Inspection Reports for
Garden Care Center
135 Franklin Avenue, Franklin Square, NY, 11010
Back to Facility Profile5 Reports
Inspection Report — Mar 4, 2026
Annual Inspection State
Date: Mar 4, 2026
Visit Reason
State-compiled facility profile showing 9 inspections from 2022 to 2026 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 33 complaints about this facility; 9 led to on-site inspections. Eight citations resulted from those complaints.
Findings
Across 9 inspections, 6 resulted in citations totaling 57 deficiencies primarily related to standard health and life safety code violations. The facility had 33 complaints with 9 on-site inspections and 3 enforcement actions involving fines.
Citations (39)
Infection Prevention & Control: Failed to meet infection prevention standards during certification survey.
Label/store Drugs And Biologicals: Deficiencies found in proper labeling and storage of drugs and biologicals.
Responsibilities Of Providers; Required Notif: Providers failed to meet notification requirements.
Sufficient Nursing Staff: Nursing staff levels were insufficient to meet resident needs.
Electrical Systems - Essential Electric Systems: Electrical systems did not meet NFPA requirements.
Emergency Lighting: Emergency lighting was deficient per NFPA standards.
Fire Drills: Fire drill procedures did not comply with NFPA requirements.
Sprinkler System - Maintenance And Testing: Sprinkler system maintenance and testing were inadequate.
Free Of Accident Hazards/supervision/devices: Facility failed to be free of accident hazards during certification/complaint survey.
Infection Prevention & Control: Infection prevention deficiencies noted during certification/complaint survey.
Pasarr Screening For Md & Id: Deficiencies in PASARR screening for mental disability and intellectual disability.
Quality Of Care: Quality of care standards were not met during certification/complaint survey.
Respiratory/tracheostomy Care And Suctioning: Deficiencies in respiratory and tracheostomy care.
Treatment/svcs To Prevent/heal Pressure Ulcer: Pressure ulcer prevention and treatment services were deficient.
Building Construction Type And Height: Building construction did not meet NFPA life safety code requirements.
Corridor - Doors: Corridor doors failed to comply with NFPA requirements.
Organization And Administration: Deficiencies in organization and administration per NFPA standards.
Stairways And Smokeproof Enclosures: Stairways and smokeproof enclosures did not meet NFPA requirements.
Free Of Accident Hazards/supervision/devices: Facility was not free of accident hazards during complaint survey.
Reporting - National Health Safety Network: Failed to properly report to the National Health Safety Network during COVID19 surveys.
Covid-19 Testing-residents & Staff: Deficiencies in COVID-19 testing protocols for residents and staff.
Develop/implement Comprehensive Care Plan: Failed to develop or implement comprehensive care plans.
Free Of Accident Hazards/supervision/devices: Accident hazards and supervision deficiencies noted.
Influenza And Pneumococcal Immunizations: Deficiencies in immunization administration.
Investigate/prevent/correct Alleged Violation: Failed to properly investigate or correct alleged violations.
Nutrition/hydration Status Maintenance: Nutrition and hydration status maintenance was deficient.
Quality Of Care: Quality of care deficiencies noted during certification/complaint survey.
Resident's Care Supervised By A Physician: Resident care supervision by a physician was inadequate.
Responsibilities Of Providers; Required Notif: Providers failed to meet notification requirements.
Safe/functional/sanitary/comfortable Environment: Environment was not safe, functional, sanitary, or comfortable.
Electrical Equipment - Power Cords And Extens: Electrical equipment power cords and extensions did not meet NFPA requirements.
Electrical Equipment - Testing And Maintenance: Electrical equipment testing and maintenance were deficient.
Electrical Systems - Essential Electric Systems: Electrical systems failed to meet NFPA requirements.
Elevators: Elevator safety issues with potential for minimal harm.
Fundamentals - Building System Categories: Building system categories deficient with potential for minimal harm.
Hazardous Areas - Enclosure: Hazardous areas enclosure did not meet NFPA standards.
Physical Environment: Physical environment deficiencies noted per NFPA requirements.
Sprinkler System - Maintenance And Testing: Sprinkler system maintenance and testing were deficient.
Subsistence Needs For Staff And Patients: Subsistence needs for staff and patients were not adequately met.
Report Facts
Inspections on page: 9
Total violations/deficiencies cited: 57
Inspections with violations: 6
Inspections without violations: 3
Total complaints: 33
On-site complaint inspections: 9
Citations from complaints: 8
Enforcement actions: 3
Total fines: 32000
Inspection Report — Aug 30, 2024
Annual Inspection CMS
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.
Citations (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 — Nov 1, 2023
Abbreviated Survey CMS
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.
Citations (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 — Jan 13, 2023
Annual Inspection CMS
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.
Citations (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 — Nov 20, 2020
Renewal CMS
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.
Citations (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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