Inspection Reports for
Garden Care Center
135 Franklin Avenue, Franklin Square, NY, 11010
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
33% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Aug 30, 2024
Visit Reason
Inspection revealed 6 health and 4 life safety code citations including accident hazards, infection control, PASARR screening, quality of care, respiratory care, pressure ulcer treatment, and life safety code issues related to building construction, doors, administration, and stairways. All deficiencies were corrected by October 2024.
Findings
Inspection revealed 6 health and 4 life safety code citations including accident hazards, infection control, PASARR screening, quality of care, respiratory care, pressure ulcer treatment, and life safety code issues related to building construction, doors, administration, and stairways. All deficiencies were corrected by October 2024.
Deficiencies (10)
Free of accident hazards/supervision/devices
Infection prevention & control
Pasarr screening for md & id
Quality of care
Respiratory/tracheostomy care and suctioning
Treatment/svcs to prevent/heal pressure ulcer
Building construction type and height
Corridor - doors
Organization and administration
Stairways and smokeproof enclosures
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Aug 30, 2024
Visit Reason
The survey was a Recertification Survey conducted from 8/26/2024 to 8/30/2024 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to complete required Pre-admission Screening and Resident Review (PASARR) for one resident, inadequate treatment and monitoring of blood glucose levels for a diabetic resident, improper pressure ulcer care related to incorrect air mattress weight settings, unsecured oxygen tanks posing accident hazards, inaccurate oxygen therapy administration for two residents, and failure to follow infection control protocols for residents with feeding tubes.
Deficiencies (6)
F 0645 PASARR screening was not completed prior to admission for one resident, failing to ensure appropriate level of care and specialized services.
F 0684 Resident with diabetes had blood glucose levels out of range on multiple occasions without physician notification and insulin injection sites were not documented as required.
F 0686 Air mattress weight settings for three residents with pressure ulcers were not adjusted to residents' actual weights, risking impaired healing and new ulcer development.
F 0689 A full oxygen E-cylinder tank was found unsecured in a resident day room, creating an accident hazard.
F 0695 Two residents receiving oxygen therapy were administered flow rates higher than their physician orders, and nursing staff failed to monitor and adjust oxygen levels appropriately.
F 0880 Staff failed to use Personal Protective Equipment when providing care to a resident with a gastrostomy tube on Enhanced Barrier Precautions, risking infection transmission.
Report Facts
Blood glucose out of range occurrences: 27
Blood glucose out of range occurrences: 13
Insulin injection sites undocumented: 50
Insulin injection sites undocumented: 70
Air mattress weight setting: 325
Air mattress weight setting: 250
Air mattress weight setting: 250
Oxygen flow rate: 4
Oxygen flow rate: 5
Oxygen tank pressure: 2000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Supervisor #2 | Unit Supervisor | Named in findings related to oxygen therapy flow rate errors and failure to use PPE for feeding tube care |
| Registered Nurse #3 | Wound Care Nurse | Named in findings related to air mattress weight setting responsibilities |
| Physician #3 | Named in findings related to expectations for blood glucose monitoring and notification | |
| Director of Nursing Services | Named in multiple interviews regarding protocol adherence for blood glucose, oxygen therapy, air mattress settings, and infection control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
Inspection identified a single Level 2 deficiency related to accident hazards, which was corrected by August 2023.
Findings
Inspection identified a single Level 2 deficiency related to accident hazards, which was corrected by August 2023.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 1, 2023
Visit Reason
The abbreviated survey was conducted to investigate compliance with care and safety standards, specifically focusing on accident prevention and adherence to the plan of care for residents requiring assistance.
Complaint Details
The investigation found probable evidence of abuse neglect or mistreatment as the assigned CNA failed to follow the resident's plan of care. The CNA was terminated and corrective actions were implemented. The complaint was substantiated.
Findings
The facility failed to protect one resident who required two-person assistance, resulting in a laceration from hitting a bedside table during care provided by a single CNA. The facility took corrective actions including staff reeducation, competency completion, and implementation of audit tools to ensure compliance.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. A CNA did not follow the plan of care requiring two-person assistance, causing a resident to sustain a laceration requiring hospital transfer and sutures.
Report Facts
Sutures required: 6
Date of hospital discharge papers: 2023
Date of incident: 2023
Date of CNA interview: 2023
Date of DON interview: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented resident's laceration and condition on 7/17/23. |
| Registered Nurse #1 | Registered Nurse | Responded to unit to observe resident's laceration and documented hospital transfer. |
| Director of Nursing | Director of Nursing | Conducted interviews, stated corrective actions, and confirmed CNA termination. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Aug 28, 2023
Visit Reason
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Findings
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 17, 2023
Visit Reason
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Findings
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 13, 2023
Visit Reason
The survey was a Recertification Survey and Abbreviated Survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to thoroughly investigate alleged violations, incomplete care plans, delayed diagnostic testing and treatment, failure to prevent accidents, inadequate nutritional monitoring and intervention, lack of timely physician oversight, incomplete vaccination documentation, failure to conduct COVID-19 testing after exposure, and unsafe environmental conditions related to room size and equipment use.
Deficiencies (9)
F0610: The facility did not ensure all alleged violations were thoroughly investigated, specifically failing to investigate the onset of pain and swelling in Resident #21 from 3/8/2022 to 3/14/2022.
F0656: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #54's hearing aid use.
F0684: Resident #21 did not receive treatment and care in accordance with professional standards, including delayed x-ray and Doppler studies leading to late fracture diagnosis.
F0689: The facility failed to prevent an avoidable accident when CNA #2 provided care alone to Resident #47 who required two-person assistance, resulting in a fall with fractures and hematoma.
F0692: Resident #163 experienced significant weight loss that was not addressed timely by the Registered Dietitian or nursing staff.
F0710: The facility failed to ensure physician oversight for Resident #163's significant weight loss, with no timely documentation or intervention by the Primary Care Physician.
F0883: The facility did not ensure influenza and pneumococcal vaccination status was documented or vaccines offered to Residents #104 and #99.
F0886: The facility failed to conduct COVID-19 testing for staff exposed to Resident #263 who was diagnosed with COVID-19 after hospital transfer.
F0921: The facility did not provide a safe and functional environment for Resident #263 and #44 in a three-bedded room, lacking sufficient space for mechanical lift transfers.
Report Facts
Weight loss percentage: 14
Weight loss percentage: 5
Hematoma size: 3
Hematoma size: 4
Fracture dates: 6
Survey completion date: Jan 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse, Unit Supervisor | Named in findings related to delayed fracture diagnosis for Resident #21 and vaccination documentation. |
| RN #4 | Wound Care Nurse and Accident Investigation Coordinator | Named in investigation of Resident #21's injury and accident investigation process. |
| RN #5 | Nursing Supervisor | Named in fall incident involving Resident #47. |
| CNA #2 | Certified Nursing Assistant | Named in fall incident involving Resident #47 for failure to follow two-person assistance plan. |
| Physician #1 | Physician | Named in treatment and diagnostic delays for Resident #21. |
| Physician #2 | Primary Care Physician | Named in oversight failure for Resident #163's weight loss. |
| RN #7 | Charge Nurse | Named in weight monitoring and nutritional care for Resident #163. |
| RD #2 | Registered Dietitian | Named in nutritional assessment and failure to timely address weight loss for Resident #163. |
| RN #2 | Evening RN Supervisor/Admission Nurse | Named in pneumococcal vaccination follow-up for Resident #104. |
| RN #3 | Unit Supervisor | Named in pneumococcal vaccination follow-up for Resident #104 and #99. |
| CNA #4 | Certified Nursing Assistant | Named in COVID-19 exposure and care for Resident #263. |
| CNA #5 | Certified Nursing Assistant | Named in COVID-19 exposure and care for Resident #263. |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 18, 2022
Visit Reason
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Findings
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 11, 2022
Visit Reason
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Findings
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 4, 2022
Visit Reason
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Findings
Covid-19 Survey found a Level 2 deficiency in reporting to the national health safety network, widespread in scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Oct 19, 2021
Visit Reason
Complaint Survey found a Level 2 deficiency related to the right to be free from physical restraints, corrected by December 2021.
Findings
Complaint Survey found a Level 2 deficiency related to the right to be free from physical restraints, corrected by December 2021.
Deficiencies (1)
Right to be free from physical restraints
Inspection Report
Renewal
Deficiencies: 1
Date: Nov 20, 2020
Visit Reason
The inspection was conducted as a Recertification Survey to assess compliance with care plan implementation and wound care for residents with pressure ulcers.
Findings
The facility failed to ensure that care was implemented to meet the medical and nursing needs of two residents with pressure ulcers. Specifically, heel booties were not consistently applied as ordered, and care plans did not reflect removal of heel booties during meals.
Deficiencies (1)
F 0656: The facility did not develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions. Resident #17 was observed without prescribed heel booties on both feet as ordered. Resident #88 had multiple pressure ulcers and heel booties were not consistently applied as ordered.
Report Facts
Residents affected: 2
Deficiencies cited: 1
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