Above 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 Gardens Court during CMS and state inspections, most recent first.
Failure to prevent accidents and investigate a transfer-related event: A resident requiring substantial assistance was transferred with a sit-to-stand lift despite limited ability to sit upright, and the lift was not locked while staff left the room. Another resident with seizure precautions had orders for bilateral floor mats and padded side rails, but the mats were left away from the bed and the side rails were not padded on repeated observations. A third resident with a prior skin tear linked to the side rail also had no padding in place despite an active order, and a totally dependent resident had a family-reported transfer injury that led to tibia/fibula fractures, yet no incident report or investigation was completed.
Failure to provide ordered tube feeding flushes led to a resident with dysphagia, a PEG tube, and dementia having 0 flushes recorded on the pump for 3 days. The pump was found set incorrectly, despite MAR documentation showing water flushes were signed as given, and STAT labs showed electrolyte imbalance with high Na, low K, and elevated BUN.
Three residents reported incidents of undignified treatment by staff, including rough handling, yelling, and ignoring preferences. One resident was left alone in the bathroom, another was yelled at about bed height, and a third was forced to use a heavy blanket. These actions violated the facility's policy on resident dignity and respect.
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care. One resident had conflicting catheter orders and no documentation of refusal to use an anchor. Another resident had an undocumented dressing on a skin tear, and a third resident experienced issues with a wound VAC, with no clear documentation of actions taken. These deficiencies highlight a failure in maintaining complete and accurate records.
Failure to Prevent Accidents and Investigate a Transfer-Related Event
Penalty
Summary
The facility failed to provide care and services to prevent accidents for four sampled residents. One resident with a history of falls, muscle weakness, cognitive communication deficit, displaced left femur fracture, and abnormal posture was observed during a transfer attempt with a sit-to-stand mechanical lift. The resident required substantial assistance for bed mobility and transfers, yet staff attempted the transfer without clear supporting documentation in the care plan or physician orders. During the observation, the resident had difficulty sitting upright, the lift was not locked, staff left the room while he remained on the side of the bed, and the resident leaned backward and fell back onto the bed during the transfer process. A second resident with seizures and dementia had physician orders for bilateral floor mats at the bedside and padded side rails every shift for seizure precautions. Multiple observations showed the bed raised in a high position, the floor mats folded against the wall or on top of each other away from the bed, and no padding on the side rails. Staff acknowledged the resident’s order for floor mats only after being shown the room and then placed the mats near the bed. The unit manager also identified the side rail padding in storage and stated that if a resident had an order for padding, it should remain on the bed except during transfers. A third resident with muscle weakness and dementia had a physician order for padded side rails every shift after a prior skin tear was documented as possibly caused by contact with the side rail. Despite the order, observations on separate days showed the bed without side rail padding, while the January TAR was signed to indicate the side rails were padded. A fourth resident, who was totally dependent for bed mobility and transfers, had a reported event in which the daughter stated the resident hit her left leg during a transfer and later complained of pain. The record showed an x-ray order was entered after the report, revealing acute nondisplaced fractures of the proximal tibia and fibula, but staff interviews confirmed there was no incident report and no investigation of the transfer-related event.
Failure to Provide Ordered Tube Feeding Flushes
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for a resident with dysphagia following a cerebral infarction, a gastrostomy tube, and dementia. The resident was readmitted to the facility and had care plan interventions for tube feeding and water flushes, including a goal to remain free of complications related to tube feeding and a separate goal to remain free of dehydration symptoms. A physician order dated 12/08/25 directed staff to provide 150 ml of water every 8 hours via pump. During an observation on 01/06/26, the resident was found in bed with tube feeding and a clear fluid bag hanging on a pump. The pump showed the feeding running at 50 ml per hour and the flush setting at 15 ml every hour, although Staff A, RN stated it should have been 150 ml every shift and reset it to 150 ml every 8 hours. The pump history reviewed by the surveyor, DON, Dietitian, and RN showed the resident received 0 flushes for the past 3 days. The January MAR showed staff signed that 150 ml of water was administered every shift. STAT CBC/CMP labs ordered the same day showed electrolyte imbalance and elevated liver enzymes, including sodium 155, potassium 3.3, chloride 118, BUN 38, and BUN/Creat 57.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat three residents with dignity and respect, as required by their policy. Resident #67, who was cognitively intact and hard of hearing, reported that a CNA, referred to as Staff A, threw a washcloth at her, left her alone in the bathroom, and was rough during care. Additionally, Staff A placed Resident #67's food tray on the counter instead of the table and screamed at her when asked to move it. Resident #67 expressed fear of retaliation and did not report the incidents initially. Resident #103, also cognitively intact, reported an incident with a nurse who yelled at him about the height of his bed during the night. The nurse made a sarcastic comment about putting the bed on the roof when he gets home. Resident #103 did not feel it was verbal abuse but did not feel treated with dignity. He mentioned the incident to his therapist but did not report it further. Resident #35, with minimal cognitive impairment, stated that some staff members were mean, providing an example of being forced to have a heavy blanket over him despite his preference not to. He was unable to provide further examples but reiterated that some staff were mean. These incidents highlight a failure to uphold the residents' rights to dignity and respect as outlined in the facility's policy.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the medical records for three residents, leading to deficiencies in care. For one resident with an indwelling urinary catheter, there were conflicting orders for catheter sizes and a lack of documentation regarding the use of an anchoring device to prevent infections. The resident expressed a preference not to use the anchor, but this refusal and the associated risks were not documented in the medical record. The Unit Manager acknowledged the absence of documentation regarding the resident's refusal and the need for an anchor. Another resident, who had a skin tear on the left elbow, was observed with a gauze wrap on the elbow, but there was no documentation of this dressing in the medical records. The resident and staff were uncertain about the dressing's purpose, and the Wound Care Nurse was unaware of any issues or dressings related to the elbow. Upon review, the electronic record lacked any documentation of the elbow condition or the dressing applied, indicating a failure in maintaining accurate medical records. For a third resident, who had undergone joint replacement surgery, there was a lack of documentation regarding the management of a wound VAC. The resident reported that the VAC had stopped working, and the staff was unsure of the appropriate actions to take. Although the wound VAC company and the surgeon's office were contacted, the medical records did not reflect these communications or any subsequent orders for care. This lack of documentation and clarity in the medical records highlights a deficiency in the facility's ability to maintain accurate and complete records for resident care.
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What surveyors actually found near you
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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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Nursing homes near Palm Beach Gardens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nursing Center At La Posada, The | 0.6 mi | ★★★★★ | 0 | 0 |
| Prosper Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Waterford, The | 2.1 mi | ★★★★★ | 0 | 0 |
| Luxe At Jupiter Rehabilitation Center (the) | 3.2 mi | ★★★★★ | 2 | 0 |
| Chatsworth At Pga National | 3.6 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.