Health inspection·February 24, 2022

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations and staff interviews, the facility failed to ensure that two (Residents #85 and #5) of three residents observed during medication administration, from a total sample of 27 residents, were provided privacy during medical treatment. Residents Affected - Few The findings include: On 2/22/22 at 11:00 AM, Registered Nurse (RN) A was observed performing blood glucose monitoring for Resident #85. RN A obtained the necessary equipment, entered the resident's room, and left the door open after verifying the resident's identity. The nurse pricked the resident's finger for blood and obtained a blood glucose result without pulling the resident's curtain to provide privacy. RN A stated the blood sugar was 211 and the resident required insulin. After hygiene, the nurse obtained 2 units of insulin and went back to Resident #85 with the door still open and the privacy curtain not pulled. The nurse administered the insulin in the resident's left lower abdomen. When asked whether she provided privacy during the process, she replied, I completely forgot about that. On 2/22/22 at 11:45 AM, Licensed Practical Nurse (LPN) B obtained the necessary equipment for blood glucose monitoring and entered Resident #5's room. The nurse did not knock on the resident's door, did not ask permission to enter, and left the door open after verifying the resident's identity. LPN B pricked the resident's finger for blood and obtained a blood glucose result without pulling the resident's curtain to provide privacy. Resident #5 was in the bed close to the door and could be observed from the hallway. LPN B stated the blood sugar reading was 463. He added that the blood sugar was beyond the parameters and the resident's physician would have to be contacted. He returned to the resident and stated LPN D/Unit Manager contacted the physician and orders were given to administer 12 units of insulin and recheck the resident's blood sugar after an hour. LPN B obtained the 12 units of insulin, entered the resident's room without closing the door or pulling the curtain for privacy, and administered the insulin in the resident's left upper arm. During a medication administration observation on 2/23/21 at 9:07 AM, LPN C was observed entering Resident #5's room without knocking on the door or requesting permission to enter. LPN C left the door open, and did not pull the privacy curtain closed before administering medication to the resident. In an interview on 2/23/22 at 9:30 AM, LPN C confirmed that she had not provided privacy to Resident #5 during medication administration. . 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 2 Event ID: 105822 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 105822 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/24/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gardens Healthcare & Rehabilitation Center 1704 Huntington Village Circle Daytona Beach, FL 32114 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)