Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Garden Care Center during CMS and state inspections, most recent first.
The facility did not maintain sufficient nursing staffing to match its staffing assessment across all three units. CMS PBJ data showed low weekend staffing, and schedule reviews found repeated shortages of CNAs, RNs, and an LPN on day and evening shifts, including shifts with only 1 RN and fewer CNAs than required for the resident census. The Staffing Coordinator reported numerous unscheduled absences and unsuccessful use of agency staff to cover call outs, and the Administrator and DON acknowledged ongoing staffing challenges.
Unlocked medication storage was observed in the central supply room when the room door was closed but not locked and two emergency supply cabinets containing OTC meds were also left unlocked. The Assistant Administrator stated the cabinets held antacids, painkillers, multivitamins, vitamins and mineral supplements, and stool softeners, while Maintenance reported the door’s slam shut lock was not functioning properly. The DON stated the cabinets and the central supply room door should be locked, and the basement area was accessible to residents using the rehab gym and hair salon.
Infection Control Lapse During Medication Administration: An LPN administered oral meds, a liquid supplement, and a respiratory treatment to a resident who was coughing, then used the same gloves to give eye drops without removing the gloves or sanitizing hands. The resident had diabetes, pneumonia, and anxiety disorder and was cognitively intact. The IP and DON stated the LPN should have removed the old gloves, sanitized hands, and put on new gloves before the eye drops.
Three residents with pressure ulcers in an LTC facility were found with improperly set low-air loss mattresses, crucial for pressure relief. One resident with multiple Stage 4 ulcers had a mattress set for 325 pounds despite weighing 85 pounds. Another resident with a history of skin damage had a mattress set for 250 pounds while weighing 173 pounds. A third resident at risk for ulcers had a mattress set for 250 pounds, but weighed 122 pounds. Staff interviews revealed a lack of adherence to facility policy requiring mattress settings to match residents' weights.
A facility failed to complete a Pre-Admission Screening and Resident Review (PASARR) for a resident before admission, as required by policy. The resident, admitted with diagnoses including Major Depressive Disorder and moderately impaired cognition, lacked documented evidence of a Level 1 PASARR. Interviews with staff revealed that the admission department did not ensure the PASARR form was included in the resident's documents, and the form was not found upon review.
A resident with Diabetes Mellitus did not receive care according to professional standards, as the facility failed to notify the physician of blood glucose levels outside the set parameters and did not document insulin injection sites consistently. Nursing staff were unaware of the facility's protocol, leading to repeated failures in monitoring and documentation.
An unsecured full oxygen E-Cylinder tank was found in the day room of a facility's third floor, contrary to the facility's policy requiring such tanks to be secured in a rolling cart or metal rack. Staff interviews revealed a lack of awareness and responsibility for securing the tank, which was identified as an accident hazard.
Two residents with severe cognitive impairments received incorrect oxygen therapy due to staff failing to adhere to physician orders. Despite orders for 2 liters per minute, one resident received 4 liters and the other received up to 5 liters. Nursing staff were responsible for monitoring and adjusting oxygen levels but did not follow the prescribed orders.
A resident with a gastrostomy tube was on Enhanced Barrier Precautions, requiring staff to wear PPE during care. A nurse supervisor failed to don PPE while disconnecting the tube feeding, despite clear signage and facility policy. The incident was confirmed by interviews with nursing leadership, highlighting a lapse in infection control practices.
Insufficient Nursing Staffing Across All Units
Penalty
Summary
The facility did not ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The deficiency was identified on all three resident units reviewed for the Sufficient Nursing Staffing Task, and the facility triggered for the low weekend staffing metric on the CMS Payroll-Based Journal Staffing Data Report for Q2, Q3, and Q4 of FY 2025. The Facility Assessment, last reviewed on 01/28/2026, documented an average daily census of 143 residents and identified staffing needs for each unit on day and evening shifts. However, review of staffing schedules showed repeated instances where actual staffing did not meet the assessment. On Unit 1, day shift schedules showed only 3 CNAs for an average census of 26 residents on multiple dates, and evening shift schedules showed only 1 RN and, on several dates, only 2 or 3 CNAs instead of the staffing levels listed in the assessment. On Unit 2, day shift schedules showed as few as 4 CNAs for 57 residents and 5 or 6 CNAs for 55 to 56 residents, while evening shift schedules showed repeated assignments of only 1 RN and, on some dates, only 5 or 6 CNAs, with one date showing only 1 LPN for 59 residents. On Unit 3, day shift schedules showed 4, 5, or 6 CNAs for 54 to 56 residents, and evening shift schedules showed repeated assignments of only 1 RN, with one date showing only 1 LPN for 52 residents and several dates showing only 5 or 6 CNAs. During interviews, the Staffing Coordinator stated there had been numerous unscheduled nursing staff absences in the last few quarters and that agency staff were used for CNAs and nurses but were not successful in covering call outs and staff absences. The Administrator stated the facility had staffing challenges when they started in June 2025, that the staffing plan for each unit and shift had remained the same during the last few quarters, and that changes to staffing improvement were not noticeable until after November 2025. The DON also stated the facility had staffing challenges in the past few quarters and was working on an improvement plan to address the nursing staff shortage.
Unlocked Medication Storage in Central Supply Room
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored in locked compartments. During observation of the medication storage area in the basement central supply room, the door to the room was closed but not locked, and the Assistant Administrator stated that the room was used to store over-the-counter medications. Two freestanding steel cabinets inside the room, both labeled as emergency supply cabinets, were also observed unlocked. One cabinet contained over-the-counter antacids and painkillers, and the other contained over-the-counter multivitamins, vitamins and mineral supplements, stool softeners, antacids, and painkillers. The facility policy stated that over-the-counter medications maintained in Central Supply must be secured to prevent unauthorized access and that the room must remain locked when unattended. Maintenance Staff stated the central supply room door had a slam shut lock that was not functioning properly and required repair because it did not automatically lock when closed. The DON stated both medication cabinets should be locked and the central supply room door should be locked at all times, and also noted that the basement was not off-limits to residents because they used the rehabilitation gym and hair salon there.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility did not ensure that it established and maintained an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. During a medication pass observation for Resident #124, who had diagnoses including diabetes mellitus, pneumonia, and anxiety disorder and was documented as cognitively intact, an LPN prepared multiple medications at the cart and then entered the resident’s room wearing gloves after sanitizing hands. The resident was repeatedly coughing and complained about coughing too much while the nurse administered oral medications, a liquid protein supplement, and a respiratory treatment. The same gloves were then used to administer eye drops to the resident. The LPN did not remove the gloves, sanitize hands, or put on clean gloves before giving the eye drops. During interviews, the LPN stated they were nervous and should have removed the gloves and sanitized hands before administering the eye drops. The Infection Preventionist and the DON both stated the nurse should have removed the old gloves, sanitized hands, and then put on new gloves before administering the eye drops.
Improper Air Mattress Settings for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for three residents who were observed with improperly set low-air loss mattresses, which are crucial for pressure relief. Resident #38, who had multiple Stage 4 pressure ulcers, was observed with an air mattress weight setting of 325 pounds, despite weighing only 85 pounds. This discrepancy was noted during multiple observations, and interviews with staff revealed a lack of proper adjustment of the mattress settings according to the resident's weight. Resident #5, who had a history of Moisture Associated Skin Damage, was also found with an air mattress weight setting of 250 pounds, while their actual weight was 173 pounds. The facility's policy required that air mattresses be set according to the resident's weight, but this was not adhered to, as confirmed by interviews with the nursing staff and the Director of Nursing Services. The staff acknowledged the importance of setting the mattress correctly to prevent further skin damage and promote healing. Similarly, Resident #82, who was at risk for pressure ulcer development, had an air mattress weight setting of 250 pounds, while their weight was recorded as 122 pounds. The wound care nurse, responsible for setting the mattress, was not present for several days, and there was no protocol for unit nurses to adjust the settings in their absence. Interviews with the nursing staff and the wound care consultant highlighted the critical role of correctly set air mattresses in preventing further pressure injuries and aiding in the healing process.
Failure to Complete PASARR Prior to Resident Admission
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed for a resident prior to their admission. This deficiency was identified during a recertification survey, where it was found that a resident admitted in October 2023 did not have documented evidence of a Level 1 PASARR being completed before their admission. The facility's policy requires the admission coordinator to ensure that a PASARR screen is completed for all new admissions, but this was not adhered to in the case of the resident in question. Interviews with facility staff revealed that the Director of Admissions, who was not employed at the time of the resident's admission, stated that the admission department is responsible for ensuring the inclusion of a PASARR form in the resident's admission documents. The Director of Social Work confirmed that the PASARR form for the resident was not found and emphasized that the admission staff should have ensured its completion. The Administrator also acknowledged the absence of the PASARR form and reiterated the importance of this document in determining the facility's ability to provide appropriate services to the resident.
Failure to Follow Protocols for Diabetes Management
Penalty
Summary
The facility failed to ensure that a resident with Diabetes Mellitus received treatment and care in accordance with professional standards of practice. The resident had a physician's order to monitor blood glucose levels as per the facility's protocol, which required notifying the physician if levels were below 100 mg/dL or above 300 mg/dL. However, on 27 occasions in July and 13 occasions in August, the resident's blood glucose levels were outside these parameters, and the physician was not notified as required by the facility's policy. Additionally, the facility did not document the insulin injection sites in the resident's medical record on numerous occasions, with 50 instances in July and 70 in August where the site was not recorded. The facility's policy required that insulin injection sites be rotated and documented to prevent repeated administration at the same location, which could lead to complications such as swelling and bruising. Interviews with nursing staff revealed a lack of awareness of the facility's protocol for reporting blood glucose levels and documenting insulin injection sites. The LPNs responsible for administering medication were not informed of the specific parameters for notifying the physician and did not consistently document the injection sites. The unit manager and the Director of Nursing Services confirmed that the facility's protocol was not followed, and the physician expected to be notified of any blood glucose levels outside the established parameters to manage the resident's diabetes effectively.
Unsecured Oxygen Tank Poses Hazard
Penalty
Summary
During a Recertification Survey, it was observed that the facility did not maintain a safe environment free from accident hazards on the third floor. Specifically, a full oxygen E-Cylinder tank was found unsecured in the day room, which is against the facility's policy. The policy, last revised in May 2024, mandates that oxygen cylinders should not be left unsecured and must be placed in a rolling cart or metal rack. However, the policy did not provide specific guidance on storing oxygen tanks in resident units. The unsecured tank was noted during an activity in the day room, with a Recreation Aide present who was unaware of the tank's presence. Interviews with staff revealed a lack of awareness and responsibility regarding the unsecured oxygen tank. The Recreation Aide stated they would notify a nurse if they noticed such a tank. The Unit Supervisor, a Registered Nurse, was unaware of the tank's presence and acknowledged that it should have been secured. The Director of Maintenance and Housekeeping confirmed that nurses are responsible for securing oxygen tanks and emphasized the potential hazard of an unsecured tank, which could become a projectile if the regulator and valve were dislodged. The Director of Nursing Services also confirmed that the tank should have been secured, highlighting the oversight as an accident hazard.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care to two residents, both of whom had physician orders to receive oxygen therapy at a specific flow rate. Resident #5, who had diagnoses including Congestive Heart Failure, Major Depressive Disorder, and Dementia, was observed receiving oxygen at a rate of 4 liters per minute instead of the prescribed 2 liters per minute on multiple occasions. This resident had severely impaired cognition and was dependent on assistance for transfers, making it impossible for them to adjust the oxygen concentrator settings themselves. Similarly, Resident #82, diagnosed with Dementia, Diabetes Mellitus, and Wheezing, was also observed receiving oxygen at incorrect flow rates. The resident was supposed to receive 2 liters per minute but was found to be receiving 4 liters per minute on several occasions and even 5 liters per minute at one point. Like Resident #5, Resident #82 had severely impaired cognition and was unable to adjust the oxygen settings independently. Interviews with Nurse Supervisor #2 and the Director of Nursing Services revealed that the nursing staff was responsible for monitoring and adjusting the oxygen flow rates. However, the staff failed to adhere to the physician's orders, resulting in both residents receiving incorrect oxygen therapy. The Director of Nursing Services emphasized that nurses should monitor oxygen levels during their shifts and obtain updated orders if adjustments are necessary.
Failure to Follow Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident with a gastrostomy tube. The resident, who had diagnoses including Type 2 Diabetes Mellitus, Cerebral Infarction, and Dementia, was on Enhanced Barrier Precautions due to the use of a feeding tube. Despite clear signage indicating the need for Personal Protective Equipment (PPE) such as gowns and gloves when providing care, a Registered Nurse Supervisor entered the resident's room and disconnected the tube feeding without donning the required PPE. This action was contrary to the facility's policy and the physician's order for Enhanced Barrier Precautions. The incident was observed during a recertification survey, and interviews with the nursing staff, including the Assistant Director of Nursing Services and the Director of Nursing Services, confirmed the expectation for staff to use PPE when caring for residents with feeding tubes. The Infection Preventionist emphasized that feeding tubes can harbor organisms that may transfer to staff and other residents, underscoring the importance of following Enhanced Barrier Precautions. The Registered Nurse Supervisor acknowledged the oversight, attributing it to nervousness and a desire to quickly address the feeding pump alarm.
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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 Franklin Square
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Shore - Lij Orzac Center For Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| Nassau Rehabilitation & Nursing Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Queen Of Peace Residence | 3.1 mi | ★★★★★ | 11 | 0 |
| The Grand Pavilion For Rhb & Nrsg At Rockville Ctr | 3.1 mi | ★★★★★ | 0 | 0 |
| Rockville Skilled Nursing & Rehabilitation Center, | 3.1 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.