revealed only one entry for Advanced Directives dated 07/28/24,
no other documentation.
During an interview conducted on 08/30/24 at 3:50 PM, Assistant Director of Nursing (ADON) stated she
was unable to find any Care Plan for Resident #94 prior to the one dated 07/28/24. She noted that there
was only the Interdisciplinary Care Plan Conference Record dated 06/04/24 in Resident #94's paper chart.
She acknowledged that Resident #94 was admitted on [DATE] and by now there should be a Care Plan in
place.
3) Record review for Resident #306 revealed that the resident was admitted to the facility on [DATE] with
the following diagnoses: Dementia, Unspecified Severity; Depression.
Review of the Physician's Orders showed that Resident #306 had an order dated 08/15/24 for Olanzapine
Tablet 5 MG, Give 1 tablet by mouth one time a day for psychotic disorder; Observe closely for side effects
of Antipsychotic medication including dry mouth, constipation, blurred vision, disorientation or confusion,
difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting, lethargy, drooling, EPS
symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or
tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of
the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings.
Review of the Care plan dated 08/10/24 revealed that the resident has impaired cognitive function/dementia
or impaired thought processes r/t Dementia. However, there was no entry for antipsychotics medications.
4) Record review for Resident #100 revealed the resident was admitted to the facility on [DATE] with
diagnoses that included in part: Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral
Infarction Affecting Left Non-Dominant Side, Transient Ischemic Attack, and Malignant Neoplasm of
Prostate.
Review of the Minimum Data Set for Resident #100 dated 06/03/24 documented a Brief Interview of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 6 of 70
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
08/30/2024
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 0656
Mental Status score of 15 indicating a cognitive response.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Physician's orders for Resident #100 revealed an order dated 06/01/24 for full code.
Residents Affected - Few
Review of the Care Plan for Resident #100 revealed there was no care plan to address advanced
directives.
During an interview conducted on 08/28/24 at 4:46 PM with the Social Service Director (SSD) who stated
she has been working at the facility since June 2024. When asked about Resident #100 the SSD said his
code status is full code. When asked about the advance directive care plan for Resident #100 the SSD
acknowledged there was no advanced directive care plan for the resident and entered one as she was
speaking with the surveyor. The SSD stated she does not know how it got missed.
Based on interviews, and record review, the facility failed to implement a Comprehensive Care Plan for
antipsychotic medications for 3 of 43 sampled residents (Resident #56, Resident #306, and Resident #94)
and a Comprehensive Care Plan for an Advance Directive for 1 of 43 sampled residents (Resident #100).
The findings included:
A review of the facility's policy titled Care Plan-Comprehensive, dated 09/01/2022, revealed an
individualized comprehensive care plan that includes measurable objectives and timetables to meet the
resident's medical, nursing, mental, and psychological needs is developed for each resident. Identifying
problem areas and their causes and developing interventions that are targeted and meaningful to the
resident are developed through an interdisciplinary process. The resident's comprehensive care plan is
developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).
Assessments of residents are ongoing, and care plans are revised as information about the resident and
the resident's condition changes.
A record review showed that Resident #56 was admitted on [DATE] with diagnoses of Alzheimer's, Anemia,
and Anxiety Disorder. A review of the Medication Administration Record revealed an order for Seroquel
(antipsychotic medication), one tablet by mouth, two types a day for psychosis, which was dated 04/07/24.
The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #56 had a Brief Interview of
Mental Status (BIMS) score of 08, which is moderate cognitive impairment.
1. A review of Resident #56's Care Plan did not show that an antipsychotic medication Care Plan with goals
and interventions was ever initiated.
In an interview conducted on 08/28/24 at 10:36 AM, with the Assistant Director of Nursing (ADON) she
stated that Resident #56 did not have a care plan for antipsychotic medication and that the exception is to
have a Care Plan developed with goals and interventions that addresses the use of antipsychotic
medications. The DON stated that they have a staff member who oversees the Care Plans, but they only
work as needed but is starting full time in December of this year.
In a phone interview conducted on 08/28/24 at 10:44 AM with Staff VV, the MDS Coordinator stated that
she is the only staff member currently working on the residents' Care Plans in the facility. For any residents
on antipsychotic medication, she will initiate a Care Plan that includes the following: gradual dose reduction,
side effects of medications, overall observation of residents, and anything related to behaviors observed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 7 of 70
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
08/30/2024
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to ensure a comprehensive care plan for smoking was
revised by the interdisciplinary team after each assessment, including both the comprehensive and
quarterly review assessments for 1 of 1 residents sampled for smoking (Resident #59).
The findings included:
Review of the Facility's policy titled, Care Plan - Comprehensive with an effective date of 09/01/22 included
in part the following: An individualized comprehensive care plan that includes measurable objectives and
timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each
resident. Assessments of residents are ongoing, and care plans are revised as information about the
resident and the resident's condition change.
Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses
that included in part: Chronic Obstructive Pulmonary Disease, Other Lack of Coordination, Muscle
Weakness, Need for Assistance with Personal Care, and Nicotine Dependence.
Review of the Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status score of 15
indicating a cognitive response.
Review of the Smoking Safety Evaluation for Resident #59 dated 05/06/24 revealed the resident utilizes
tobacco. Supervision will be required for all residents during designated smoking times. This evaluation will
be utilized for the Resident's smoking care plan on admission and as indicated.
Review of the Care Plan for Resident #59 dated 09/01/23 with a problem/need of Resident is a smoker
related to resident choice. The Goal was for resident to comply with facility smoking rules through next
review date (Target Date of 12/01/23). The interactions/Approaches included the following: Educate on
facility smoking policy. Educate resident on designated smoking area. Assess resident for smoking safety.
Supervision for smoking. Encourage cessation. This revealed the care plan was not reviewed and revised
since 12/01/23.
During an interview conducted on 08/26/24 at 1:31 PM with Resident #59 who stated she is a smoker.
During an interview conducted on 08/30/24 at 2:00 PM with the Medical Records Personnel who stated she
has worked at the facility for 3 years. When asked about the Interdisciplinary Care Plan Conference
Records provided to surveyors who asked for Care Plans for residents, the Medical Records Personnel
stated she thought the Interdisciplinary Care Plan Conference Records were the care plans.
During an interview conducted on 08/30/24 at 4:30 PM with the Assistant Director of Nursing and the
Director of Nursing, who were asked about the Care Plans being revised by the interdisciplinary team after
each assessment, including both the comprehensive and quarterly review assessments, they both
acknowledged the paper care plans have not been revised and there are no electronic care plans for
Resident #59 except for the advanced directive care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 8 of 70
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
08/30/2024
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**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 necessary
services to maintain good nutrition for 1 (Resident #45) of 6 sampled residents that are unable to eat
without staff assistance.
Residents Affected - Few
The findings included:
During an observation of Resident #45 on 08/28/24 at 12:20 PM, it was noted that the resident's lunch tray
had been placed on the over-bed table directly in front and in reach of the resident. It was also noted that a
large container of non -thickened water with drinking straw was also placed in reach of the resident. It was
noted that the resident was scooping large portions of pureed foods with bare hands above her head and
dropping the pureed foods into her mouth. It was noted that the resident started coughing and regurgitation
the pureed foods from her mouth onto her chest.
The surveyor immediately requested the nurse to come to Resident #45's room. The Director of Nursing
(DON) was noted to come to the room and observed the surveyors findings of the resident eating large
scoops of pureed foods with hands and coughing and regurgitating foods. The surveyor informed the
Director of Nursing that the resident is assessed to be cognitively impaired, required Honey Thick liquids,
and requires maximum assistance with eating. The DON removed the lunch tray which was 75% finished
and stated to the surveyor that he would take care of the incident. The CNA (Staff F) who was assigned to
Resident #45 stated that she was assigned to the dining room for the lunch meal on 08/28/24 and did not
know who put the lunch tray in front of Resident #45 and allowed the cognitively, dysphagia diagnosed
resident to eat without supervision.
Review of Resident #45's clinical record revealed an admission date of 12/31/24 with diagnoses that
include Hemiplegia and Dysphagia. Further review noted physician orders for No Added Salt, Pureed Diet
with Honey Thick Liquids.
Review of the Minimum Data Set (MDS) dated [DATE] documented the resident is rarely
understood/understands and that the resident requires maximum assistance with eating.
Review of the Nutritional assessment dated [DATE] documented Purred Diet with independent feeding.
Review of the current care plan dated 03/06/24 documented maximum assistance with eating.
On 08/29/24 at 7:45 AM during an observation of Resident #45 it was noted that the resident was provided
maximum assist with the eating of the breakfast meal and no water was available at the beside of resident
according to facility policy. The DON was also interviewed and it was again confirmed that the resident is
cognitively impaired, diagnosed with Dysphagia, required maximum assistance with eating, and requires
Honey Thick Liquids.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 9 of 70
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
08/30/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record review the facility failed to ensure it was free from accident/hazard as
evidenced by not providing direct supervision for 1 of 23 residents who smoke (Resident #59), paper trash
observed in 1 of 1 red smolder cigarette butt bin on the smoking patio and excess lint in 1 of 2 dryers in the
laundry room.
The findings included:
1) On 08/28/24 at 4:08 PM an observation was made of several residents on the smoking patio, with Staff
NN, a Certified Nursing Assistant who was present on the inside of the facility watching residents on the
smoking patio through the window. Visibility of entire smoking patio and all residents smoking was not
visible from inside the facility through the window. Resident # 59 was smoking on the smoking patio at the
far end away from the glass door and window and not visible from the inside of the facility.
Record review for Resident #59 revealed the resident was admitted to the facility on [DATE] with diagnoses
that included in part: Chronic Obstructive Pulmonary Disease, Other Lack of Coordination, Muscle
Weakness, Need for Assistance with Personal Care, and Nicotine Dependence.
Review of the Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status score of 15
indicating a cognitive response.
Review of the Smoking Safety Evaluation for Resident #59 dated 05/06/24 revealed the resident utilizes
tobacco. Supervision will be required for all residents during designated smoking times. This evaluation will
be utilized for the Resident's smoking care plan on admission and as indicated.
During an interview conducted on 08/26/24 at 1:31 PM Resident #59 stated she is a smoker.
During an interview conducted on 08/28/24 at 4:10 PM with Staff NN CNA, When asked if she is the
responsible staff member at this time to observe residents smoking, she said yes. When asked why she
was inside the facility, she said they watch from the inside and just gets up to go outside from time to time
when residents are outside. When asked if she can see/observe all residents specifically at the other end of
the patio who were smoking, she said not while she was inside. When asked if she always performs this
duty by herself, she said they take turns and usually there are 2 staff present, but not today they are a little
short staffed.
Review of the facility's policy titled, Smoking-Residents with an effective date of 08/01/23 included the
following in part: The residents are only permitted to smoke under the direct supervision of facility staff.
2) On 08/26/24 at 11:00 AM an observation was made of the smoking patio with multiple cigarette butts
scattered over the entire floor, red smolder cigarette butt bin contained cigarette butts and paper trash
(Photographic Evidence Obtained). There were no residents or staff on the patio.
On 08/28/24 at 4:08 PM an observation was made of several residents on the smoking patio, with Staff NN
Certified Nursing Assistant who was present on the inside of the facility watching residents on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 10 of 70
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
08/30/2024
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the smoking patio through the window. On the smoking patio in the red smolder cigarette butt bin contained
several cigarette butts and various paper trash.
During an interview conducted on 08/28/24 at 4:10 PM with Staff NN CNA who was asked about the red
smolder cigarette butt bin with lid containing several cigarette butts and various paper trash; she
acknowledged the paper trash should not be in there.
On 08/28/24 at 6:25 PM a side by side observation was conducted with Staff UU Certified Nursing
Assistant (CNA) who acknowledged the red smolder cigarette butt bin lid contained several cigarette butts
and various paper trash. She stated: I guess it needs to be emptied.
3) On 08/30/24 a review of the Lint Removal Log in the laundry area revealed no documentation indicating
the dryer lint removal was completed at 7:00 AM and 9:00 AM on 08/30/24.
During an observation conducted on 08/30/24 at 10:20 AM of the laundry noted 1 of 2 of the dryers was
being used. Staff EE Laundry Aide was asked to open the lint compartment of the dryers. She stopped the
dryer and opened the compartment. Upon opening the compartment a pile of lint was noted at the base
and a coat of lint noted on the vent (Photographic Evidence Obtained). Staff EE Laundry Aide removed the
lint with a broom and was about to put the cover back. Further observation of the vent revealed that more
lint was piled on top of the vent.
During an interview conducted on 08/30/24 at 10:20 AM with Staff EE Laundry Aide stated that they clean
the lint in the dryer every 2 hours.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 11 of 70
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
08/30/2024
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 0693
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations and interviews, the facility failed to follow the doctor's orders for tube feeding
administration, complete a nutritional assessment, and identify a severe weight loss for 1 of 1 resident
reviewed for tube feeding (Resident #210).
The findings included:
Resident #210 was admitted to the facility on [DATE] with diagnoses of Seizures, Dementia, Hypertension,
and Protein Calorie Malnutrition.
Hospital records dated 08/07/24 (8 days before his admission to the facility) showed the following: Resident
#210 presented to the hospital with lethargy, lack of appetite, poor intake of meals, and Altered Mental
Status. Resident #210 ' s daughter agreed to move forward with a Percutaneous endoscopic gastrostomy
(PEG) placement. The Speech Language Pathologist deemed inappropriate for food by mouth trials and at
high risk for aspiration. Upon physical exam, Resident #210 ' s weight was 132 pounds.
The Minimum Data Set (MDS) dated [DATE] revealed that Resident #210 has severe cognitive impairment.
A review of the physicians ' orders showed an order for enteral feeding Jevity 1.5 (tube feeding formulary)
and bolus feeding six times a day, which started on 08/16/24. The bolus tube feeding regimen times are to
be given at 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 9:00 PM. A can of Jevity 1.5 provides 355
calories/can and 15.1 grams of protein/can. This above order will provide 2130 calories a day and 90.6
grams of protein if six cans of Jevity 1.5 are given as ordered.
A review of Resident #210's electronic chart showed that no initial nutritional assessment was completed
for Resident #210, and no admission weight was taken on Resident #210.
In an interview conducted on 08/27/24 at 12:30 PM with Staff AA, the Clinical Dietitian stated that she
completed Resident #210 ' s initial nutrition assessment on 08/25/24 but did not know why it was not in the
electronic system and could not provide a copy of the evaluation to this Surveyor. She further said she
completes an initial nutrition assessment within seven days of admission. If the residents are at high
nutritional risk, she will try to complete the assessment sooner. Staff AA said that she did not have an
admission weight obtained on admission for Resident #210 and was unaware of Resident #210 ' s weight
history.
In an interview conducted on 08/27/24 at 2:30 PM with Staff HH, a Certified Nursing Assistant (CNA) stated
that a designated CNA (Staff GG) takes the weights on all residents.
In an interview conducted on 08/27/24 at 2:47 PM with Staff FF, Registered Nurse, she reported Resident
#210 is tolerating his bolus tube feeding well with no issues.
In an interview conducted on 08/27/24 at 2:55 PM with Staff GG, CNA stated that the weights are taken
and given to the assigned Nurse to put in the electronic system. Sometimes, the CNA assigned to the
specific resident will take the weight on the resident. Staff GG said that she only sometimes takes the
weights on all residents and that she is sometimes given other duties and assignments. When residents get
admitted or readmitted their weights are taken the same day or the day after. The
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 12 of 70
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
08/30/2024
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 0693
weights are monitored on a monthly basis, and sometimes, they are monitored on a weekly basis,
depending on the specific resident.
Level of Harm - Actual harm
Residents Affected - Few
This Surveyor requested a new weight on 08/27/24 at 3:10 PM. The weight showed that Resident #210 was
109.8 pounds, which revealed a 17% severe weight loss in less than one month.
In an observation conducted on 08/28/24 at 8:20 AM, Resident #210 was noted in bed with no tube feeding
running at the time of this observation.
In an interview conducted on 08/28/24 at 8:10 AM with Staff CC, a Registered Nurse (RN) was asked about
the scheduled bolus tube feeding times for Resident #210. She said that the night Nurse who worked the
11:00 PM to the 7:00 AM shift did not tell her when the last bolus tube feeding was given. Staff CC then
proceeded to look in the physical paper chart for Resident #210 ' s tube feeding order. Staff CC reported
that the tube feeding was not clear and that she needed to look at the electronic records for an accurate
tube feeding order. After a few minutes of trying to look for Resident #210 ' s tube feeding order in the
electronic system, she turned to the Assistant Director of Nursing (ADON), who was next to her, to help her
find the tube feeding order in the electronic system. The ADON was observed helping Staff CC look for
Resident #210 ' s tube feeding orders in the electronic system. Staff CC verified that the bolus tube feeding
regimen times are given at 5:00 AM, 8:00 AM, 11:00 AM, 2:00 PM, 5:00 PM, and 9:00 PM.
In an observation conducted on 08/28/24 at 8:20 AM, Resident #210 was noted in bed with no tube feeding
running at the time of this observation.
In an interview conducted on 08/28/24 at 8:26 AM, the ADON stated that Staff CC usually works on
different floors and was unfamiliar with Resident #210. She said that the 11:00 PM to 7:00 AM shift Nurse
should have communicated the tube feeding times and orders to Staff CC.
In an observation conducted on 08/28/24 at 9:00 AM, Resident #210 was noted in bed with no tube feeding
running in the room.
In an observation conducted on 08/28/24 at 9:30 AM, Resident #210 was noted in bed with no tube feeding
running in the room.
In an observation conducted on 08/28/24 at 9:40 AM, Staff CC noted feeding Resident #210 his bolus tube
feeding order, which was 1:40 minutes later than his scheduled feeding time of 8:00 AM.
In an observation conducted on 08/28/24 at 11:00 AM, Resident #210 was noted in bed with no tube
feeding running at the time of this observation.
In an interview conducted on 08/28/24 at 12:25 PM, with Staff, CC stated that she was just getting ready to
give Resident #210 his tube feeding since she gave the earlier feeding late.
A phone interview conducted on 08/28/24 at 1:00 PM with Resident #210 ' s daughter stated that her father
was 138 pounds about one month ago. She further stated that she is waiting on a Modified Barium Swallow
(MBS) exam to assess for possible diet upgrade by mouth which he was in the past.
In an interview conducted on 08/28/24 at 2:45 PM, with Staff CC reported she still needs to give Resident
#210 his tube feeding bolus feeding since the last bolus feeding was given at 12:30 PM. She
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 13 of 70
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
08/30/2024
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 0693
further said that she only gives one bottle of tube feeding at a time as per the Physician ' s orders and does
not give two bottles to compensate for the late times.
Level of Harm - Actual harm
Residents Affected - Few
A progress note dated 08/22/24 by the Physician revealed the following: Resident #210 with a history of
Dementia and Protein Calorie Malnutrition.
The care plan initiated on 08/27/24 showed that Resident #210 was at risk for alteration in nutrition and
hydration related to malnutrition/risk for malnutrition and tube feeding. Resident #210 will eat above 50% of
his meals daily through the next review date. Diet as ordered, cue, set up, and assist as needed with meals.
A review of the Medication Administration Audit Report for Resident #210 revealed the following: On
08/22/24, the tube feeding scheduled for 9:00 PM was given at 10:20 PM, which was one hour and 20
minutes later. On 08/23/24, the tube feeding that was scheduled to be given at 5:00 PM was given at 6:36
PM, which was 1 hour and 36 minutes later. On 08/23/24, the tube feeding that was scheduled to be given
at 9:00 PM was given at 11:07 PM, which was 2 hours and 7 minutes later. On 08/24/24, the tube feeding
was scheduled to be given at 9:00 PM and was given at 1:02 AM, which was 4 hours and 2 minutes later.
On 08/26/24, the tube feeding was scheduled to be given at 9:00 PM and was given at 4:58 AM, which was
7 hours and 58 minutes later. On 08/27/24, the tube feeding was scheduled to be given at 8:00 AM and was
given at 12:06 PM, which was 4 hours and 6 minutes later. On 08/27/24, the tube feeding was scheduled to
be given at 11:00 AM and was given at 12:14 PM, which was one hour and 14 minutes later. On 08/27/24,
the tube feeding was scheduled to be given at 9:00 PM and was given at 12:50 AM, which was 3 hours and
50 minutes later.
A review of the electronic record on 08/28/24 showed that Resident #210 did not complete an initial
nutrition assessment, which was 13 days after his admission.
A review of the facility's policy titled Nutrition Policy dated 09/07/2023 revealed the following: A Registered
Dietitian or other clinically qualified nutritional professional is responsible for the completion of a
comprehensive nutrition assessment for all residents/patients for the purpose of identifying and planning
the nutrition care based on the needs, goals, and preferences of each resident/patient. The resident/patient
nutrition status will be assessed upon admission and monitored at least quarterly thereafter.
A review of the facility ' s policy titled Weight Management-Residents titled 12/2008 revealed the following:
The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our
residents. The nursing staff will measure the residents ' weights on admission/readmission. The threshold
for significant unplanned and undesired weight loss will be based on the following criteria [where the
percentage of body weight loss = (usual weight -= actual weight) / (usual weight) X 100]: a. month -= 5%
weight loss three months -- 7.5% weight loss six months -- 10% weight loss.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 14 of 70
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
08/30/2024
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
Based on record review interviews and observations, the facility failed to ensure minimum nursing staff was
provide daily related services to assure resident safety and attain or maintain the highest practicable
physical, mental, and psychosocial well-being of each resident, as determined by resident assessments
and individual plans of care and considering the number, acuity and diagnoses of the facility's resident
population affecting resident census of 111 out of 120 bed facility .
1) Review of the facility's State Minimum Nursing Staffing from 06/23/24 to 08/24/24 revealed on 06/30/24
the daily average for nursing (Registered Nurses and Licensed Practical Nurses) was 0.9899 (below the
minimum 1.0).
On 08/30/24 at 3:00 PM the administrator provided updated Minimum Nurse Staffing forms.
During an interview conducted 08/27/24 at 11:00 AM with the Administrator who stated she is the person
responsible for completing the Nurse Staffing Calculations. When asked what the minimum should be, she
said the daily average total Nursing hours should be 1.0, the daily average CNA 2.0 , and the weekly
average of combined Nursing, CNA, and Direct Care Staff should be 3.6. When asked about 06/30/24 with
the daily average for nursing being 0.9899, and 08/04/24 with the daily average for nursing being 0.9967
she said the nurses must have punched in late. The DON was asked about food/nutrition service staff, she
said those are the hours for all food service staff including the prep and cooking. She was informed the
hours are for direct care only. She said she would revise the forms and provide revised forms to the
surveyor.
Observation on 08/28/24 at 4:08 PM several residents were noted on the smoking patio, with Staff NN
Certified Nursing Assistant who was present on the inside of the facility watching residents on the smoking
patio through the window.
During an interview conducted on 08/28/24 at 4:10 PM with Staff NN, CNA. When asked if she is the
responsible staff member at this time to observe residents smoking, she said yes. When asked why she
was inside the facility, she said they watch from the inside and just gets up to go outside from time to time
when residents are outside, she said not while she was inside. When asked if she always performs this duty
by herself, she said they take turns and usually there are 2 staff present, but not today they are a little short
staffed.
An interview was conducted on 08/28/24 at 5:02 PM with Staff ZZ. She stated she feels that the facility is
short staffed,but we all work together to get the work done.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 15 of 70
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
08/30/2024
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interviews the facility failed to ensure a performance review of every Certified
Nursing Assistant (CNA) was completed at least every 12 months.
Residents Affected - Few
The findings included:
On 08/27/24 at 9:00 AM the Director of Nursing (DON) was asked for the performance review for the
following Certified Nursing Aides:
Staff II Certified Nursing Assistant with hire date of 11/04/20
Staff JJ Certified Nursing Assistant with hire date of 11/09/21
Staff KK Certified Nursing Assistant with hire date of 01/19/22
Staff LL Certified Nursing Assistant with hire date of 02/22/24
Staff MM Certified Nursing Assistant with hire date of 08/23/23
During an interview conducted on 08/29/24 at 9:50 AM with the DON who stated they are not able to
provide any performance review evaluations for the 5 CNAs that was requested due to transition of
ownership this week. When asked if he could try to request the information requested from the previous
owner, he said Human Resources informed him it is not available to be requested.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 16 of 70
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
08/30/2024
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 0732
Post nurse staffing information every day.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations and interviews the facility failed to post Nurse Staffing Data daily with current date
and in a prominent place readily accessible to residents and visitors.
Residents Affected - Some
The findings included:
On 08/26/24 from 10:00 AM to 11:00 AM during an initial tour of the facility, an observation was made on
the second floor. The nurse staffing data posted was dated 08/23/24 (Photographic Evidence Provided).
There was no other nurse staffing data posted in the facility.
During an interview conducted on 08/26/24 at 11:25 AM with Staff CC Registered Nurse. When asked if
there is nursing staffing data posting in the facility with the number of all staff and all nurses, she said no,
and she only knows about her floor (3rd), and they just have the white board that they write the
assignments for this floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 17 of 70
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
08/30/2024
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
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
onrecord reviews and the facility failed to administer medications in a timely
Residents Affected - Some
manner for 1 of 5 residents sampled for medication administration (Resident #70) and failed to ensure
medications administered as ordered for 1 of 6 residents sampled for medication reconciliation (Resident
#52) and failed to ensure drug records are in order and that an account of all controlled drugs is maintained
and periodically reconciled for 4 of 6 residents sampled for medication reconciliation (Residents #52, #54,
#16, #42).
The findings included:
Review of the facility's policy titled, Medication Administration Policy - General with an effective date of
08/07/23 included in part the following: Procedure:
3.7 Verify that the medication name and dose are correct when compared to the medication order on the
medication administration record.
4. Verify each time a medication is administered that it is the correct medication, at the correct dose, at the
correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's
medication administration schedule.
4.1 Confirm that the MAR (Medication Administration Record) reflects the most recent medication order.
Review of the facility's policy titled, Medication Reconciliation with an effective date of 08/07/23 included in
part the following: Medications shall be administered in a timely manner, and as prescribed. Procedure:
2. The Director of Nursing will supervise and direct all nursing personnel who administered medications
and/or have related functions.
3. Medications must be administered in accordance with the orders, including any required time frames.
4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified
(for example before and after meals).
1) Record review for Resident #70 revealed the resident was admitted to the facility on [DATE] with
diagnoses that included but not limited to: Type 2 Diabetes Mellitus with Other Specified Complication,
Acquired Absence of Right Leg Below Knee, Bipolar II Disorder, and Anxiety Disorder.
Review of the Minimum Data Set (MDS) for Resident #70 dated 07/13/24 documented a Brief Interview of
Mental Status score of 15 indicating a cognitive response.
Review of the Medication Administration Audit Report for Resident #70 from 08/15/24 to 08/26/24
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 18 of 70
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
08/30/2024
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
Revealed the following.
Level of Harm - Minimal harm
or potential for actual harm
On 08/15/24 the following medications were scheduled for 9:00 PM and given as follows:
Residents Affected - Some
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/16/24 at 12:51 AM
Levetiracetam 500 mg (milligram) tablet administered on 08/16/24 at 12:49 AM
Protein Oral Liquid 15 ml (milliliters) administered on 08/16/24 at 12:51 AM
Famotidine 10 mg tablet administered on 08/16/24 at 12:49 AM
Gabapentin 100 mg capsule administered on 08/16/24 at 12:49 AM
Atorvastatin Calcium 400mg tablet administered on 08/16/24 at 12:48 AM
Quetiapine Fumarate 50mg tablet administered on 08/16/24 at 12:51 AM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/16/24 at 12:51
AM
On 08/16/24 the following medications were scheduled for 9:00 AM and given as follows.
Losartan Potassium 100mg 1 tablet was administered on 08/16/24 at 12:41 PM
Trulicity Solution Pen-Injector 4.5 mg/0.5 ml (Dulaglutide) inject 4.5 mg subcutaneous was administered on
08/16/24 at 12:41 PM
On 08/16/24 the following medications were scheduled for 9:00 PM and given as follows:
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/17/24 at 12:15 AM
Famotidine 10mg tablet administered on 08/17/24 at 12:14 AM
Protein Oral Liquid 15 ml administered on 08/17/24 at 12:15 AM
Levetiracetam 500mg tablet administered on 08/17/24 at 12:14 AM
Gabapentin 100 mg capsule administered on 08/17/24 at 12:14 AM
Atorvastatin Calcium 400mg tablet administered on 08/17/24 at 12:14 AM
Quetiapine Fumarate 50mg tablet administered on 08/17/24 at 12:15 AM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/17/24 at 12:14
AM
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 19 of 70
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
08/30/2024
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
On 08/17/24 the following medications were scheduled for 9:00 PM and given as follows:
Level of Harm - Minimal harm
or potential for actual harm
Tivicay 50mg tablet administered on 08/17/24 at 10:02 PM
Folic Acid 1 mg tablet administered on 08/17/24 at 10:02 PM
Residents Affected - Some
Finasteride 5mg tablet administered on 08/17/24 at 10:02 PM
Clopidogrel Bisulfate 75 mg tablet administered on 08/17/24 at 10:01 PM
Buspirone HCL 10mg tablet administered on 08/17/24 at 10:01 PM
Protein Oral Liquid 15 ml administered on 08/17/24 at 10:02 PM
Dapagliflozin Propanediol 10mg tablet administered on 08/17/24 at 10:01 PM
Levetiracetam 500mg tablet administered on 08/17/24 at 10:47 PM
Losartan Potassium 100mg tablet administered on 08/17/24 at 10:47 AM
On 08/19/24 the following medications were scheduled for 9:00 PM and given as follows:
Levetiracetam 500mg tablet administered on 08/19/24 at 11:04 PM
Protein Oral Liquid 15 ml administered on 08/19/24 at 11:04 PM
Famotidine 10mg tablet administered on 08/19/24 at 11:04 PM
Gabapentin 100 mg capsule administered on 08/19/24 at 11:04 PM
Atorvastatin Calcium 40 mg tablet administered on 08/19/24 at 11:04 PM
Quetiapine Fumarate 50mg tablet administered on 08/19/24 at 11:04 PM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/19/24 at 11:04
PM
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/19/24 at 11:13 PM
On 08/20/24 the following medications were scheduled for 9:00 PM and given as follows:
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/20/24 at 11:53 PM
Famotidine 10mg tablet administered on 08/20/24 at 11:53 PM
Protein Oral Liquid 15 ml administered on 08/20/24 at 11:53 PM
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 20 of 70
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
08/30/2024
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
Levetiracetam 500mg tablet administered on 08/20/24 at 11:53 PM
Level of Harm - Minimal harm
or potential for actual harm
Gabapentin 100 mg capsule administered on 08/20/24 at 11:53 PM
Atorvastatin Calcium 40 mg tablet administered on 08/20/24 at 11:52 PM
Residents Affected - Some
Quetiapine Fumarate 50mg tablet administered on 08/20/24 at 11:53 PM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/20/24 at 11:53
PM
On 08/21/24 the following medications were scheduled for 9:00 PM and given as follows:
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/22/24 at 12:19 AM
Protein Oral Liquid 15 ml administered on 08/22/24 at 12:19 AM
Famotidine 10mg tablet administered on 08/22/24 at 12:19 AM
Gabapentin 100 mg capsule administered on 08/22/24 at 12:19 AM
Atorvastatin Calcium 40 mg tablet administered on 08/22/24 at 12:19 AM
Quetiapine Fumarate 50mg tablet administered on 08/22/24 at 12:19 AM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/22/24 at 12:19
AM
Levetiracetam 500mg tablet administered on 08/22/24 at 12:19 AM
On 08/22/24 the following medications were scheduled for 9:00 AM and given as follows:
Daily-Vite tablet administered on 08/22/24 at 10:03 AM
Tivicay 50mg tablet administered on 08/22/24 at 10:03 AM
Losartan Potassium 100mg tablet administered on 08/22/24 at 10:03 AM
Buspirone HCL 10mg tablet administered on 08/22/24 at 10:03 AM
Clopidogrel Bisulfate 75 mg tablet administered on 08/22/24 at 10:03 AM
Folic Acid 1 mg tablet administered on 08/22/24 at 10:03 AM
Finasteride 5mg tablet administered on 08/22/24 at 10:03 AM
Ascorbic Acid 500mg administered on 08/22/24 at 10:03 AM
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 21 of 70
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
08/30/2024
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
Dapagliflozin Propanediol 10mg tablet administered on 08/22/24 at 10:03 AM
Level of Harm - Minimal harm
or potential for actual harm
Protein Oral Liquid 15 ml administered on 08/22/24 at 10:03 AM
Levetiracetam 500mg tablet administered on 08/22/24 at 10:03 AM
Residents Affected - Some
On 08/24/24 the following medications were scheduled for 9:00 AM and given as follows:
Daily-Vite tablet administered on 08/24/24 at 10:35 AM
Losartan Potassium 100mg tablet administered on 08/24/24 at 10:35 AM
Tivicay 50mg tablet administered on 08/24/24 at 10:35 AM
Buspirone HCL 10mg tablet administered on 08/24/24 at 10:35 AM
Clopidogrel Bisulfate 75 mg tablet administered on 08/24/24 at 10:35 AM
Folic Acid 1 mg tablet administered on 08/24/24 at 10:35 AM
Finasteride 5mg tablet administered on 08/24/24 at 10:35 AM
Ascorbic Acid 500mg administered on 08/24/24 at 10:35 AM
Dapagliflozin Propanediol 10mg tablet administered on 08/24/24 at 10:35 AM
Protein Oral Liquid 15 ml administered on 08/24/24 at 10:35 AM
Levetiracetam 500mg tablet administered on 08/24/24 at 10:35 AM
On 08/24/24 the following medications were scheduled for 9:00 PM and given as follows:
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/25/24 at 12:19 AM
Famotidine 10mg tablet administered on 08/25/24 at 12:19 AM
Protein Oral Liquid 15 ml administered on 08/25/24 at 12:19 AM
Gabapentin 100 mg capsule administered on 08/25/24 at 12:19 AM
Atorvastatin Calcium 40 mg tablet administered on 08/25/24 at 12:19 AM
Quetiapine Fumarate 50mg tablet administered on 08/25/24 at 12:19 AM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/25/24 at 12:19
AM
Levetiracetam 500mg tablet administered on 08/22/24 at 12:19 AM
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 22 of 70
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
08/30/2024
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
On 08/25/24 the following medications were scheduled for 9:00 PM and given as follows:
Level of Harm - Minimal harm
or potential for actual harm
Novolog Injection Solution 100 unit/ml inject per sliding scale before meals and at bedtime administered on
08/26/24 at 4:08 AM
Residents Affected - Some
Protein Oral Liquid 15 ml administered on 08/26/24 at 4:08 AM
Famotidine 10mg tablet administered on 08/26/24 at 4:08 AM
Gabapentin 100 mg capsule administered on 08/26/24 at 4:08 AM
Atorvastatin Calcium 40 mg tablet administered on 08/26/24 at 4:08 AM
Quetiapine Fumarate 50mg tablet administered on 08/25/24 at 4:08 AM
Basaglar KwikPen Solution 100 unit/ml inject 22 units subcutaneously administered on 08/26/24 at 4:08 AM
Levetiracetam 500mg tablet administered on 08/26/24 at 4:08 AM
In summary from 08/15/24 to 08/26/24 Resident #70 was administered his medication more than 1 hour
late on 89 times including 57 times the medication was administered 2 to 6 hours late
During an interview 08/26/24 at 12:59 PM with Resident #70 who said the nurses give him his meds late,
sometimes he has to remind them to give him his meds because they forget to bring all of his meds that are
due at the same time, he said they almost always forget to give him his protein supplement, and he has a
wound and needs it to help his wound heal. When asked how often this happens, he said pretty much daily.
During an interview conducted on 08/29/24 at 5:00 PM with the Assistant Director of Nursing (ADON) who
was asked about medication administration times, she said medications should be given within 1 hour of
the scheduled time. When asked about Resident # 70, she acknowledged the medications are not given
timely.
2 Record review for Resident #52 revealed the resident was initially admitted to the facility on [DATE] with
most recent readmission on [DATE] with diagnoses that included in part the following: Encephalopathy,
Anxiety Disorder, and Parkinson's Disease with Dyskinesia Without Mention of Fluctuations.
Review of the MDS for Resident #52 dated 08/25/24 documented a BIMS score of 12 indicating moderate
cognitive impairment.
Review of the Physician's Orders for Resident #52 revealed an order dated 08/07/24 for Clonazepam oral
tablet 0.5 mg give 1 tablet by mouth one time a day for seizure was discontinued on 08/07/24 at 2:37 PM.
Review of the Medication Administration Record (MAR) for Resident #52 from 08/08/24 to 08/15/24 for the
medication Clonazepam 0.5 mg revealed no documentation of the medication being administered during
this time.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 23 of 70
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
08/30/2024
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 - Some
During a 3rd floor west med cart review conducted on 08/29/24 at 6:02 AM with Staff H Licensed Practical
Nurse (LPN) included Resident #52 Medication Clonazepam 0.5 mg. Staff H LPN verified with the surveyor
there were 11 pills of Clonazepam 0.5 mg for Resident #52 in the cart and listed as remaining on the
Medication Monitoring/Control Record.
Review of the Medication Monitoring/Control Record for Resident #52 for the medication Clonazepam 0.5
mg from 08/09/24 to 08/15/24 documented the medication had been signed out 08/9/24, 08/9/24, 08/10/24,
08/11/24, 08/14/24, and 08/15/24 with each day as the amount given 1 tablet leaving a remaining number
of tablets as 11.
During an interview conducted on 08/29/24 at 6:05 PM with the Assistant Director of Nursing (ADON) who
was asked about the Clonazepam 0.5 mg for Resident #52, the ADON acknowledged it appears according
to the Monitoring/Control Record the medication was signed out and given to the resident after the
medication had been discontinued on 08/07/24.
3) Record review for Resident #16 revealed the resident was admitted to the facility on [DATE] with the
following diagnoses: Anxiety Disorder; Other Specified Depressive Episodes; Delusional Disorder;
Unspecified Psychosis not due to Substance or Known Physiological Condition.
Review of the Physician's Orders showed that Resident #16 had an order dated 03/19/24 for Clonazepam
oral tablet 1 mg, give 1 tablet by mouth at bedtime for Anxiety.
Review of the August Medical Administration Record (MAR) showed that Resident #16 was administered
one tablet of Clonazepam 1 mg on 08/28/24 at bedtime.
Review of the Medication Monitoring/Control Record (Reconciliation) revealed that Resident #16 was
administered 2 tablets of Clonazepam on 08/28/24.
4) Record review for Resident #42 revealed the resident was admitted to the facility on [DATE] with the
following diagnoses: Schizoaffective Disorder; Other Specified Depressive Episodes.
Review of the Physician's Orders showed that Resident #42 had an order dated 03/20/24 for Clonazepam
oral tablet 1 mg, give 1 tablet by mouth three times a day for Anxiety.
Review of the August 2024 Medication Administration Record (MAR) revealed the nurses signed on
08/21/24, 08/28/24, and 08/29/24 for Clonazepam 1 mg tablet was administered to Resident #42.
Review of the Medication Monitoring/Control Record (Reconciliation) revealed that the order sticker on the
form states: Clonazepam tablet 1 mg, one tablet by mouth twice daily. Resident #42 received Clonazepam 1
mg tablet 3 times daily except on 08/21/24, 08/28/24 and 08/29/24, which he received Clonazepam 2 times
daily (not 3 times daily as per physician's orders.
5) Record review for Resident #54 revealed the resident was admitted to the facility on [DATE] with the
following diagnoses: Unspecified Dementia.
Review of the Physician's Orders showed that Resident #54 had an order dated 08/21/24 for Clonazepam
oral tablet 1 mg, give 1 tablet by mouth two times a day for Anxiety.
Review of the August 2024 MAR revealed Resident #54 was administered Clonazepam 1 mg 2 times daily
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 24 of 70
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
08/30/2024
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
as per physician's orders including 08/22/24, 08/26/24, and 08/27/24.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Medication Monitoring/Control Record (Reconciliation) revealed that Resident #54 received
Clonazepam 1 mg tablet only once on 08/22/24, 08/26/24, and 08/27/24 instead of twice daily as per
physician's orders.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 25 of 70
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
08/30/2024
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 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A record
review showed that Resident #56 was admitted on [DATE] with diagnoses of Alzheimer's, Anemia, and
Anxiety Disorder. A review of the Medication Administration Record revealed an order for Seroquel
(antipsychotic medication), one tablet by mouth two times a day for psychosis, which was dated
04/07/24-Mirtazapine (antidepressant medication) 30 milligrams (mg) at bedtime which was dated
03/19/24. Monitor for the following behaviors (specify): itching, picking at skin, restlessness, agitation,
hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions,
hallucinations, psychosis, aggression, and refusal of care. every shift for Mirtazapine 15 mg Document: 'Y' if
monitored and none of the above observed. 'N' if monitored and any of the above was observed, select
chart code 'Other' See Nurses Notes' and progress note findings, which was dated 03/19/24.
Residents Affected - Some
The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #56 had a Brief Interview of
Mental Status (BIMS) score of 08, which is moderate cognitive impairment.
A review of the Treatment Administration Record (TAR) for August 2024 revealed that from August 1st to
August 22nd, an N was written in each box indicating that behaviors were observed. A continued review did
not show a section for 'Other' indicating the type of behaviors that were observed.
In an interview conducted on 08/28/24 at 11:10 AM with the Assistant Director of Nursing stated that when
a N is marked in the TAR, nurses are supposed to select the code 9 for Other and documents in the nursing
progress notes the behaviors that they observed which they have not been doing.
In an interview conducted on 08/28/24 at 4:55 PM with Staff BB, a Registered Nurse stated that he
monitors Resident #56's behaviors and documents in the Treatments Administration Record. Once you see
a behavior, he documents a Y for behaviors observed and a N for no behaviors observed. For any
behaviors observed he will go ahead and write a note regarding the behaviors observed in the progress
notes. When asked to clarify the monitoring orders he stated that he was under the impression that a Y
meant that behaviors were observed, and N meant that behaviors were not observed.
Based on observations, interviews, and record review, the facility failed to ensure behaviors were
adequately monitored for residents on psychotropic medications for 4 of 5 residents reviewed for
unnecessary medications (Resident #76, Resident #306, Resident #307, and Resident #56).
The findings included:
Review of the facility's policy titled, Behavior Monitoring, dated 09/01/23, included the following: Residents
who have not used psychotropic medications are not given these medications unless the medication is
necessary to treat a specific condition as diagnosed, documented in the clinical record and per physician
order.
Procedure:
1.Resident(s) receiving psychotropic medication should have specific condition documented indications in
the medical record.
4. Monitor behavior and side effects every shift utilizing the electronic Behavior Monitoring Flow Record.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 26 of 70
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
08/30/2024
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
11. Care plan to include person centered goals and non-pharmaceutical interventions. Update Care Plan as
indicated.
1) Record review for Resident #76 revealed the resident's initial admission was 04/28/23 and was
readmitted to the facility on [DATE] with the following diagnoses: Major Depressive Disorder, Recurrent,
Severe with Psychotic Symptoms; Post-Traumatic Stress Disorder; Anxiety Disorder Due To Known
Physiological Condition.
Review of the Physician's Orders showed that Resident #76 had an order dated 06/18/24 for Risperdal oral
tablet 2 mg, give 1 tablet via Percutaneous Endoscopic Gastrostomy (PEG) Tube two times a day for
Psychosis; observe closely for side effects of Antipsychotic medication including dry mouth, constipation,
blurred vision, disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea
or vomiting, lethargy, drooling, EPS (Extrapyramidal symptom) symptoms (tremors, disturbed gait,
increased agitation, restlessness, involuntary movement of mouth or tongue) every shift Document: 'Y' if
monitored and none of the above observed. 'N' if monitored and any of the above was observed, select
chart code 'Other/ See Nurses Notes' and progress note findings.
Review of the behavior notes and health status notes for Resident #76 for August 2024 revealed no notes
related to behaviors or symptoms.
Review of the Behavior Monitoring Record for Resident #76 for August 2024 revealed only a check mark
each day on each shift (morning, evening and night) for each day. The documentation did not indicate a Y or
N as ordered.
Review of the CNA (Certified Nursing Assistant) Task for Monitor - Behavior Symptoms for Resident #76 for
August 2024 documented the resident had no symptoms.
2)Record review for Resident #306 revealed that the resident was admitted to the facility on [DATE] with the
following diagnoses: Dementia, Unspecified Severity; Depression.
Review of the Physician's Orders showed that Resident #306 had an order dated 08/15/24 for Observe
closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision,
disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting,
lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary
movement of mouth or tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if
monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress
note findings.
Review of the behavior notes and health status notes for Resident #306 for August 2024 revealed no notes
related to behaviors or symptoms.
Review of the Behavior Monitoring Record for Resident #306 for August 2024 revealed only a check mark
each day on each shift (morning, evening and night) for each day. The documentation did not indicate a Y or
N as ordered.
Review of the CNA Task for Monitor - Behavior Symptoms for Resident #306 for August 2024 documented
the resident had no symptoms.
3) Record review for Resident #307 revealed that the resident was admitted to the facility on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 27 of 70
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
08/30/2024
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 0757
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
[DATE] with the following diagnoses: Bipolar Disorder; Other Specified Depressive Episodes; Anxiety
Disorder; Paranoid Schizophrenia.
Review of the Physician's Orders showed that Resident #307 had an order dated 08/14/24 tor observe
closely for side effects of Antipsychotic medication including dry mouth, constipation, blurred vision,
disorientation or confusion, difficulty urinating, hypotension, dark urine, yellow skin, nausea or vomiting,
lethargy, drooling, EPS symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary
movement of mouth or tongue) every shift Document: 'Y' if monitored and none of the above observed. 'N' if
monitored and any of the above was observed, select chart code 'Other\See Nurses Notes' and progress
note findings.
Review of the behavior notes and health status notes for Resident #307 for August 2024 revealed no notes
related to behaviors or symptoms.
Review of the Behavior Monitoring Record for Resident #307 from 08/14/24 to 08/27/24 revealed only a
check mark each day on each shift (morning and night) for each day. The documentation did not indicate a
Y or N as ordered.
Review of the CNA Task for Monitor - Behavior Symptoms for Resident #307 for August 2024 documented
the resident had no symptoms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 28 of 70
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
08/30/2024
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 0760
Ensure that residents are free from significant medication errors.
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 ensure that residents are free of any
significant medication errors for high-risk medications for 1 of 4 residents reviewed for medication
administration (Resident #9).
Residents Affected - Few
The findings included:
Review of the facility's policy titled, Medication Administration Policy-General, dated 08/07/23, included the
following:
Procedure:
3. Dose Preparation: take all measures required by Facility policy and Applicable Law, including, but not
limited to the following:
3.7 Verify that the medication name and dose are correct when compared to the medication order on the
medication administration record.
Record review for Resident #9 revealed that the resident was admitted to the facility on [DATE] with the
following diagnoses: Hemiplegia, Type 2 Diabetes Mellitus, Hypertension.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview for
Mental Status of 15, which indicated that she was cognitively intact.
Review of the Physician's Orders showed that Resident #9 had an order dated 03/29/24 for Labetalol HCL
100mg tablet, give 1.5 tablets (total to be given 150 mg) by mouth every 12 hours for Hypertension.
During a medication administration observation conducted on 08/27/24 at 8:28 AM with Staff CC,
Registered Nurse (RN); she was observed preparing all the morning medications for Resident #9 including
Labetalol HCL 100mg tablet. Upon further observation, Staff CC only prepared one tablet of Labetalol 100
mg. After all medication were prepared, Staff CC was stopped by surveyor in Resident #9's room prior to
her administering the incorrect dose of Labetalol. At this point, the surveyor asked Staff CC to review the
medications that she was administering to Resident #9 especially the Labetalol. Upon review of the
medication orders, Staff CC acknowledged that the order was for one and a half tablet of Labetalol which
would be 150 mg dose instead of the 100 mg dose that she was about to administer, she then prepared the
correct dose of the Labetalol (one and a half tablets equal to 150 mg).
In summary, this indicated that the nurse was about to give the wrong dose of the high-risk medication,
Labetalol.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 29 of 70
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
08/30/2024
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews and record reviews the facility failed to ensure medications were secured at
bedside for 1 of 43 sampled residents (Resident #28), failed to secure medications in 1 of 1 clean linen
closet located on 2nd floor, and failed to secure wound treatment cart for 2 of 2 wound treatment carts.
The findings included:
Review of the facility's policy titled, Medication Storage with an effective date 12/08/23 included in part: The
facility shall store all drugs and biologicals in a safe, secure and orderly manner. Procedure:
4. The facility shall not use discontinued, outdated, deteriorated drugs or biologicals. All such drugs shall be
returned to the dispensing pharmacy or destroyed.
7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes)
containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such
items shall not be left unattended if open or otherwise potentially available to others.
Review of the facility's policy titled, Self-Administration of Medications with an effective date of 08/01/23
included in part the following: As part of their overall evaluation, the staff and practitioner will assess the
resident's mental and physical abilities, to determine whether a resident is capable of self-administering
medications for those residents who express a desire to self-administer medications. Procedure: 5.
Self-administered medications must be stored in a safe and secure place, which is not accessible by other
residents. If safe storage is not possible in the resident's room, the medications of residents permitted to
self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer
the unopened medication to the resident when the resident requests them.
1) On 08/26/24 at 10:41 AM an observation was made of 3rd floor clean utility closet located across from
the nursing station next to respiratory room; inside the unlocked, closet was a bottle of Dakin's solution for a
resident who no longer resides in the facility (Photographic Evidence Obtained).
During a side-by-side observation of 3rd floor clean utility closet with the Director of Nursing (DON) who
was asked about the bottle of Dakin's solution, he said I think someone must have emptied the bottle and
filled it with water he did acknowledge it should not be in the closet.
2) On 08/26/24 at 12:55 PM an observation was made of Resident # 28 sitting in wheelchair next to her bed
with several items neatly placed on her bed including 2 tubes of Cortisone cream (Photographic Evidence
Obtained).
During an interview conducted on 08/26/24 at 12:55 PM with Resident #28 who was asked what she does
with the Cortisone cream, she said she uses it for her skin cancer cells, when asked how long she has
been doing this, she said for a long time. Record review for Resident # 28 revealed the resident was
admitted to the facility on [DATE] with diagnoses including Chronic obstructive Pulmonary
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 30 of 70
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
08/30/2024
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 0761
Disease and Delusional Disorders.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Minimum Data Set (MDS) for Resident #28 dated 06/06/24 in documented a Brief Interview
of Mental Status score of 10 indicated a moderate cognitive impairment.
Residents Affected - Some
Review of the Physician Orders for Resident #28 revealed no order for Cortisone cream.
Record review of Resident #28's chart revealed no self-administration of medication evaluation.
During an interview conducted on 08/28/24 at 7:30 PM with the Director of Nursing (DON). When asked if
they have any residents who can self-administer medications, the DON said no. The DON said for any
resident to be able to self-administer meds they would need to be evaluated, and the medication would
need to be secured at all times. When asked if Resident #28 can self-administer medications, he said no,
why do you ask? When the DON was informed of Resident #28 noted with 2 tubes of Cortisone cream on
her bed, the DON acknowledged she should not have any medications at the bedside.
3) On 08/28/24 at 06:20 PM an observation was made of a wound treatment cart left unlocked and
unattended at the 3rd floor nursing station. Inside the wound treatment cart was scissors and various
medications, including creams and solutions. Staff ZZ Registered Nurse (RN) approached the Surveyor and
the unlocked/unattended wound treatment cart.
During an interview conducted on 08/28/24 at 6:25 PM with Staff ZZ RN; when asked about the
unlocked/unattended wound treatment cart, she acknowledged the various medications and scissors in the
unlocked/unattended treatment cart. Staff ZZ RN was asked who is responsible for the wound treatment
cart, she said the wound care nurse. When asked where the wound care nurse was, she said she may have
gone to the second floor but was not on the third floor. Staff ZZ RN acknowledged the wound treatment cart
should be locked at all times.
3) During a wound care observation conducted on 08/28/24 at 2:48 PM, Staff XX, Licensed Practical Nurse
(LPN) stated she has been working at the facility for 3-4 months as the wound care nurse. Staff XX was
observed gathering supplies from the wound care cart for the wound treatment. She entered the resident's
room and set-up all the supplies on the overbed table. Further observation revealed Staff XX left the wound
care cart unlocked in the hallway and the surveyor observed two residents in their wheelchairs pass by and
stopping by the wound care cart. During the wound treatment Staff XX ran out of supplies and went back to
the wound care cart to gather more supplies. She was observed again leaving the wound care cart
unlocked.
During an interview conducted on 08/28/24 at 3:00 PM, Staff XX was asked why she left the wound care
cart unlocked, she stated that she does not have the keys to the wound cart. She further added that the
floor nurses have the keys to the wound care cart therefore, she leaves it open not to bother the nurses on
the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 31 of 70
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
08/30/2024
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 0800
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional
and special dietary needs.
Based on observation, interview, and record review, it was determined that the facility failed to provide 107
of 111 facility residents with a nourishing, palatable, well-balanced diet that meet dietary needs and taking
into consideration of food preferences of the residents.
The findings included:
1) During the observation of the Breakfast meal of 08/28/24 at 7:30 AM, it was noted that all resident meal
trays include a 4 ounce serving of a light colored pink liquid. A review of numerous resident meal tray tickets
were noted to have documentation of a preference of a Orange Juice serving.
A review of the approved menu for the breakfast meal of 08/28/24 noted documentation of a 6 ounce
portion of Vitamin C Juice to be served.
On 08/28/24 at 9:30 AM the surveyor went into the main kitchen to investigate the juice that was served for
the 08/28/24 breakfast meal. During an interview with the Diet Aide's (Staff C & D) a container of Tropical
Punch (63 ounce powder) was given to the surveyor. The staff stated that 6-7 scoops of the powder is
mixed with approximately 1 gallon of water, poured into a 4 ounce cup and served to the residents. The
staff stated that they have been using the same open container for the last 3 days for the breakfast meals.
The container that was being used was noted to be 1/2 full (30 ounces) of the powder with the scoop
directly embedded into the powder. Further examination of the container noted that the lid was documented
as being opened on 08/24/24. Further review of the Nutrition Facts listed on the label noted that a whole
container provides 69 - 12 ounce servings per drink and 100 calories/ 25 grams of sugar, and 13 mg (15%)
of Daily value. This analysis would indicated that the serving provided to the resident's would provide only
50 calories, 12.5 grams Sugars, and 6.5 mg (7.5 % Daily Value - DV) of Vitamin C. The calculations also
revealed that in order to provide at least 110 residents with a 6 ounce portion of punch that 3 whole
containers 189 ounces of the punch powder) would have to be utilized for the preparation of the breakfast
juice.
Photographic Evidence Obtained
* Note that a 4 ounce serving of natural Orange Juice would provide 60 calories and and 75% of Vitamin C
Daily Value.
Interview with the Certified Dietary Manager during the review noted that Orange Juice has not been
available to the residents over the last 2 days and hoped that a delivery would be coming on 08/29/24. It
was also stated that there were no other Citrus Juice ( Apples Juice, or Cranberry Juice) It was also
confirmed that the Punch directions for mixing were not being followed and watered down version of the
punch was being provide. At the request of the surveyor a list of residents requesting a juice preference of
Orange Juice with the breakfast meal was provided. The list noted that 43 residents requested Orange
Juice with the breakfast meal, 3 residents' requested Orange/Cranberry/or Apple Juice with the breakfast
meal, and 14 resident's requesting just Juice.
2) During the observation of the breakfast meal in the main kitchen on 08/27/24 at 7:00 AM, it was noted
that the approved menu for the breakfast meal of 08/27/24 documented that Sausage Links (2 links per
serving) to be served to Regular and No Concentrated Sweets Diet. Review of the Diet Census for 08/26/24
noted that there were 71 residents with physician ordered Regular Consistency Diet.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 32 of 70
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
08/30/2024
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 0800
Level of Harm - Minimal harm
or potential for actual harm
Observation of the breakfast meal noted that only 50 sausage links were prepared for the breakfast meal
(25 portions). Continued observation of the breakfast meal in the main kitchen and on the second and third
floors noted that many residents received only 1 sausage link or received no sausage link at all on the main
entree plate. Numerous residents were noted to only receive only a serving of cereal, and toast (1 slice ) for
the breakfast meal.
Residents Affected - Some
3) During the observation of the breakfast meal in the main kitchen on 08/27/24 at 7:00 AM, it was noted
that the approved menu for the breakfast meal of 08/27/24 documented a Banana (1 each) be served to all
regular and therapeutic diets. Review of the Diet Census for 08/26/24 noted that 107 of the 11 facility
residents were to be served a fresh Banana. Observation of the breakfast meal in the main kitchen on
08/27/24 at 7:30 AM noted that fresh Bananas were not available for the meal as per the approved menu.
Further observation noted that a nutritional substitute for the Banana was not planned or served. Interviews
conducted with diet staff (A, B, C, and D) at the time of the meal observation noted to state the Bananas
are not available on a regular basis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 33 of 70
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
08/30/2024
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on record review, observation and interview, it was determined that the facility failed to prepare in
advance and follow the approved menu menu for 107 of the facility's 111 residents.
Residents Affected - Some
The findings included;
1) During the review of the approved menu for the lunch meal on 08/26/24, the following were noted to be
served to Regular, Mechanical Soft, Pureed, and No Concentrated Sweets Diets:
* Homemade Chili (6 ounce portion = 2 ounce protein)
* Watermelon Cubes (#8 scoop = 1/2 cup)
* Cornbread (1 piece)
Observation of the lunch meal in the main kitchen on 08/26/24 at 11:30 AM noted the following were being
serve to the facility residents:
* Homemade Chill - (#10 scoop - 2 ounce portion was being served)
* Watermelon Cubes (no water melon available - canned pineapple substituted)
* Cornbread ( pureed regular bread served to the pureed diets)
Interview with the facility cook ( Staff A) at the time of observation; Staff A noted to state that she did not
review the approved menu for the lunch meal of 08/26/24 and thought that a 2 ounce portion be served and
was also not aware that pureed cornbread was to be served to Pureed Diets. Further stated that
Watermelon is never purchased according to the approved menu.
2) Review of the approved menu for the breakfast meal of 08/27/24 noted the following to be served to the
residents with physician ordered Regular, Mechanical Soft, Pureed , and No Concentrated Sweets diets.
* Banana (1 each)
* Sausage Link (2 links = 1 ounce Protein)
During the observation of the breakfast meal conducted in the main kitchen on 08/27/24 at 7:30 AM, the
following were noted:
* Banana (no Banana's available/purchased)
* Sausage Links ( Only 50 sausage links prepared - noted many reside received on 1 sausage link and
numerous did not receive any sausage links)
Interview with the facility cook (Staff E) at the time of the observation; Staff E revealed Bananas are never
purchased or served according to the approved menu and that an insufficient supply of
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 34 of 70
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
08/30/2024
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 0803
sausage Links was purchased.
Level of Harm - Minimal harm
or potential for actual harm
A review of the facility's Diet Census for 08/26/24 noted that there were 71 residents with physician ordered
Regular consistency diets, 10 residents with physician ordered Pureed diet, and 20 residents with physician
ordered Mechanical Soft.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 35 of 70
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
08/30/2024
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, it was determined that the facility failed to prepare
foods by the use of standardized recipes to ensure nutritive value, flavor, appearance, and food that is
attractive and appetizing for 107 of the facility's 111 residents.
Residents Affected - Some
The findings included:
During the review of the approved menu for the lunch meal on 08/27/24 noted documentation for the
entree, Turkey Burger Patty Melt to be served as the entree for Regular, Mechanical Altered (Mechanical
Soft and Pureed), and No Concentrated Sweets Diets. A review of the resident's Diet Census for 08/26/24
noted 107 of there facility's 111 residents were to receive Regular, Mechanical Altered, and No
Concentrated Sweets Diets.
At the request of the surveyor a copy of the facility's standardized recipe for Turkey Burger Patty Melt was
requested from the Dietary Manager (CDM). A review of the standardized recipe noted the following:
Turkey Burger Patty Melt (recipe)
Ingredients:
Turkey Burgers
Margarine
Sautéed Onions
Swiss Cheese
Bread
Directions:
1) Arrange burgers on sheet pan and cook 350 F for 10-12 min.
2) Arrange a single layer of bread on lined and greased sheets
3) Top each bread slice with cooked turkey burger, 2 Tablespoons sautéed onions and a slice of
Swiss. Cheese
4) Cover with remaining slice of bread
5) Arrange on baking sheet in a single layer
6) [NAME] 8-10 min, flipping and halfway through cooking to evenly brown bread
7) [NAME] until bread is golden brown
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 36 of 70
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
08/30/2024
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 0804
8) Hold at 135 degrees F
Level of Harm - Minimal harm
or potential for actual harm
During the observation of the lunch meal in the main kitchen on 08/27/24 at 11:30 AM noted the Turkey
patty Melt was prepared and served in the following manor:
Residents Affected - Some
The steam table contained a deep pans of cooked turkey burgers that were not brown in color (white), and
appeared uncooked.
A single turkey burger was put onto a slice of white bread with a slice of American Cheese and covered
with another slice of white bread and served on a ungarnished plate to the facility's residents.
Interview with the Lunch [NAME] (Staff D) at the time of the above observation, Staff D stated she has
never seen or utilized the facility's standardized recipe for the preparation of the Turkey Patty Melt. Further
stated that no onions are ever available and sautéed, and no Swiss cheese was available for the
sandwich and she was unaware that the sandwiches were to be cooked until golden brown in the oven.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 37 of 70
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
08/30/2024
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**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 prepare food in a form
designed to meet individual needs that included; Thickened Liquids for 1 of 1 sampled resident (Resident
#45) and Purred Diet for 10 facility residents that included 5 sampled residents (Resident #17, #45, #211,
#193, and #301).
The findings included:
During an observation of Resident #45 on 08/28/24 at 12:20 PM, it was noted that the resident's lunch tray
had been placed on the over-bed table directly in front and in reach of the resident. It was also noted that a
large container of non -thickened water with drinking straw was also placed in reach of the resident. Further
observation of the resident noted to be scooping large portions of pureed foods with bare hands above her
head and dropping the pureed foods into her mouth. It was noted that the resident started coughing and
regurgitation the pureed foods from her mouth onto her chest.
The surveyor immediately requested the nurse to the room of Resident #45. The Director of Nursing (DON)
was noted to come to the room and observed the surveyors findings of the resident eating large scoops of
pureed foods with hands and coughing and regurgitating foods. The surveyor informed the Director of
Nursing that the resident is assessed to be cognitively impaired, required Honey Thick liquids, and requires
maximum assistance with eating. The DON removed the lunch tray which was 75%finished and stated to
the surveyor that he would take care of the incident. An interview was conducted with the CNA (Staff F)
who was assigned to Resident #45 and stated that she was assigned to the dining room for the lunch meal
on 08/28/24 and did not know who put the lunch tray in front of the resident and allowed the cognitively,
dysphagia diagnosed resident to eat with supervision.
On 08/29/24 at 7:45 AM during an observation of Resident #45 it was noted that the resident was provided
maximum assist with the eating of the breakfast meal and no water was available at the beside of resident
according to facility policy. The DON was also interviewed and it was again confirmed that the resident is
cognitively impaired, diagnoses of Dysphagia, required maximum assistance with eating, and requires
Honey Thick Liquids.
During the review of the clinical record of Resident #45 on 08/27-28/24 it was noted an admission date of
12/31/24 with diagnoses of Hemiplegia, ASHD, Dementia, and Dysphagia. Further review noted physician
orders for No Added Salt, Pureed Diet with Honey Thick Liquids. Further review of the MDS dated [DATE]
documented that the resident is rarely understood/understands and that the resident requires maximum
assistance with eating. Review of the Nutritional assessment dated [DATE] documented Purred Diet with
independent feeding. Review of the current care plan dated 03/06/24 documented maximum assistance
with eating.
2) During the review of the approved menu for the Breakfast meal of 08/28/24 , it was noted that Pureed
diets were to receive a portion of Pureed Grits (#8 scoop - 4 ounces) and Pureed Scrambled Eggs (#12
scoop).
Observation of the breakfast meal in the main kitchen on 08/28/24 at 7:30 AM noted pureed Grits and
Scrambled were not located on the steam table. Further observation noted that regular consistency Grits
and Scrambled Eggs were being served to residents on a Pureed Diet. Interview with the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 38 of 70
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
08/30/2024
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
breakfast cook (Staff E) at the time of the observation noted to state that the approved breakfast menu for
08/28/24 was not reviewed prior to the preparation of the breakfast meal and that she was unaware that the
Pureed Diet included Pureed Grits and Pureed Eggs. Staff E cease serving Regular Grits and Scrambled
Eggs, pureed the Grits and Scrambled Eggs that were to be served to Pureed Diets. Staff E proceeded to
puree the Regular Scrambled Eggs to the proper pureed consistency however stated to the surveyor that
the Grits were the Regular Grits and would be fine for Pureed Diets. The surveyor stated to Staff E that that
resident with physician orders for Pureed Diet and a diagnoses of Dysphagia have the possibility of
chocking/aspiration of regular consistency foods.
Review of the Diet Census dated 08/26/24 noted that there were currently 10 facility residents with
physician orders for Pureed Diet and had a diagnoses of Dysphagia. Further review noted that the 10
residents included sampled Residents #17, #45, #193, #211, and #301.
Review of the facility's Policy and Procedure for Thickened Liquids that was requested by the surveyor on
08/28/24 and was submitted by the Director of Nursing on 08/28/24, the following was noted:
Policy:
Thickened liquids shall be prescribed by the attending Attending Physician /Practitioner.
Procedure:
* Residents on thickened liquids should not have liquids kept at bedside.
* A qualified Speech Therapist may be determine the appropriate consistency that is safe for the resident
and communicate the findings to the attending physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 39 of 70
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
08/30/2024
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to follow the diet orders as per Physicians'
orders for one of 7 residents reviewed for nutrition (Resident #84).
The findings:
In an observation conducted on 08/28/24 at 8:03 AM, Resident #84 was in his room with the breakfast tray.
The meal ticket showed no concentrated sweets (NCS), no added salt, and a (NAS) diet with double
portions (no fortified meals noted on the meal ticket). The breakfast tray revealed oatmeal, eggs (regular
serving), muffin, and a glass of 4-ounce juice. The breakfast meal did not have the double portions and the
fortified foods as per doctor's orders. In this observation, Resident #84 told this Surveyor that he wanted
more meat and that what they served him this morning was not enough.
Resident #84 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes and Iron Deficiency.
The Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #84 had a Brief Interview of
Mental Status (BIMS) score of 15, which is cognitively intact.
A review of the Physician's orders showed an order for double portions for all meals 3 times a day for
dietary demands dated 03/5/24. Fortified foods at all meals every shift which was dated 03/05/24.
In an observation conducted on 08/28/24 at 12:20 PM, Resident #84's meal ticket showed doubled portions
(no fortified meals noted on the meal ticket). The lunch meal plate was pointed out with the following:
chopped roast pork (regular portion), spinach with onions, potatoes, a slice of bread, and juice. The lunch
meal did not have any fortified foods on the tray or double portions as ordered by the Physician.
An interview conducted on 08/29/24 at 10:27 AM; the Dining Manager stated that the following food items
are fortified: fortified oatmeal for breakfast, fortified soups for lunch, and fortified pudding for dinner. For any
residents on fortified foods, it will show on the actual meal tickets for the kitchen staff members. The Clinical
Dietitian will write the order on a communication slip and bring it down to the kitchen for any residents who
have orders for fortified foods. It is then placed in the electronic system for residents with double portions,
which will usually provide double portions of the protein for breakfast, lunch, and dinner.
A review of the Dietary Information meal tickets provided by the Dining Manager revealed that nine
residents were on fortified meals, which did not include Resident #84 in the list for fortified meals. The
Dietary Manager did not know that Resident #84 had an order for Fortified Meals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 40 of 70
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
08/30/2024
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 0810
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, it was determined that the facility failed to provide
special eating equipment (Divided Plate) 5 of (Resident's #16, #30, #34, #42, and #45) sampled residents
who need them when consuming meals.
Residents Affected - Few
The findings included:
During the observation of the lunch meal conducted in the second floor dining room on 08/26/24, it was
noted that the meal tray ticket for Resident #16 and Resident #19 both documented that a Divided Plate be
provided with the meal. Further observation noted that that the no Divided Plate was provided for either
resident and further noted that the resident's attempt to eat independently and the use of a Divided Plate
would assist the resident with self feeding.
On 08/27/24 at 7:30 AM a second observation of the breakfast meal was conducted in the second floor
dining room. It was noted again that the meal tray tickets documented a Divided Plate be provided, however
the adaptive plate was not included on the resident's meal tray.
Following the 08/27/24 observation the surveyor interviewed kitchen staff concerning resident's whop
require adaptive equipment and specifically a Divided Plate. Interviews conducted with dietary staff (A, B, C
and D) and the Certified Dietary Manger stated that there were no residents with physician orders for
adaptive equipment that included Divided Plate's. It was noted during the staff interviews that there was 1
Adaptive Divided Plate located in the serving area of the kitchen, and staff stated that is the only adaptive
eating equipment in the dietary department.
Following the interviews the clinical records of Resident's #16 and #30 were reviewed. The record review
noted no current physician orders for a Divided Plate to be provided for all meals. Following the record
review the Director of Skilled Therapy was interviewed on 08/27/24 concerning the Divided Plate issues
and it was requested by the surveyor a list of residents who requires adaptive eating equipment (Divided
Plate) and provided according physician orders. On 08/28/24 the Director of Skilled Therapy provided a list
of resident's who have been assessed by Occupation Therapist to require adaptive eating equipment. A
review of the list documented that 5 facility resident's required a Divided Plate for all meals that included
resident's #16, 30, #34, #42, and and #45. The director also provided provided documentation concerning
each resident that included skilled therapy assessment and physician orders for the Divided Plate. A review
of the resident documentation included the following:
Resident #16: Therapy Screening Form dated 03/21/22 documented patient assessed for adaptive
equipment (Plate Guard/Divided Plate) for feeding skills. Physician order dated 04/04/22 documented
recommendation for for a 3-Compartment /Divided Plate for 3 meals per day.
Resident #30: Therapy Screening Form dated 01/24/19 documented a Divided Plate to be provided for
breakfast , lunch, and dinner to facilitate self feeding. Physician order dated 03/11/19 documented to
provide patient with divided plate for breakfast, lunch, and dinner to facilitate self feeding.
Resident #34: Therapy Screening Form dated 06/18/24 documented to continue to provide with divided
plate for breakfast, lunch, and dinner to facilitate self feeding. Physician order dated 08/16/08 documented Clarification: Divided Plate to be provided for B-L-D (breakfast, Lunch, Dinner) to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 41 of 70
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
08/30/2024
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 0810
improve self feeding skills.
Level of Harm - Minimal harm
or potential for actual harm
Resident #42: Occupational Therapy (OT) - Evaluation dated 3/3/22 documented efficient use of adaptive
equipment - divided plate for meals. Physician order dated 04/27/24 documented Discharge from skilled OT
services - Divided plate to be provided at all meals.
Residents Affected - Few
* Resident #45; Therapy Screening Form dated 06/16/18 documented continue with divided plate for
breakfast, lunch, and dinner to facilitate feeding. Physician order dated 05/19/21 documented a
3-Compartment Plate with meals to facilitate self feeing.
Following the documentation provided to the surveyor by the Director of Skilled Therapy it was noted that
she was not aware of the current physician orders did not document the physician orders for the Divided
Plates. It was further noted that the resident's ( Resident #16, #30, #34, #42, and #45) still required the use
of Adaptive Divided Plates to facilitate self feeding skills and that the attending physician's would be
contacted for clarification of the order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 42 of 70
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
08/30/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, it was determined that the facility failed to store,
prepare, distribute, and serve food in accordance with professional standards for food service safety for
potentially 107 facility residents.
the findings included:
1) During the initial kitchen/food service observation tour conducted on 08/26/24 at 8:50 AM, the following
were noted:
(a) The exteriors of 2 kitchen utility carts were noted to be heavily soiled, stained, and areas of peeling
paint.
* Photo Evidence Obtained
(b) Large areas of the kitchen floor and walls were cracked stained, and in disrepair.
* Photo Evidence Obtained
(c) The floor area of the dry/canned food storage area was heavily soiled, stained, and areas of rust.
* Photo Evidence Obtained
(d) Staff clothing and purses (2) were noted to be stored directly onto clean food storage shelving.
* Photo Evidence Obtained
(e) A chemical test of 3 of 3 cleaning cloth buckets noted extremely high concentration of Quaternary
Chemical
* Photo Evidence Obtained
(f) The entry door of the walk-in refrigerator was noted to have a build-up of black mold type substance
around the gasket area. The gasket was noted to have a large tear (12) and was in need of replacement.
* Photo Evidence Obtained
(g) The exteriors of 6 food storage shelves located within the walk-in refrigerator were noted to be soiled
and rust laden. The shelving was noted to be in need of replacement and potential for food contamination of
falling rust into foods.
* Photo Evidence Obtained
(h) The cooling fan unit located in the walk-in refrigerator was noted to be steadily dripping into
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 43 of 70
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
08/30/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
a bin pan. The pan was noted to be half full of dripping condensation and was a potential for food
contamination.
* Photo Evidence Obtained
(i) The exterior of the commercial bench mounted can opener was noted to be rust laden throughout the
stem and the blade housing unit. It was also noted that the blade was heavily soiled and a build-up of black
mold like type matter. The unit was not being properly cleaned and sanitized daily basis and the blade
required replacement.
* Photo Evidence Obtained
(j) The exteriors of the base and lid shelving carts (2) were noted to be soiled and rust laden. * Photo
Evidence Obtained
(k) The ceiling frame and tiles located with in the dish machine room were noted soiled and rust laden. The
ceiling and frames were not being properly maintained to prevent soiling and rust.
* Photo Evidence Obtained
(l) The exteriors of 8 of 8 aluminum sheet pans were noted to have a heavy build-up of black carbon and a
potential of food contamination.
* Photo Evidence Obtained
(m) The internal conveyor belt of the commercial toaster was noted to be heavily soiled and rust laden. The
unit was old and not properly maintained.
* Photo Evidence Obtained
2) Second observation tour of the kitchen /food service conducted on 08/26/24 at 11:15 noted the following:
(a) Numerous small flying insects were noted in the dish room area and in the food preparation/serving
area.
(b) The 3-shelf rack where clean food preparation equipment were being stored and noted to be rust laden.
Three large commercial cooking skillets were noted to be covered with a thick layer of black carbon.
3) On 08/27/24 at 7:30 AM accompanied with the facility Administrator during the observation of the
breakfast meal in the main kitchen the surveyor requested that temperatures be taken of hot and cold foods
located in on the steam table and foods located on food transportation carts (4) located near the steam
table. The food temperatures were taken by the use of the facility's calibrated digital food service
thermometer. The temperature testing noted that cold foods were not being held at the regulatory
temperature of 41 degrees F or below as evidenced by the following:
Individual 8 ounce portions (60) of milk = 62 degrees F
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 44 of 70
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
08/30/2024
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 0812
Individual 4 ounce portions (60) of Orange Juice = 60 degrees F
Level of Harm - Minimal harm
or potential for actual harm
It was discussed with the diet aide (Staff ) at the time of the observation that the portions of milk and juice
were being placed on the residents' trays too early (30 minutes at room temperature) prior to be sending to
the residents floor.
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 45 of 70
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
08/30/2024
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 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation , interview, it was determined that the facility failed to dispose of garbage and refuse
properly.
Residents Affected - Few
The findings included:
Observation tour of the outside garbage/refuse area on 08/26/24 at 9:45 AM noted the following:
(a) A large body of stagnant water was noted to be located between garbage dumpster and cardboard
recycling dumpster. Further observation noted that the area was approximately 10-12 feet wide and
approximately 12 inches deep in the center. Further observation noted large areas of stagnant algae in the
water along with what appeared to be medical waste that included medication bottles, medication inhaler
tubes, disposable gloves, disposable masks, disposable gowns, and other unidentifiable waste. The area
also contained numerous large and small piece of garbage and trash. The areas behind the dumpster and
the walkway to and around the rear of the building were also noted to be littered with the same type of
medical waste and garbage /trash. Also located next to the dumpster's were 4 large tires which were filled
with stagnant water and a potential source of insect and rodent activity. The large area around the tires was
littered with garbage and trash.
On 08/27/24 at 9:00 AM a meeting was held by the surveyor with facility Administrator to discuss the
garbage /refuse area. The administrator acknowledged she was aware of the area and the seriousness of
the potential of infection control and pest activity. The administrator stated that the large area of stagnant
water must be removed via pump and the clogged ground drains be cleared.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 46 of 70
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
08/30/2024
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 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record reviews and interviews; the facility's Administrator failed to follow up on reported rodent sightings in
a timely manner and address them immediately, failed to ensure the designated Infection Preventionist who
is responsible for the facility's Infection, Prevention and Control Program (IPCP) had completed specialized
training in infection prevention and control. The facility's administrative staff failed to ensure that their
policies for pest control services were followed, coordinate with other department heads, failed to contact
the appropriate local agencies regarding the rodent infestation. The facility's failure to immediately
implement an effective pest control program to eradicate and contain the rodents identified in residents'
areas had the potential to spread diseases to residents and potentially affect 111 residents residing in this
120 bed facility. Rats and mice are known to carry many diseases. These diseases can spread to people
directly, through handling of rodents; contact with rodent feces (poop), urine, or saliva (such as through
breathing in air or eating food that is contaminated with rodent waste); or rodent bites. Rodents can also
carry ticks, mites, or fleas that can act as vectors to spread diseases between rodents and people.
Residents Affected - Some
The system failure to ensure pest control/infection control and prevention interventions and services were
effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in
the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were
determined to be ongoing on 8/30/2024.
The findings included:
A review of the facility's Administrator's job description signed on 04/04/2022 revealed the following:
Delegate the administrative authority, responsibility, and accountability necessary for carrying out assigned
duties. Responsible for day-to-day clinical and administrative activities of the facility, including profit and loss
responsibility, and ensures compliance with all state and federal regulations. Provide leadership to all facility
staff to meet the goal of providing quality resident care. Schedule regular meetings with direct report staff to
provide supervision, ensure communication, and monitor the facility. Ensure a safe, clean and comfortable
environment for residents, visitors and staff. Maintain effective relationships and open communication with
residents, families, staff, contractors, and the outside community.
A chart review revealed that Resident #9 (room [ROOM NUMBER]) was initially admitted to the facility on
[DATE] with diagnoses of Hemiplegia, Muscle Weakness, and Gout. The last Minimum Data Set (MDS),
dated [DATE], section C, revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15,
which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed
that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a
wheelchair.
In an interview conducted on 08/26/24 at 11:24 AM, Resident #9, stated that for the last 4 Saturdays there
has not been any housekeeping services and the place was dirty. The facility's Supervisors were aware that
there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any, she
said, They practically live here. Resident #9 then pointed at a flat, sticky trap (with a rat picture on the label)
used for mice/rats in her room that was still in an unused packet sitting on top of her belongings. Resident
#9 reported that these traps were used for mice/rats sighting in her room near the air-conditioning area. In
this interview, the Surveyor observed a white
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 47 of 70
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
08/30/2024
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 0835
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
boxed container, which was located by the air-conditioning unit and was labeled for pests and roaches.
According to Resident #9, the white box used for trapping pests did not work for rats or rodents, and this
was why she kept requesting the pest control technician to get her the unused designated mice trap that
was seen earlier on top of her belongings. During this entire interview, the Surveyor noted that food
packaging that were opened on the over bed table, and other unsealed food items were around the bed.
In an interview conducted on 08/29/24 at 7:20 AM with Staff OO, the Pest Control Technician stated that the
facility does not have a Pest Control Log that he checks every time he comes into the facility for the specific
locations and rooms that need treatments. The facility's Administrator reports all pest sightings verbally to
him. The facility's Administrator only told him of rodent sightings for the first time last week.
In an interview conducted on 08/26/24 at 1:30 PM with the facility's Administrator, she stated she was not
aware of any rodents sighting in the facility and reported that any residents or staff members had not told
her of any rodents in the facility. She further stated that Pest Control Services are here once a week, and
she is in constant contact with the pest control technician.
In an interview conducted on 08/29/24 at 7:53 AM, the Director of Nursing (DON) stated that he had never
seen any rodents or rats in the facility but was told by Staff RR, a Registered Nurse who saw three rodents
in room [ROOM NUMBER] which was on 06/27/24. The DON sent a message to the Administrator letting
her know of the sighting which was reported by Staff RR. The Administrator told him that she would let Staff
PP, the Former Maintenance Director who is no longer an employee with the facility, to take care of the
issue According to the DON, he received multiple complaints of rodent sightings in the last six months from
various staff members. Some staff members reported rodents coming out of the air-conditioning unit, but
this was never verified. He always discussed these sightings in the department heads' meetings that are
conducted daily, and the Administrator was aware of the rodent issue for the last six months. He was told by
the facility's Administrator that the rodent issue would be handled in-house by the Maintenance Department
rather than called a Pest Control Company. He did not document any of the reports or sightings from staff
members and did not report the dates and times of the sightings. The DON stated that he expected the
Administrator to take care of the rodent issue immediately, but she did not. Since he expected the
Administrator to take care of the rodent concern, he did not notify the Health Department of the rodent
infestation. He further reported that he is responsible for ensuring that the residents are kept in a safe,
clean environment. He even discussed with the Administrator why she did not call the Pest Control
Company but decided to take care of it in-house by the Maintenance Director. The Director of Nursing said
that the Administrator was not overly concerned and said that she would have the in-house team take care
of the rodents' sightings.
In an interview with the Administrator on 08/29/24 at 8:00 AM, she revealed being was aware that Resident
#9 reported seeing rodents in her room last Thursday and she told the pest control technician to treat
Resident #9's room. The Administrator said they were going to deep clean the room and put all the food
items in the room in tight plastic containers.
In a phone interview conducted on 08/29/24 at 8:40 AM with Staff PP, who started working in the facility in
December of 2023 and left a month ago( July).; revealed the Administrator was aware of the rodent issue in
the facility and was very involved in the pest control area before he was even hired. Around March of this
year, he started getting reports of rodents sighting around the facility. He was not sure as to what
arrangements were made with the Staff OO, the Pest Control Technician, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 48 of 70
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
08/30/2024
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 0835
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
the Administrator, but Staff OO did not know of the rodent infestation in the facility. Staff OO visited the
facility weekly, and they always discussed pest control issues. Staff OO never mentioned any rodent
sightings reported to him by the Administrator. Staff PP received multiple complaints of rodents sighting by
staff members which were not documented or written down in a pest control log. Most of the rodent's
sightings were reported on the 2nd floor [NAME] Wing. He further revealed he never felt the support or
leadership skills from the facility's Administrator. There were no systems in place to control the rodent's
problem from the source. The in-house treatments that were done in some of the rooms did not resolve the
problem and were only a temporary fix. Staff PP advised the Administrator to close the [NAME] Wing unit to
treat the entire wing and eradicate the issue, which she refused.
A chart review revealed Resident #36 (room [ROOM NUMBER]) was admitted to the facility on [DATE] with
diagnoses of Dementia and Bipolar Disorder. The Minimum Data Set (MDS) dated [DATE] revealed a BIMS
score of 12 which is mild cognitive impairment.
In an interview conducted on 08/29/24 at 9:38 AM with Staff RR, Registered Nurse stated she has worked
in the facility for the last 13 months. Around two months ago, she came down to the Director of Nursing
(DON) office and told him that she saw three rodents running around in Resident #36's room; it was during
medication administration, it was late in the evening when she noticed the rodents located at the end of the
room. The DON told her that he would let management know of the rodent's sighting. A few days later, the
DON told her that rodent traps would be placed in the resident's room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 49 of 70
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
08/30/2024
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 - Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
Based on observations, interview and record review, the facility failed to demonstrate effective plan of
actions were implemented to correct identified quality deficiencies in the problem area related to repeated
deficient practices for F584 Safe/clean/comfortable/homelike environment, F755 Pharmacy
Srvcs/Procedures/pharmacist/records, F867 Qapi/qaa Improvement Activities, and F925 Maintains
Effective Pest Control Program. These deficiencies have the potential to affect 111 residents residing in the
facility at the time of survey.
The findings included:
Record review of the facility's survey history revealed, during a recertification survey with exit dated
05/19/2023, F755 Pharmacy Srvcs/Procedures/pharmacist/records, F867 Qapi/qaa Improvement Activities,
and F925 Maintains Effective Pest Control Program and a complaint survey with exit date 10/03/2023 F584
Safe/clean/comfortable/homelike environment were cited.
Review of the Policy and procedures revealed;
The Center organization has a comprehensive, date-drive Quality Assurance Performance Improvement
Program that focuses on indicators of the outcomes of care and quality of life.
Procedure:
Program Design and Scope
The center's QAPI program is on-going comprehensive review of care and services provided to residents.
May include but not limited to:
Medical care, Clinical care, Rehabilitation, Pharmacy Services, Dining Services, Social Services,
Community Life Services, Hospitality Services, Environmental Services, Admissions, Business Office,
Medical Records.
2. Important functional areas may include but are not limited to:
Residents rights and responsibilities, admission process, Resident assessment, Quality of care, Quality of
life, Potential Adverse Events, Continuity of care, Infection control, Plant technology and safety
management, Information management, Human resources, Leadership and credentialing, Resident/family
education, Allegations of abuse, neglect, misappropriation of resident property.
3. Review of activities may include but not limited to:
Infection control, Incident/accident reports, Resident/family complaints/satisfaction,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 50 of 70
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
08/30/2024
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 - Some
Interdisciplinary care planning, Medication use, Environment of care/safety, Restraint reduction, Wound
care/prevention, Staff orientation, in-service and competence, Weight Program, Psychotropic Drug
Reduction, Fall prevention, medical record, Physician services.
4. The program is a coordinated effort among departments and services with the organization that involves
leadership working with input from Center staff, residents and families.
5. The Quality Assessment and Assurance Committee (QAA) meeting are at least quarterly but may be
held more frequently as appropriate.
Performance Indicators:
The center will utilize performance indicator to establish goals, identify opportunities for improvement, and
evaluate progress towards goals. They will evaluate performance indicators at least annually for updates.
The center may develop performance indicators using the following but not limited to: National benchmark,
State benchmark, Company established benchmark.
Systematic Analysis and Action:
The center will establish and utilize a systematic approach to identify underlying causes of problems,
including but not limited to: Root cause analysis, and Failure Mode Effect Analysis.
The center will develop corrective actions based on the information gathered and review effectiveness of
the actions.
Performance Improvement Projects:
The center utilizes performance improvement projects to improve a systematic problem or improve quality
in the absence of a problem. Performance Improvement Projects:
a.
The PIP should focus on high-risk or problem prone areas, Identified by the center.
b.
The team may consist of one or more team members
c.
The team will complete the following functions:
i.
Collect and analyze data
ii.
Determine Root Cause
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 51 of 70
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
08/30/2024
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
iii.
Level of Harm - Minimal harm
or potential for actual harm
Determine steps for resolution
iv.
Residents Affected - Some
Implement Corrective action(s)
v.
Evaluate effectiveness of action(s)
vi.
Report progress to QAPI Committee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 52 of 70
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
08/30/2024
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observations, interviews, the Administrator failed to follow up on reported rodent sightings in
a timely manner and address them immediately, the administrative staff failed to follow infection preventions
and control techniques and CDC (Centers for Disease Control) guidelines for How to Control Wild Rodent
Infestations, the facility's administration staff failed to ensure that their policies for pest control services
were followed, coordinate with other department heads; failed to contact the appropriate local agencies
regarding the rodent infestation. The facility's failure to immediately implement an effective pest control
program to eradicate and contain the rodents. The facility's failure to properly inspect, clean and remove
food sources identified in 2 of 17 Residents' rooms (Resident #9 and Resident #36). Rats and mice are
known to carry many diseases. This can cause a severe life-threatening disease, Mpox (virus that affects
rodents, and causes a painful rash, enlarged lymph nodes and fever in humans), and rat-bite fever (causes
fever, vomiting, headache, muscle, and joint pain, and rash in humans) which has the potential to affect 111
residents residing in the 120-bed facility. The facility failed to ensure that infection control procedures and
guidelines were followed to properly handle the Glucometer for 1 of 1 resident reviewed for Blood Glucose
Monitor Testing (Resident #48). The facility failed to ensure proper hand hygiene and Enhanced Barrier
Precautions (EBP) guidelines were followed during wound care treatment for 1 of 1 resident observed for
wound care (Resident #307). The facility failed to ensure a clear separation between the soiled linen area
and the clean laundry areas to prevent cross-contamination during 2 of 2 observations of the laundry room.
Facility failed to ensure designated Infection Preventionist who is responsible for the facility's Infection,
Prevention and Control Program (IPCP) had completed specialized training in infection prevention and
control.
Residents Affected - Some
The system failure to ensure pest control/infection control and prevention interventions and services were
effective and implemented resulted in the likelihood for serious injury and/or death. This failure resulted in
the determination of Immediate Jeopardy on 06/27/2024. The findings of Immediate Jeopardy were
determined to be ongoing on 8/30/2024.
The findings included:
1) The Surveyor requested to review completed copy of specialized training in infection prevention and
control from the Director of Nursing (DON), who was also assigned the infection Preventionist (IP). No
certificate of completion was provided.
Review of job description for DON/IP dated 10/31/23 sign by the DON/IP revealed that the Certification in
Infection Control as specified by Appendix PP at 880 is required or must obtain within the first 90 days of
employment.
An interview was conducted on 08/30/24 at 11:45 AM with the DON/IP. He stated he has worked at the
facility since 10/31/23 and that he was not aware that he was assigned as the infection Preventionist until 2
months ago when the Administrator informed him to start the infection Preventionist modules. When asked
if he had completed the entire IPCP training program and had a certificate, he stated that he started the
modules but has not finished and has not obtained a certificate.
Review of the facility's job description titled, Infection Preventionist, included the following:
The primary purpose of your job position is to plan, organize, develop and direct the overall
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 53 of 70
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
08/30/2024
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 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
operation of our Infection Control and Prevention Program in accordance with current federal, state, and
local standards, guidelines, and regulations that govern our center and as may be directed by the Medical
Director or Director of Nursing (DON) to ensure that the center provides a safe, sanitary, and comfortable
environment and to help prevent and control the development and transmission of communicable diseases
and infections.
Experience: Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain
within the first 90 days of employment.
2) During an observation conducted on 08/26/24 at 11:50 AM, two Surveyors were on the 2nd floor [NAME]
Wing hallway across from Resident #9's room. Upon exiting the room across, they observed a rodent
running in the [NAME] Wing hallway toward Resident #9's room. Further observation revealed Resident #9
was sitting in her wheelchair in the hallway. She was noted lifting one leg to avoid touching the rodent with
her feet. Resident #9 then said to the Surveyors, There it is. Did you see it? as she pointed at the rodent
running into her room.
Record review for Resident #9 revealed that the resident was admitted to the facility on [DATE] with
diagnoses that include: Hemiplegia, Muscle Weakness, and Gout.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview of
Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate.
Section GG of the MDS revealed that Resident #9 could wheel at least 150 feet in a corridor or similar
space once she is seated in a wheelchair.
During an interview conducted on 08/26/24 at 11:24 AM with Resident #9, she stated that for the last 4
Saturdays, there had not been any housekeeping services and that the place was dirty. The facility's
Supervisors were aware that there were pests, roaches, and mice/rodents in the facility. When asked how
often she has seen any, she said, They practically live here. During this entire interview, the Surveyor noted
that food packaging was opened and laying on the overbed table, and other unsealed food items were
around the bed and on the bedside table.
During an interview conducted on 08/29/24 at 7:53 AM with the DON/IP, he stated that he had never seen
any rodents in the facility but was told by Staff RR, a Registered Nurse who saw rodents in a resident's
room on 06/27/24 and reported it to him. Staff RR reported seeing rodents in room [ROOM NUMBER]
running around by the window. She further said to him that she witnessed 2 out of 3 medium-sized rodents
who were not fully grown and who went by her very fast. This sighting was passed to the Administrator, who
said she would handle the issue.
During an interview with the Administrator on 08/29/24 at 8:00 AM, she stated that she was aware that
Resident #9 reported seeing rodents in her room last Thursday. The Administrator stated that they are
going to treat the entire room, take all furniture and belongings out, and look for possible openings and
holes. According to the facility's administration, Resident #9 has been in the facility for 20 years, and her
family brings her groceries every week, which are stored all around her room.
During an interview conducted on 08/29/24 at 9:38 AM with Staff RR, the Registered Nurse reported
around two months ago, she came down to the Director of Nursing (DON) office and told him that she saw
three rodents running around in Resident #36's room. It was late in the evening, during medication
administration, when she noticed the rodents were located at the end of the room. The DON told her that he
would let management know of the rodent's sighting. A few days later, the DON told her that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 54 of 70
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
08/30/2024
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 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
rodent traps would be placed in the resident's room. Any rodents or pest sightings are documented on the
pest control log in the nurse's station. When asked if she had documented the sighting in the pest control
log, she said no.
Record review for Resident #36 revealed that the resident was admitted to the facility on [DATE] clinical
diagnoses include: Dementia, Bipolar Disorder. Review of the MDS dated [DATE] revealed a BIMS score of
12, which was slight cognitive impairment.
Review of the CDC's How to Control Wild Rodent Infestations, 01/03/23,
https://www.cdc.gov/healthy-pets/rodent-control/index. html included in part the following: Rodents, such as
rats, mice, and chipmunks, are known to carry many diseases. These diseases can spread to people
directly, through: Handling of rodents. Contact with rodent droppings (poop), urine, or saliva. Rodent bites.
Rodent droppings, urine, and saliva can spread by breathing in air or eating food that is contaminated with
rodent waste. Rodents can also carry ticks, mites, or fleas that can spread diseases.
Review of the facility's policy titled, Pest Control Services, dated 12/08/23, included the following: A
program will be established for the control of insects and rodents within the facility.
Procedure:
1. The Administrator coordinates with the Maintenance Department to arrange pest control services on a
monthly basis, or as needed.
2. Food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin
3) Record review for Resident #48 revealed that the resident was admitted to the facility on [DATE]
diagnoses that include: Metabolic Encephalopathy.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #48 had a Brief Interview for
Mental Status of 07, which indicated that he was severely cognitively impaired.
Review of the Physician's Orders showed that Resident #48 had an order dated 04/24/24 for Humalog
KwikPen Subcutaneous Solution Pen-injector 100 Unit/ml (Insulin Lispro), Inject as per sliding scale before
meals and at bedtime for DM. Injector 1 Fingerstick blood glucose monitoring QID (four times a day) before
meal and at bedtime for Diabetes Mellitus (DM).
On 08/27/24 at 4:00 PM observation of blood glucose monitoring test (Accu-Chek) conducted by Staff WW,
Licensed Practical Nurse (LPN) Staff WW gather all the following supplies: Glucometer, 2 alcohol wipes,
lancet, a container of blood glucose test strips, and placed them all on a foam tray. She entered the room
for Resident #48, washed her hands, donned gloves, placed the foam tray on the bedside table, and
performed the Accu-Chek on Resident #48. She then, placed the dirty Glucometer and the container of
blood glucose strips back on the foam tray and walked outside of the room to discard the used lancet into
the sharp's container. Staff WW returned to Resident #48's bedside table, placed the dirty Glucometer and
the container of blood glucose strips into her uniform pocket and threw away the foam tray, then walked to
the bathroom and washed her hands. She exited Resident #48's room and removed the dirty Glucometer
and the container of blood glucose strips from her pocket and placed them on top of her medication cart.
Staff WW donned gloves, bleach wipes and cleaned the dirty Glucometer and sat it on top of Medication
cart to dry. When asked why she placed the dirty Glucometer in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 55 of 70
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
08/30/2024
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 0880
her pocket, Staff WW stated that she had no place to carry it, and she needed to wash her hands.
Level of Harm - Immediate
jeopardy to resident health or
safety
Review of the CDC's Infection Prevention during Blood Glucose Monitoring and Insulin Administration,
02/06/13, https://www.cdc.gov/celiac/docs/addenda/celiac/07b_celiac_2013march_glucose_monitoring
Residents Affected - Some
Blood Glucose Meters: General: Whenever possible, blood glucose meters should be assigned to an
individual person, and not be shared. If blood glucose meters must be shared, the device should be
cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and
infectious agents. Unused supplies and medications should be maintained in clean areas separate from
used supplies and equipment (e.g., glucose meters). Do not carry supplies and medications in pockets.
4) Record review for Resident #307 revealed that the resident was admitted to the facility on [DATE], clinical
diagnoses include but not limited to: Type 2 Diabetes Mellitus with other Specified Complication; Pressure
Ulcers.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #307 had a Brief Interview for
Mental Status of 11, which indicated moderate cognitive impairment.
Review of the Physician's Orders showed that Resident #307 had an order dated 07/04/24 for Enhanced
Barrier Precautions every shift for Wounds PPE (Personal Protective Equipment) required; Wound care
Cleanse the wound with Dakins and pat dry with gauze. Apply Santyl to the wound bed followed by
alginate. Cover with foam with silicone bordered dressing daily and PRN (as needed) for soiled or loose
dressing. Collagenase Ointment 250 Unit/GM, apply to Left Posterior Groin topically as needed for Wound
care Cleanse the wound with Dakins and pat dry with gauze.
During a wound care observation conducted on 08/28/24 at 2:48 PM, Staff XX, Licensed Practical Nurse
(LPN) noted she has been working at the facility for 3-4 months as the wound care nurse. Staff XX was
observed gathering the following supplies from the wound care cart: a hand sanitizer pump, gloves (placed
on a foam tray), gauzes, a cup of the powered medication (alginate), and a cup of clear liquid (Dakin's
solution). She entered Resident #307's room and set-up the supplies on the over-bed table that was
covered with a chuck pad. Staff XX went to the bathroom, washed her hands and returned to the bedside
and donned on double gloves (no gown was donned). She soaked gauze with the Dakin's solution and
cleaned the groin area, removed the top pair of gloves, leaving bottom pair of gloves on and donned a new
clean pair of gloves over dirty pair that remained on her hands. Staff XX continued to double glove and don
clean gloves over the dirty pair of gloves at least six times during the wound treatment procedure. In
addition, Staff XX was observed in the bathroom washing her hands, used a small bottle (which she
thought it was soap, however it was labeled hand sanitizer) to wash her hands. She then stated that the
soap dispenser has not been working.
Review of the CDC's Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to
Prevent Spread of Multidrug-resistant Organisms (MDROs), 04/02/24,
https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html included in part the following:
Enhanced Barrier Precautions (EBP)
Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities
that provide opportunities for transfer of MDROs to staff hands and clothing. The use of gown and gloves for
high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for
nursing home residents with wounds and/or indwelling medical devices
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 56 of 70
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
08/30/2024
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 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of
high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include
Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any
skin opening requiring a dressing.
Review of the CDC's Clinical Safety: Hand Hygiene for Healthcare Workers, 02/27/24,
https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html included in part the following:
Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task
such as placing an indwelling device or handling invasive medical devices. Before moving from work on a
soiled body site to a clean body site on the same patient. After touching a patient or patient's surroundings.
After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.
During an interview conducted on 08/28/24 at 3:00 PM, Staff XX was asked why she did not wear a gown
during the wound treatment, she just lowered her head and shrugged her shoulders. In addition, she was
asked why she did not perform hand hygiene after removing her gloves, Staff XX stated that the hand
sanitizer dries her hands, so she does not use it and that's why she wore double gloves.
Review of the facility's policy titled, Infection Control Guidelines for All Nursing Procedures, dated April
2013, included the following: To provide guidelines for general infection control while caring for residents.
General Guidelines:
3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or
non-antimicrobial soap and water under the following conditions:
a. Before and after direct contact with residents.
d. after removing gloves.
4. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are
not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the
following situations:
a. Before and after direct contact with residents.
f. Before moving from a contaminated body site to a clean body site during resident care.
j. After removing gloves.
5. Wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or
body fluids or other potentially infectious materials.
5) An observation was conducted on 08/26/24 at 10:48 AM of Staff I, Certified Nursing Assistant (CNA)
dumping an open bag of dirty laundry down the 3rd floor laundry chute.
During an interview conducted on 08/26/24 at 10:49 AM, Staff I was asked if she just dumped dirty
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 57 of 70
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
08/30/2024
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 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
laundry down the chute in an open bag, she stated yes. She acknowledged that sometimes she does dump
dirty laundry down the laundry chute in an open bag and sometimes she does not. During this interview,
the Assistant Director of Nursing (ADON) approached Staff I and stated that the dirty laundry should
always be in a closed bag before dumping it down the laundry chute.
Review of the facility's policy titled, Laundry Services- Handling/Storing/Transporting Linen, dated 12/08/23,
included the following: The purpose of this procedure is to provide a process for the safe and aseptic
handling, washing, and storage of linen.
Procedure: Standard Precautions
1. Separate soiled and clean linen at all times.
Bagging and Handling/Sorting Soiled Linen:
1. All soiled linen must be placed directly into a covered container designated for soiled linen and/or plastic
bag which can contain the moisture.
4. Handle soiled linen as little as possible to prevent agitation.
5. Employees sorting or washing linen must wear a gown and gloves.
Washing Linen and other Soiled Items:
5. Keep soiled and clean linen, their respective hampers and laundry carts, separate at all times.
7. Wash mops separately from linens, using bleach/EPA registered germicidal
A tour of the facility's laundry room was conducted on 08/30/24 at 10:20 AM with the Maintenance Director
and the Environmental Director. Upon entering the laundry room, it was noted that Staff EE, laundry aide,
was not wearing personal protective equipment (PPE) and she was about to load soiled linen into the
washer. She realized that the surveyor had entered the laundry and donned on a gown. The laundry was a
small room that had 2 washers and 2 dryers (no separation between the contaminated linens and the clean
laundry areas). There was an attached room for receiving the soiled laundry via the chute from the 2nd and
3rd floor, and another room where residents' clean clothing is sorted and stored; both room doors were
propped open. In addition, there were 4 labeled laundry carts used to transfer linens between the soiled
room, the washers, the dryers and the clean clothing room. Further observation revealed one of the carts
was filled with clean dry residents' clothing, however, the cart was labeled for soiled linens.
During an interview conducted on 08/30/24 at 10:30 AM, Staff EE stated she sorts the soiled linens and
residents' clothing by color in the container in the soiled/chute room (the clothing are left inside the
container until enough accumulate of the same color). Observation of the soiled room revealed that the
chute and container were filled with soiled linen and residents' clothing; some of the clothing were in plastic
bags and some were not. Staff EE acknowledged that the space is small and not divided, however, the staff
is aware which cart to use for soiled linen versus clean linen since they are labeled.
On 08/30/24 at 3:15 PM, a 2nd visit to the laundry room was conducted; only one laundry aide was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 58 of 70
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
08/30/2024
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 0880
Level of Harm - Immediate
jeopardy to resident health or
safety
observed in the room, Staff K, housekeeping and laundry aide. The surveyor noted a laundry basket
overflowing with wet clean linens (hanging out of the basket and very close to the floor). Staff K stated that
she was not sure why the other dryer was not working and was waiting for the one dryer currently working.
.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 59 of 70
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
08/30/2024
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 0882
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Designate a qualified infection preventionist to be responsible for the infection prevent and control program
in the nursing home.
Based on interviews and record review, the facility failed to ensure the facility designated Infection
preventionist who is responsible for the facility's Infection Prevention and Control Program (IPCP) had
completed specialized training in infection prevention and control.
The findings included:
Review of the facility's job description titled, Infection Preventionist, included the following:
The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our
Infection Control and Prevention Program in accordance with current federal, state, and local standards,
guidelines, and regulations that govern our center and as may be directed by the Medical Director or
Director of Nursing to ensure that the center provides a safe, sanitary, and comfortable environment and to
help prevent and control the development and transmission of communicable diseases and infections.
Experience: Certification in Infection Control as specified by Appendix PP at 880 is required or must obtain
within the first 90 days of employment.
Record review of the infection Preventionist (IP) job description revealed that on 10/31/23 the Director of
Nursing (DON) signed and dated the document as the Infection Preventionist for the facility.
An interview was conducted on 08/26/24 at 2:50 PM with the Director of Nursing (DON) and the Assistant
Director of Nursing (ADON). They both stated that they were both the Infection Preventionist (IP), however,
when asked who the lead for Infection Control was, the DON noted that he was the lead as the infection
preventionist.
An interview was conducted on 08/30/24 at 11:45 AM with the DON/IP. He stated he has worked at the
facility since 10/31/23 and that he was not aware that he was assigned as the infection preventionist until 2
months ago when the Administrator informed him to start the infection preventionist modules. When asked
if he had completed the entire IPCP training program and had a certificate, he stated that he started the
modules but has not finished and has not obtained a certificate. The DON/IP stated that he was hired as
the ADON back in October 2023, but within 2 weeks he was moved to the DON position. He acknowledged
that he did not know who was the infection preventionist, however he has been pushing to get an infection
preventionist hired.
An interview was conducted on 08/30/24 at 4:03 PM with the ADON. She stated that the DON was the one
assigned to handle infection control. The ADON stated that when she came onboard with the facility, the
DON was taking care of the infection control. She noted that 2 months ago, the Administrator provided
log-in information for the infection preventionist training modules to both the DON and herself. She
acknowledged finishing the modules and getting her certificate on 08/29/24. She noted that she has not
signed the agreement to be the IP because she mentioned to the administrator that the DON has been
taking care of infection control and that he was the lead.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 60 of 70
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
08/30/2024
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, and record review, the facility failed to offer influenza and pneumococcal vaccinations for
Resident #72 and to properly document immunization records for 3 of 5 residents reviewed for
immunizations (Resident #72, Resident #89, and Resident #210).
Residents Affected - Few
The findings included:
Review of the facility's policy titled, Resident Influenza Vaccine, dated 09/25/23, included the following:
Residents who have no medical contraindications will be offered the influenza vaccine annually to
encourage and promote the benefits associated with vaccinations against influenza.
Procedure:
1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents.
4. A resident's refusal of the vaccine shall be documented in the medical record.
Review of the facility's policy titled, Pneumonia Vaccine, dated 09/07/23, included the following:
Procedure:
1. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine
series, and when indicated, are offered the vaccine series within thirty (30) days of admission to the facility
unless medically contraindicated or the resident has already been vaccinated.
2. Assessments of pneumococcal vaccination status are conducted within five (7) working days of the
resident's admission if not conducted prior to admission.
5. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is
documented in the resident's medical record indicating the date of the refusal of the pneumococcal
vaccination.
1)Record review for Resident #72 revealed that the resident was admitted to the facility on [DATE]. No
documentation of the influenza and pneumococcal immunizations was found in the electronic medical
records nor in Resident #72's paper chart. Further review of Resident #72's paper chart and the electric
medical records revealed no consent of refusing the influenza and pneumococcal vaccines since
admission. During an interview conducted on 08/30/24 at 4:00, the ADON acknowledged looking thru the
paper chart as well as the electronic records for Resident #72 and was unable to locate any immunization
documentation.
2) Record review for Resident #89 revealed that the resident was admitted to the facility on [DATE]. During
an interview conducted on 08/30/24 at 11:30 AM with the DON and Infection Preventionist (IP) revealed
that he offered Resident #89 the Influenza vaccine on 02/24/24 and on 04/17/24 spoke over the phone with
Resident #89's father and he refused the vaccine, however, no consent was signed by the resident's father,
nor the refusal was documented in Resident #89's electronic medical record. In addition, the DON/IP noted
that Resident #89 is [AGE] years old, and he was not sure Resident #89
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 61 of 70
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
08/30/2024
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 0883
can receive the pneumonia vaccine.
Level of Harm - Minimal harm
or potential for actual harm
3) Record review for Resident #210 revealed that the resident was admitted to the facility on [DATE]. During
an interview with the DON/IP, he stated that upon admission the residents are asked about their
immunizations by the admission nurse. He stated that any resident that had vaccines prior to admission are
documented in the electronic medical record, however, if the resident did not have the vaccines, the
admission nurse will offer the influenza and pneumococcal vaccines. Review of Resident #201's
immunization record revealed no record of influenza and pneumococcal vaccines documented and no
refusal consents on file.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 62 of 70
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
08/30/2024
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 0917
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground
level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to provide each resident with individual closet
space in the resident room and ensure closets had privacy doors for 5 out of 43 sampled residents
(Resident #79, Resident#20, Resident #15, Resident #212 and Resident #90).
The findings included:
In a tour of the facility conducted on 08/28/24 at 3:00 PM, the following were noted:
1. room [ROOM NUMBER] had Resident #79 by the door with a closet that did not have a door for privacy,
and his roommate, Resident #81, did not have a closet on his side of the room. In this observation,
Resident #79 said that he was sharing his closet with just about everyone on the floor and that his
roommate did not have his own closet.
2. room [ROOM NUMBER] had Resident #20 by the door, with a closet that did not have a door for privacy,
and his roommate Resident #211, who did not have a closet on his side of the room. In this observation,
Resident #20 said that his roommate did not have a closet on his side of the room.
3. Resident #102 in room [ROOM NUMBER] had a closet with a door, and his roommate, Resident #15
near the window, had a closet without a door for privacy.
4. room [ROOM NUMBER] had Resident #83's closet with a door and Resident #212's closet by the
window, which had no door for privacy.
5. room [ROOM NUMBER] had Resident #84, who had a closet with a door, and Resident #9, who was by
the door, with a closet that had no door for privacy.
In an interview conducted on 08/28/24 at 4:13 PM with Staff CC, a Registered Nurse, she was asked why
some closets do not have doors, and she said, You will have to ask Maintenance. She further
acknowledged that room [ROOM NUMBER] by the window did not have an individual closet.
In an interview on 08/28/24 at 4:15 with Staff DD, Certified Nursing Assistants, she was asked about the
closets, and she stated that every resident has their own individual closet and that they never have to share
a closet and if for some reason they had to share a closet it would be divided. She acknowledged that
Rooms 342 (window) and 344 (door) did not have closet doors. She then proceeded to follow this Surveyor
to room [ROOM NUMBER]'s window and acknowledged that Resident #211 did not have a closet. She then
said Resident #211 only wears gowns and has no belongings, so he did not need to have a closet space.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 63 of 70
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
08/30/2024
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 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A chart
review revealed that Resident #83 had a Brief Interview of Mental Status (BIMS) score of 14, which is
cognitively intact. This was taken from the Quarterly Minimum Data Set (MDS) dated [DATE].
Residents Affected - Some
In an interview conducted on 08/26/24 at 9:55 AM, Resident #83 stated that the call light had not been
working for a long time. Resident #83 then proceeded to press the call light button noted at the end of the
call light cord. No light was noted outside Resident #83 ' s room, indicating that the call light was used in
the room. No light was noted in the nurse ' s station, indicating to staff that the call light was used in
Resident #83 ' s room. Further observation did not see any staff coming into Resident #83 ' s room. No staff
came into the room [ROOM NUMBER] minutes later at 10:25 AM, and no staff came into the room an hour
later at 10:55 AM.
This Surveyor attempted to use the call light inside Resident #83 ' s room at 11:00 AM. No light was noted
outside Resident #83 ' s room, indicating that the call light was used in the room. No light was noted in the
nurse ' s station, indicating to staff that the call light was used in Resident #83 ' s room. Further observation
from 11:00 AM to 11:50 AM showed no staff coming into Resident #83 ' s room.
An interview conducted on 08/26/24 at 11:55 AM with Staff YY Certified Nursing Assistant stated that she
has been working in the facility for the last nine years. When a resident uses the call light to call for
assistance, a light will go on outside the room, indicating that the resident needs help. She further said that
the light would also go on at the nurse ' s station, indicating the room number that the call light was used.
6. In an observation conducted on 08/26/24 at 10:50 AM, in Resident #88 ' s room, this Surveyor used the
call light noted on the bed to call for assistance. No light was noted outside the room to notify staff that the
call light was used to call for assistance. Further observation revealed no light in the nurse ' s station,
indicating to staff that the call light was used in Resident #88 ' s room
In an interview conducted on 08/27/24 at 1:50 PM, the Administrator stated that someone came in this
morning to work on the call lights, but it is not something that can be done in a day and needed to be
completed next week at some point and that they are waiting on specific parts.
Based on observations, interviews, and record review, the facility failed to ensure residents have functioning
communication system to call for staff assistance from their room (including bathroom) to a centralized staff
work area for 5 of 43 residents reviewed for call lights (Resident #6, Resident #9, Resident #19, Resident
#83, and Resident #88).
The findings included:
Review of the facility's policy titled, Call Lights, dated 09/01/23, included the following: The purpose of this
policy is ensuring residents' requests and needs are responded to.
Procedure:
2. Answer the resident's call as soon as possible.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 64 of 70
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
08/30/2024
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 0919
5. Report malfunctioning call lights to Maintenance, ED, and/or DON promptly.
Level of Harm - Minimal harm
or potential for actual harm
6. Offer stationary bells and/or round frequently on residents if the call light system is malfunctioning.
Residents Affected - Some
1)Record review for Resident #6 revealed that the resident was admitted to the facility on [DATE] with the
following diagnoses: Multiple Sclerosis; Generalized Anxiety Disorder; Need for Assistance with Personal
Care.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #6 had a Brief Interview for
Mental Status of 15, which indicated that she was cognitively intact. Resident #6 was dependent on staff for
toilet hygiene and substantial/maximal assistance for personal hygiene.
During an interview conducted on 08/26/24 11:14 AM, Resident #6 stated that she has been soaking wet
since this morning, but her call light does not work. In addition, she noted this is not the first time she has
been left soaking wet in the bed and forced to wait for the staff. Resident #6 stated staff is aware that the
call light doesn't work, however, nothing has been done about it. She acknowledged that the facility is short
staff and therefore she waits until is her turn to get changed.
2)Record review for Resident #9 revealed that the resident was admitted to the facility on [DATE] with the
following diagnoses: Hemiplegia, Muscle Weakness, and Gout.
Review the Minimum Data Set (MDS) dated [DATE] revealed that Resident #9 had a Brief Interview of
Mental Status (BIMS) score of 15, which indicated that she was cognitively intact and able to communicate.
Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a wheelchair.
During an interview conducted on 08/26/24 at 11:24 AM, Resident #9 stated that her call light has not
worked for over 6-months now; and she has complaint to the staff, and they have not done anything about
it. She noted that maintenance has worked on the call light, however the call light works for a few days and
then it stops working again. She acknowledged having 2 Call bells (this a manual call bell that you tap on
top and it is only auditory), however the staff told her that they cannot hear them, so she doesn't bother to
use them. Resident #9 stated that she will call 911 if she sees herself in an emergency; this is not right; we
pay for everything to work at the facility. She noted that she only sees the staff during meal trays and
medication administration, the staff doesn't come to check on the residents.
3)Record review for Resident #19 revealed that the resident was admitted to the facility on [DATE] with the
following diagnoses: Hemiplegia, unspecified affecting Left Nondominant Side; Generalized Anxiety
Disorder; Type 2 Diabetes Mellitus.
Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #19 had a Brief Interview for
Mental Status (BIMS) score of 14, which indicated that he was cognitively intact. Resident #19 required
supervision from staff for toilet transfer and shower/bath self; Resident #19 uses a wheelchair.
During an observation conducted on 08/26/24 at 11:43 AM, Resident # 19 stated that his call light has not
worked for over a month. He noted that maintenance staff told him that it was an issue with the electrical
outlets, however, the maintenance staff stated that he was not an electrician. He
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 65 of 70
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
08/30/2024
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 0919
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
acknowledged wheeling himself in his wheelchair out of his room to get the staff's attention when he needs
assistance.
4)During an inspection of the call light system in Resident #19's bathroom revealed that the call light when
activated would not light up in the bathroom or outside of the resident's room to notify staff that Resident
#16 required assistance. Further observation revealed that while the bathroom call system was activated,
no auditory was heard at the nurses' station.
During an interview conducted on 08/26/24 at 11:43 AM, Resident #19 stated that he can wheel himself in
his wheelchair to the bathroom and use the sink and toilet.
During an interview conducted on 08/26/24 at 11:21 AM Staff O, Certified Nursing Assistant (CNA), stated
that she has been working at the facility for 6 months. She acknowledged that the call lights have not been
working since she has been working at the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 66 of 70
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
08/30/2024
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility's administrative staff failed to implement, maintain,
and measure an effective pest control program to eradicate and contain rodent infestation. Facility
administrative staff was unable to address rodent sightings in a timely manner. The facility's administrative
staff failed to follow their own policy for pest control and educate staff members appropriately. These
diseases can spread to people directly through the handling of rodents; contact with rodent feces (poop),
urine, or saliva (such as through breathing in air or eating food that is contaminated with rodent waste); or
rodent bites. This had the potential to affect 111 residents residing in this 120-bed capacity facilities.
Residents Affected - Some
The system failure to ensure pest control/infection control and prevention interventions and services were
effective and implemented resulted in the likelihood for serious injury
and/or death. This failure resulted in the determination of Immediate Jeopardy on 06/27/2024. The findings
of Immediate Jeopardy were determined to be ongoing on 8/30/2024.
The findings included:
A review of the facility policy titled Pest Control Services dated 12/08/23 showed the following:
A program will be established to control insects and rodents within the facility. The Administrator
coordinates with the Maintenance Department to arrange pest control services monthly or as needed. Staff
should report to the Administrator and Maintenance Department sightings of live pests, which are
documented in the pest control log. Food preparation, service, and storage areas will be monitored
regularly for any signs of pests or vermin. The Administrator and Maintenance Department will be notified
immediately of any concerns.
A chart review revealed that Resident #9 (room [ROOM NUMBER]) was initially admitted to the facility on
[DATE] with diagnoses of Hemiplegia, Muscle Weakness, and Gout. The last Minimum Data Set (MDS),
dated [DATE], section C, revealed Resident #9 had a Brief Interview of Mental Status (BIMS) score of 15,
which indicated that she was cognitively intact and able to communicate. Section GG of the MDS revealed
that Resident #9 could wheel at least 150 feet in a corridor or similar space once she is seated in a
wheelchair.
A chart review revealed that Resident #36 (room [ROOM NUMBER]) was admitted to the facility on [DATE]
with diagnoses of Dementia, Bipolar Disorder. The MDS dated [DATE] revealed a BIMS score of 12, which
was slight cognitive impairment.
In an interview conducted on 08/26/24 at 11:24 AM, Resident #9 stated that for the last 4 Saturdays, there
had not been any housekeeping services and that the place was dirty. The facility's Supervisors were aware
that there were pests, roaches, and mice/rodents in the facility. When asked how often she has seen any,
she said, They practically live here. Resident #9 then pointed at a flat, sticky trap (with a rat picture on the
label) used for mice/rats in her room that was still in an unused packet sitting on top of her belongings.
Resident #9 reported that these traps were used for mice/rats sighting in her room near the air-conditioning
area. In this interview, the Surveyor observed a white boxed container, which was located by the
air-conditioning unit and was labeled for pests and roaches. According to Resident #9, the white box used
for trapping pests did not work for rats or
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 67 of 70
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
08/30/2024
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 0925
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
rodents, and this was why she kept requesting the pest control technician to get her the unused designated
mice trap that was seen earlier on top of her belongings. During this entire interview, the Surveyor noted
that food packaging was opened over the bed table, and other unsealed food items were around the bed.
In an observation conducted on 08/26/24, at 11:50 AM, Two Surveyors were on the 2nd floor [NAME] Wing
hallway across from Resident #9' room. Upon exiting the room across, they observed a rodent running in
the [NAME] Wing hallway toward Resident #9's room. Resident #9, who was sitting in her wheelchair in the
hallway, lifted one leg to avoid touching the rodent with her feet. Resident #9 then said to Surveyors, There
it is. Did you see it? as she pointed at the rodent running into her room.
In an interview conducted on 08/26/24 at 1:30 PM, with the facility's Administrator, she stated she was not
aware of any rodents sighting in the facility and reported that she was not told by any residents or staff
members of any rodents in the facility.
A chart review revealed Resident #9's roommate, Resident #96, was admitted to the facility on [DATE] with
diagnoses of Altered Mental Status, Dementia, and Cerebral infarction. The MDS dated [DATE] showed a
BIMS score of 14, which was cognitively intact.
In an interview conducted on 08/26/24 at 12:10 PM with Resident #96, she was not able to answer any of
the Surveyor's questions regarding the rodent sighting.
In an interview conducted on 08/26/24 at 1:07 PM with Staff PP, the Psychologist stated that she had not
seen any rodents in the facility but was told by several residents that they observed rodents in the facility.
A review of the Pest Control service reports showed the following: On 02/1/24, a pest control service report
showed that a routine rodent control service was provided. On 03/7/24, a pest control service report that
showed a routine rodent control service was provided. On 4/4/24, a pest control service report that showed
a routine rodent control service was provided. On 05/02/24, the pest control service report showed that a
routine rodent control service was provided. On 06/6/24, a pest control service report that showed a routine
rodent control service was provided. On 07/11/24, a pest control service report showed that a rodent
control service was provided for exterior perimeter rodent control for roof rats. On 08/01/24, the pest control
service report showed that a routine rodent control service was provided.
In an interview conducted on 08/29/24 at 6:28 AM with Staff OO, Pest Control, he stated that he had been
coming to the facility four times a week for the last seven months. When asked if he had seen any rodents
in the facility, he said no and that he had not seen any rodent droppings. Staff OO stated that Resident #9
told him that she saw a rodent in her room near the window by the air-conditioning unit last Thursday. He
then placed two glue traps in the room by the air-conditioning unit. Staff OO stated that during the above
routine rodent control services conducted monthly, he checks on the five black rodent control boxes that are
placed outside the facility perimeter. These boxes are checked once a month for any activities or sighting of
rodents. He never found any rodents inside the black boxes, but he did see some activities inside the boxes
indicating that rodents took the bates that were placed in these boxes. The rodent trap boxes are part of a
routine service for preventative measures. According to Staff OO, once a week for his visits is sufficient, but
twice a week would be better. He had reports of rodents being seen in the main kitchen about two months
ago, and he placed traps. Staff OO did not see any rodent activities or capture any rodents from the traps
that he
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 68 of 70
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
08/30/2024
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 0925
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
placed in the main kitchen. According to Staff OO, the facility does not have a Pest Control Log that he
checks every time he comes into the facility to review the areas and rooms that need to be sprayed or
treated. The staff tells him verbally about the areas that need treatment when he comes into the facility.
In an interview conducted on 08/29/24 at 7:53 AM with the Director of Nursing (DON), he stated that he had
never seen any rodents in the facility but was told by Staff RR, a Registered Nurse who saw rodents in a
resident's room on 06/27/24 and reported it to him. Staff RR reported seeing rodents in room [ROOM
NUMBER] running around by the window. She further said to him that she witnessed 3 medium-sized
rodents who were not fully grown and who went by her very fast. This sighting was passed to the
Administrator, who said she would handle the issue. An overnight staff member whose name he did not
know told Staff SS, Medical Records, that she saw a rodent on the 2nd floor but did not give any specific
room or location of this sighting.
In an interview with the Administrator on 08/29/24 at 8:00 AM, she stated that he verbally tells Staff OO of
pest control issues and sightings when he comes for his weekly visits. According to the Administrator, it is
not written on any pest control logs. She was aware that Resident #9 reported seeing rodents in her room
last Thursday, and she told Staff OO to treat the room. The Administrator stated that they are going to treat
the entire room, take all furniture and belongings out, and look for possible openings and holes. According
to the facility's administration, Resident #9 has been in the facility for 20 years, and her family brings her
groceries every week, which are stored all around her room.
In a phone interview conducted on 08/29/24 at 8:40 AM with Staff PP, the Former Maintenance Director
stated that he started working in the facility in December of last year and left the facility a month ago. He
was told by Staff QQ, Maintenance Staff, that Resident #36 had rodents running around her room. Staff QQ
placed glue traps in Resident #36's room to try to trap the rodents, but this did not work since rodent
sightings were still noted in the room. In March of 2024, he started getting multiple complaints of rodents
around the facility from multiple staff members who reported sighting, but none of the sightings were
documented in a pest control log. Most of the rodent sightings were coming from the 2nd floor [NAME]
Wing.
In an interview conducted on 08/29/24 at 9:38 AM with Staff RR, the Registered Nurse reported that she
has been working in the facility for the last 13 months. Around two months ago, she came down to the
Director of Nursing (DON) office and told him that she saw three rodents running around in Resident #36's
room. It was late in the evening, during medication administration, when she noticed the rodents were
located at the end of the room. The DON told her that he would let management know of the rodent's
sighting. A few days later, the DON told her that rodent traps would be placed in the resident's room. Any
rodents or pest sightings are documented on the pest control log in the nurse's station. When asked if she
had documented the sighting in the pest control log, she said no.
In an interview conducted on 08/29/24 at 9:52 AM with Staff SS, Medical Records stated that she was
unaware of any rodents sightings in the facility or any other staff members reporting sighting of rodents.
She denied any staff telling her verbally or via text messages of any rodents sightseeing in the facility. When
asked about the policy for pest sightings, she said that she would tell the Administrator and Maintenance
staff. When asked if she was part of any group chat regarding the facility, she said yes.
In an interview conducted on 08/29/24 at 10:04 AM with Staff QQ, Maintenance staff reported that he
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 69 of 70
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
08/30/2024
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 0925
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
has been working in the facility since 2001. He has never seen any rodents around the facility and was
never told by any staff members or residents of any rodent sighting. Staff PP never told him about the
rodents that were sighted in Resident #36's room. Staff QQ stated that he looks at the pest control log
located on each unit for any pest control issues or sightings from staff. He knows that the Pest Control
technician comes into the facility once a week but does not know what was treated and which areas.
In another interview conducted on 08/29/24 at 10:10 AM with Staff SS, she reported that after she was
done with the earlier interview on 08/29/24 at 9:52, she suddenly remembered that a staff member said to
her that they saw a rodent on the unit which was on 08/20/24. She did not know the name of the staff
member who told her but knew that they worked the night shift. Staff SS sent the information to the facility's
group chat.
In an interview conducted on 08/29/24 at 10:18 AM with Staff TT, Physical Therapy Assistance stated that
she had never seen any rodents in the facility. This week, she was told of a rodent sightseeing, which was
observed by Surveyors and Resident #9. She is part of a group chat from the facility by all department
heads. She read on the group chat that a rodent was seen by a staff member last week, on 08/20/24. The
facility's Administrator was aware of these sightings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105765
If continuation sheet
Page 70 of 70
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Back to topCitations
43 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.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F576 - The resident has the right to have reasonable access to the use of a telephone,
Ensure residents have reasonable access to and privacy in their use of communication methods.
F584 - Safe Environment
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.
F585 - Grievances
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F800 - Food and nutrition services
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F882 - Infection preventionist
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F917 - Private closet space in each resident room, as specified in §483
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
F919 - Resident Call System
Make sure that a working call system is available in each resident's bathroom and bathing area.
F924 - Equip corridors with firmly secured handrails on each side
Put firmly secured handrails on each side of hallways.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0100GeneralS&S Dpotential for harm
Meet other general requirements.
- 0211GeneralS&S Dpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Dpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0372GeneralS&S Dpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0531GeneralS&S Dpotential for harm
Have elevators that firefighters can control in the event of a fire.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F911 - Accommodate no more than four residents
Meet requirements for the installation and maintenance of electrical systems.
FAQ · About this visit
Common questions about this visit
What happened during the August 30, 2024 survey of GARDENS NURSING AND REHAB CENTER?
This was a inspection survey of GARDENS NURSING AND REHAB CENTER on August 30, 2024. The surveyor cited 43 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDENS NURSING AND REHAB CENTER on August 30, 2024?
Yes, 43 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
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.