Inspection Reports for
Palm Gardens Center For Nursing And Rehabilitation
NY, 11218
Back to Facility Profile5 Reports
Inspection Report — Sep 19, 2025
State
Date: Sep 19, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 39 complaints about this facility; 6 led to on-site inspections. Two citations resulted from those complaints.
Findings
Across 5 inspections, 37 citations were issued including 23 standard health and 14 Life Safety Code citations. The facility had 39 complaints with 6 on-site inspections and 2 formal enforcement actions recorded.
Citations (25)
Drug Regimen Review, Report Irregular, Act On: Standard Health Citation — quality of care with Level 2 minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with Level 2 minor potential harm.
Posted Nurse Staffing Information: Standard Health Citation — quality of care with Level 1 potential for minimal harm.
Resident Rights/exercise Of Rights: Standard Health Citation — quality of care with Level 2 minor potential harm.
Respiratory/tracheostomy Care And Suctioning: Standard Health Citation — quality of care with Level 2 minor potential harm.
Right To Survey Results/advocate Agency Info: Standard Health Citation — quality of care with Level 1 potential for minimal harm.
Sufficient Nursing Staff: Standard Health Citation — quality of care with Level 2 minor potential harm.
Building Construction Type And Height: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Means Of Egress - General: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Multiple Occupancies: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Sprinkler System - Installation: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Accuracy Of Assessments: Standard Health Citation — quality of care with Level 2 minor potential harm.
Drug Regimen Review, Report Irregular, Act On: Standard Health Citation — quality of care with Level 2 minor potential harm.
Free From Unnec Psychotropic Meds/prn Use: Standard Health Citation — quality of care with Level 2 minor potential harm.
Increase/prevent Decrease In Rom/mobility: Standard Health Citation — quality of care with Level 2 minor potential harm.
Pharmacy Srvcs/procedures/pharmacist/records: Standard Health Citation — quality of care with Level 2 minor potential harm.
Surety Bond-security Of Personal Funds: Standard Health Citation — quality of care with Level 2 minor potential harm.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Hazardous Areas - Enclosure: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Sprinkler System - Installation: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation — NFPA requirements with Level 2 minor potential harm.
License/comply W/ Fed/state/locl Law/prof Std: Standard Health Citation — quality of care with Level 2 minor potential harm.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with Level 2 minor potential harm.
Reporting - National Health Safety Network: Standard Health Citation — quality of care with Level 2 minor potential harm not yet corrected.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 37
Inspections with violations: 4
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 22000
Number of enforcement actions: 2
Inspection Report — Aug 31, 2023
Annual Inspection CMS
Date: Aug 31, 2023
Visit Reason
The inspection was a recertification survey conducted from 8/24/2023 to 8/31/2023 to assess compliance with regulatory requirements for Palm Gardens Center for Nursing and Rehabilitation.
Findings
The facility was found deficient in multiple areas including inadequate surety bond coverage for residents' personal funds, inaccurate Minimum Data Set (MDS) assessments, failure to provide appropriate care to prevent contractures, improper narcotics reconciliation, failure to act on pharmacist medication irregularities, and inappropriate use and documentation of psychotropic medications for residents.
Citations (6)
Facility did not ensure a surety bond was purchased to cover the total personal needs accounts (PNA) of residents.
Minimum Data Set (MDS) assessment did not accurately reflect a resident's left upper extremity range of motion impairment.
Resident with limited mobility was not provided appropriate services and assistance to prevent further contractures, specifically missing prescribed hand roll.
Facility did not maintain and periodically reconcile an accurate account of all controlled drugs for one unit.
Facility failed to document in the resident's medical record that pharmacist-identified medication irregularities were reviewed and acted upon.
Residents were not free from unnecessary antipsychotic medications; failure to implement gradual dose reductions and document rationale for continued use.
Report Facts
Residents with personal needs accounts: 60
Total residents: 226
Surety bond coverage amount: 100000
Medication units observed: 6
Medication discrepancy count: 1
Residents reviewed for unnecessary medications: 35
Residents affected by unnecessary antipsychotic medication: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in narcotics count discrepancy for Resident #184 |
| ADON | Assistant Director of Nursing | Interviewed regarding narcotics discrepancy and pharmacy recommendations |
| DON | Director of Nursing | Interviewed regarding narcotics discrepancy and pharmacy recommendations |
| Physical Therapist Assistant | Interviewed regarding Resident #12's range of motion impairment and care | |
| MDS Coordinator | Interviewed regarding Resident #12's MDS assessment error | |
| RN #3 | Registered Nurse | Interviewed regarding Resident #12's hand roll application |
| Psychiatrist | Interviewed regarding psychotropic medication use and recommendations | |
| Attending Physician | Interviewed regarding psychotropic medication use and documentation | |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding care of Resident #199 |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding care of Resident #199 |
| Nursing Supervisor/Assistant Director of Nursing | Interviewed regarding care and medication management of Resident #199 | |
| Director of Nursing DNS | Director of Nursing | Interviewed regarding pharmacy recommendations and documentation |
Inspection Report — Aug 30, 2023
Abbreviated Survey CMS
Date: Aug 30, 2023
Visit Reason
The inspection was conducted as an abbreviated survey to investigate the facility's failure to timely report suspected abuse, neglect, or theft and to ensure compliance with applicable laws regarding licensed nursing staff and medication administration.
Findings
The facility failed to implement policies and procedures for timely reporting of reasonable suspicion of a crime, specifically reporting an incident 4 days late and not reporting to local law enforcement. A Certified Nursing Assistant (CNA #1) administered medications to 15 residents without a nursing license, posing as a Licensed Practical Nurse (LPN). The facility allowed CNA #1 to perform licensed nurse activities without verification of credentials, violating New York State Education Laws.
Citations (3)
Failure to timely report suspected abuse, neglect, or theft to proper authorities.
Permitting an unlicensed person (CNA #1) to perform licensed nurse activities including medication administration.
Failure to comply with New York Education Law Sections 6512 and 6509 regarding unauthorized practice and professional misconduct.
Report Facts
Residents affected: 15
Medications administered: 106
Date of incident: Jul 10, 2023
Date reported to NYSDOH: Jul 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Administered medications without nursing license, posed as Licensed Practical Nurse. |
| RNS #1 | Registered Nurse Supervisor | Did not verify CNA #1's job title or check staffing schedule; permitted CNA #1 to perform licensed nurse activities. |
| LPN #1 | Licensed Practical Nurse | Showed CNA #1 how to administer medications and gave keys to medication cart. |
| Director of Nursing | Director of Nursing | Received report of incident; stated misunderstanding of reporting requirements. |
| Administrator | Administrator | Did not report incident to local law enforcement; assumed agency staff would report. |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated RNS must verify staff names against nursing schedule. |
Inspection Report — Jun 16, 2021
Annual Inspection CMS
Date: Jun 16, 2021
Visit Reason
The inspection was conducted as a Recertification survey to assess compliance with medication storage and labeling regulations.
Findings
The facility failed to ensure that medications and biologicals were discarded by their expiration dates, with expired medications found in the medication room. Staff interviews and record reviews confirmed lapses in checking and discarding expired medications despite existing policies and training.
Citations (1)
Expired medications, including a bottle of eye vitamins with an expiration date of 08/2019, were found in the medication room.
Report Facts
Date of expired medication: 201908
Date of survey completion: Jun 18, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Responsible for medication room checks and medication pass; interviewed regarding expired medication |
| RN #1 | RN Supervisor | Observed expired medication in medication room and noted need for discard |
| RN #2 | Registered Nurse | Supervises 2nd and 3rd floors; interviewed about medication expiration checks |
| Assistant Director of Nursing | ADNS | Interviewed regarding medication checking policies and audits |
| Pharmacy Consultant Supervisor | PCS | Conducts monthly medication room inspections and reports findings |
| Director of Nursing Services | DNS | Interviewed about medication checking frequency and labeling procedures |
Inspection Report — Apr 5, 2019
Annual Inspection CMS
Date: Apr 5, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements and evaluate the facility's care and medication practices.
Findings
The facility was found deficient in ensuring accurate resident assessments, developing comprehensive care plans with measurable goals, and appropriate use of psychotropic medication. Specifically, Resident #22 was inaccurately assessed with a diagnosis of Non-Alzheimer's Dementia, and the use of Seroquel was not justified by documented delirium or psychotic disorder. Resident #160 lacked a comprehensive care plan addressing depression with measurable objectives. The psychiatrist did not provide a definitive diagnosis of dementia for Resident #22, and the facility failed to demonstrate that antipsychotic medication was used appropriately.
Citations (3)
Failure to ensure accurate resident assessment, specifically misdiagnosis of Non-Alzheimer's Dementia for Resident #22.
Failure to develop and implement a comprehensive care plan with measurable goals for Resident #160's depression.
Failure to ensure appropriate use of antipsychotic medication (Seroquel) for Resident #22, prescribed for non-FDA approved indication (delirium) without documented evidence of delirium or psychosis.
Report Facts
Residents sampled: 35
Residents affected: 1
Residents affected: 1
Medication doses: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #22's condition and medication use |
| RN #2 | Registered Nurse | Interviewed regarding care plan updates for Resident #160 |
| RN #3 | Registered Nurse | Interviewed regarding behavior and care plan for Resident #160 |
| Psychiatrist | Interviewed regarding diagnosis and medication for Resident #22 | |
| CNA #1 | Certified Nursing Assistant | Interviewed regarding Resident #22's behavior and care |
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