Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Gardens Rehab & Care Center during CMS and state inspections, most recent first.
The facility failed to provide required RN coverage for at least 8 consecutive hours in a 24-hour period when only LPNs were scheduled and worked on both the day and night shifts, and the DON did not serve as charge nurse despite census levels that would have allowed this. Review of staffing postings, assignment sheets, and time cards confirmed that no RN was on duty, while interviews with the DON, Administrator, and CEO confirmed that facility expectations require daily RN coverage for a consecutive 8 hours and that the DON did not function as charge nurse. The facility assessment listed various nursing roles, including DON, RN, LPN, CNA, medication technician, wound nurse, and MDS nurse, but did not define specific RN coverage expectations.
The facility did not complete or submit required PASARR Level II referrals for three residents with serious mental illness diagnoses, including schizophrenia, bipolar disorder, major depression, and anxiety disorder. These residents had documented cognitive status on the MDS, were prescribed psychotropic medications such as antipsychotics and antidepressants, and had PASARR forms completed by the admissions coordinator that listed their mental health diagnoses and medications. Despite this, no Level II referrals were made, even though the admissions coordinator later acknowledged that residents with diagnoses such as bipolar disorder should be referred and that facility policy requires all individuals with mental disorders or intellectual disability to be sent to the state for Level II determinations. The DON and administrator confirmed that PASARRs are expected to be conducted according to policy when residents have qualifying mental health conditions.
The facility failed to follow its smoking policy and standard care plan procedures for multiple residents who smoked. Several residents with complex medical conditions had either no identified smoking risk on their care plans or, when smoking risk was documented, lacked the required MD orders for smoking, despite having signed smoking contracts. The standard care plan and smoking policy required an MD order, supervised smoking only in designated areas at designated times, and quarterly assessment, but these elements were not consistently implemented or documented. Staff interviews showed that a CNA did not know the smoking policy or where smoking status was recorded, an LPN believed smoking orders were unnecessary despite care plan language requiring them, the admissions coordinator was often unaware of smoking status at admission and unfamiliar with the full policy, the DON knew only what was in the smoking contract and acknowledged that providers might be unaware of residents’ smoking status without orders, and the administrator described policy elements such as supervision and smoking aprons while indicating that care plan interventions were part of the policy.
A resident with multiple medical conditions and cognitive impairment had their confidentiality compromised when an unattended medication cart computer was left unlocked and visible, displaying the resident’s full name, date of birth, photo, room location, code status, and medication information. An LPN reported believing the computer had been locked but acknowledged that leaving it open could allow access to patient information. The DON and administrator both stated that leaving a med cart computer open would be a HIPAA violation and confirmed that facility policy requires computers containing resident information to be locked to safeguard confidential records.
A resident with severe cognitive impairment was verbally abused by her spouse in a common area, with staff overhearing profane and demeaning language. Although the incident was documented and the spouse was removed from the facility, the event was not reported to the state agency within the required two-hour timeframe due to staff's lack of awareness that the incident was reportable. This delay violated the facility's abuse reporting policy.
A resident with moderate cognitive impairment was verbally abused by a roommate with severe cognitive impairment and PTSD, involving racial slurs and threats. The incident was triggered by a TV program and reported by staff who intervened to prevent escalation. The facility lacked a behavior management plan for the aggressive resident, contributing to the deficiency.
A resident with moderate cognitive impairment reported verbal abuse involving threats and racial slurs by a roommate. The facility initiated an investigation but failed to report the incident to the state agency within the required timeframe. Staff interviews confirmed awareness of the reporting requirement, but the facility's policy lacked a specific timeline for reporting.
A resident with a history of verbal outbursts verbally abused another resident, calling them derogatory names. The incident was overheard by a staff member who intervened and reported it to the administration. Despite the facility's policies on resident rights and abuse prevention, the incident occurred, highlighting a failure to prevent verbal abuse.
Failure to Provide Required RN Coverage or DON Charge Nurse Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for at least 8 consecutive hours in a 24-hour period, and the DON did not serve as charge nurse as permitted when census is 60 or fewer residents. Review of the daily staff posting, daily assignment sheet, and time cards for May 26, 2025, showed that no RN was scheduled or worked on either the day shift (6:00 AM to 6:30 PM) or the night shift (6:00 PM to 6:30 AM). Instead, two LPNs were scheduled and worked on the day shift, and two LPNs were scheduled and worked on the night shift, with no documentation of RN presence or coverage for that date. During interviews, the DON confirmed that there was no RN scheduled to work for 8 consecutive hours on that date and acknowledged that facility expectations are to have an RN scheduled and on shift to delegate care and oversee LPNs and nursing aides. The DON initially stated she could serve as charge nurse due to the facility’s bed occupancy but later confirmed she did not serve as charge nurse on May 26, 2025, so no hours could be counted toward the RN coverage requirement. The Administrator and CEO also confirmed that the expectation is to have RN coverage for a consecutive 8 hours, 7 days a week, and that the DON did not function as charge nurse on that date. Review of the facility assessment, last updated October 24, 2025, showed it listed nursing roles such as DON, RN, LPN, CNA, medication technician, wound nurse, and MDS nurse as needed resources but did not specify staffing expectations for RN coverage.
Failure to Complete Required PASARR Level II Referrals for Residents With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that required PASARR Level II evaluations were completed and submitted to the state for three residents with serious mental illness diagnoses. One resident was admitted with schizophrenia, encephalopathy, unspecified psychosis, hallucinations, recurrent bipolar disorder, anxiety disorder, and other depressive episodes, had a BIMS score of 12 indicating moderate cognitive impairment, and was actively prescribed Risperidone and Duloxetine. The PASARR form for this resident, completed by the admissions coordinator, documented schizophrenia, major depression, bipolar disorder, and anxiety disorder, along with Duloxetine, but no Level II referral was made. A second resident was admitted with schizophrenia, anxiety disorder, and recurrent major depressive disorder, had a BIMS score of 15 indicating intact cognition, and was receiving Fluoxetine and Olanzapine; the PASARR, also signed by the admissions coordinator, documented schizophrenia, major depression, anxiety disorder, and the psychotropic medications, but again no Level II referral was submitted. A third resident was admitted with unspecified mood disorder and bipolar disorder, had an admission BIMS score of 12 indicating moderate cognitive impairment, and was prescribed Depakote with a psychiatry referral ordered. The PASARR for this resident, completed by the admissions coordinator, documented major depression, anxiety disorder, and Depakote, but no Level II PASARR referral was made. In interviews, the admissions coordinator stated she is responsible for admission, 30‑day, and change-in-condition PASARRs, acknowledged that residents with diagnoses such as bipolar disorder require a Level II PASARR referral, and confirmed that all three residents should have been referred under the facility’s policy requiring all individuals with mental disorders and intellectual disability to be referred to the state for Level II determinations. The DON and the administrator both acknowledged that PASARRs are expected to be conducted per policy when residents have qualifying mental health diagnoses.
Failure to Implement and Document Required Smoking Policy and Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its smoking policy and standard care plan procedures for multiple residents who smoked. For seven residents with various medical conditions, including end stage renal disease, COPD, cardiovascular disease, diabetes, and psychiatric and neurologic diagnoses, the clinical record review showed either no initial identification of smoking risk on the care plan or, when smoking risk was identified, the required physician orders for smoking were absent. One resident’s care plan initially lacked any identified smoking risk, and another resident’s smoking activity was only documented under activities interests as a desire to be included in smoke breaks, without a corresponding smoking risk care plan. In all reviewed cases, the residents had signed smoking contracts acknowledging the facility’s smoking policy. Further review of the care plans for several residents showed a standardized problem of “risk related to smoking” with interventions that explicitly required an MD-signed order, consent signed by the responsible party, smoking only with supervision in a designated area, and quarterly smoking assessment per protocol. Despite these written interventions, the physician order sections of the records contained no smoking orders for any of the seven residents. The facility’s written policy, “Resident Smoking,” stated that smoking safety is included in the Standard Care Plan and reviewed at least quarterly, and the Standard Care Plan specified that an MD order is required, smoking is allowed only with supervision at designated times and locations, and smoking supplies are to be left with personnel. Staff interviews revealed a lack of awareness and inconsistent practices regarding identification and management of residents who smoke. A CNA reported she was unsure where in the chart a resident’s smoking status was documented and learned who smoked only when other staff informed her; she also stated she did not know the smoking policy. An LPN stated he knew which residents smoked based on familiarity and did not think residents needed a smoking order, believing that signing the contract was sufficient, even though he read aloud from a care plan that an MD order was an intervention. The admissions coordinator stated she was not often aware of smoking status at admission, sometimes documented it when known, and did not know the full policy beyond designated times and the need for accompaniment. The DON stated all residents sign the smoking contract regardless of smoking status and acknowledged not being aware of the smoking policy beyond the contract, noting that without smoking orders providers may be unaware of residents’ smoking status. The administrator stated the smoking policy includes supervision and use of smoking aprons and, after reviewing the policy, indicated that the care plan interventions were part of that policy.
Unattended Unlocked Med Cart Computer Exposed Resident Health Information
Penalty
Summary
The facility failed to maintain privacy and confidentiality of a resident’s personal and medical information when a medication cart computer was left unlocked and unattended, displaying identifiable health information. The affected resident had multiple diagnoses, including hypotension, history of TIA and cerebral infarction without residual deficits, unspecified dementia, acute respiratory failure with hypoxia, major depressive disorder, and anxiety disorder. The resident’s care plan identified confusion and poor decision-making related to cognitive impairment, with interventions such as explaining procedures and reorienting as needed. Physician orders for several PRN medications, including Loperamide, Ondansetron, Hydroxyzine, and an aluminum/magnesium hydroxide suspension, were present in the record. On the survey date at 6:18 AM, a medication cart was observed unattended with an unlocked device on top that displayed the resident’s full name, date of birth, photo, room location, code status, and medications. During interview, the LPN responsible for the cart stated she thought she had locked the computer and acknowledged that failing to close the computer could allow others to access patient information, though she could not recall the term for this. The DON stated that an open medication cart computer would be a HIPAA violation and that facility policy requires nursing computers to be locked in compliance with HIPAA. The administrator similarly stated that leaving medication cart computers open would be a HIPAA violation if someone saw them and that resident information, including first and last names, should be protected. Review of the facility’s “Confidentiality of Information” policy, last reviewed March 1, 2025, showed that the facility is to safeguard all resident records to protect confidentiality, which was not followed in this instance.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for one resident. A resident with severe cognitive impairment and multiple diagnoses, including dementia and a recent fracture, was verbally abused by her spouse in a common area. The spouse was overheard by staff using profane and demeaning language towards the resident, including calling her 'stupid' and 'worthless.' A nurse intervened, separated the spouse from the resident, and escorted him out of the facility. The incident was witnessed by staff and documented in nursing notes. Despite the clear observation and documentation of verbal abuse, the incident was not reported to the state agency until two days after it occurred. Facility policy requires that suspected abuse, neglect, exploitation, or mistreatment be reported within two hours. Interviews with staff revealed that the Assistant Administrator was unaware that the incident was reportable as verbal abuse, and the Administrator confirmed the delay in reporting. The Director of Nursing also acknowledged the delay and stated that all allegations of abuse should be reported within two hours, as per policy. The internal investigation confirmed the timeline, showing the event occurred on one day and was reported online to the state agency two days later. The delay in reporting was attributed to a lack of recognition by the Assistant Administrator that the incident constituted reportable abuse. The facility's failure to report the allegation of abuse within the required timeframe constituted a deficiency in compliance with abuse reporting regulations.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, which included racial slurs and threats of physical harm. The incident involved a resident with moderate cognitive impairment who reported being threatened by his roommate, a resident with severe cognitive impairment and a history of PTSD. The altercation was reportedly triggered by a television program that the first resident was watching, which led to the second resident making racially charged threats. The incident was initially reported by a dietary staff member who witnessed the argument and heard the threatening remarks. A certified nursing assistant intervened by removing the aggressive resident from the room to prevent further escalation. Despite the intervention, the facility's failure to have a behavior management plan in place for the aggressive resident, who had a known history of PTSD, contributed to the deficiency. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the lack of a care plan addressing the aggressive resident's behaviors and PTSD. The Director of Nursing acknowledged that the threats and racial slurs constituted verbal abuse, highlighting a gap in the facility's ability to prevent and manage such incidents. The investigation into the incident confirmed the verbal abuse, but no physical injuries were reported for either resident.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the state agency within the required regulatory timeframe. The incident involved a resident with moderate cognitive impairment who reported to his therapist that his roommate had threatened him with harm and used racial slurs. The therapist informed the administration, and an investigation was initiated immediately. However, the facility did not report the incident to the state agency until three days later, which is outside the required timeframe for reporting such allegations. The investigation revealed that the incident occurred when a certified nursing assistant was informed by dietary staff about an argument between two residents, during which one resident threatened the other. The facility's policy on abuse prohibition did not specify the timeline for reporting allegations to the state agency, contributing to the delay. Interviews with staff confirmed that they were aware of the requirement to report allegations of abuse within two hours, but this was not adhered to in this case.
Failure to Prevent Verbal Abuse Between Residents
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident. Resident #1, who was admitted with diagnoses including syncope, major depressive disorder, and schizophrenia, was verbally abused by Resident #2. Resident #2, admitted with conditions such as hemiplegia, major depressive disorder, and anxiety disorder, was cognitively intact with a BIMS score of 15. On September 19, 2024, a staff member overheard Resident #2 using abusive language towards Resident #1, calling them a 'psycho bitch.' The staff member intervened to de-escalate the situation and reported the incident to the facility's administration. Resident #2 had a history of verbal outbursts, as noted in their care plan, which included swearing and insults during meals and activities. The facility's policies on resident rights and abuse prevention emphasize the importance of treating residents with respect and ensuring they are free from abuse. Despite these policies, the incident occurred, indicating a failure to prevent verbal abuse between residents. Resident #1 later described the incident as a misunderstanding and expressed feeling safe in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Lingenfelter Center | 0 mi | ★★★★★ | 1 | 0 |
| Desert Highlands Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| The Legacy Rehab & Care Center | 29.7 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.