ElderGrade

Inspection citations at Garden Spring Rehab And Care Center

46 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 3 0
2025 6 1
2024 10 0
2023 6 0
2022 21 0
D May 6, 2026 Tag F0628 Complaint investigation Corrected May 2026

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

D May 6, 2026 Tag F0627 Complaint investigation Corrected May 2026

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

No actual harm, potential for more than minimal harm

D April 15, 2026 Tag F0580 Complaint investigation Corrected May 2026

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

K November 5, 2025 Tag F0880 Complaint investigation Corrected Dec 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Immediate jeopardy to resident health or safety

D July 11, 2025 Tag F0880 Complaint investigation Corrected Aug 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D July 11, 2025 Tag F0686 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D July 11, 2025 Tag F0684 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D July 11, 2025 Tag F0677 Complaint investigation Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

E July 11, 2025 Tag F0921 Complaint investigation Corrected Aug 2025

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

C October 18, 2024 Tag F0623 Corrected Nov 2024

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, minimal potential

D October 18, 2024 Tag F0684 Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D October 18, 2024 Tag F0607 Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

No actual harm, potential for more than minimal harm

D October 2, 2024 Tag F0686 Complaint investigation Corrected Oct 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D August 8, 2024 Tag F0759 Complaint investigation Corrected Sep 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D August 8, 2024 Tag F0684 Complaint investigation Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0689 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 12, 2024 Tag F0558 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

D June 17, 2024 Tag F0559 Complaint investigation Corrected Jun 2024

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

No actual harm, potential for more than minimal harm

C February 27, 2024 Tag F0732 Complaint investigation Corrected Mar 2024

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D November 16, 2023 Tag F0761 Corrected Dec 2023

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D November 16, 2023 Tag F0699 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

D November 16, 2023 Tag F0689 Corrected Dec 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D November 16, 2023 Tag F0688 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D November 16, 2023 Tag F0684 Corrected Dec 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E November 16, 2023 Tag F0584 Complaint investigation Corrected Dec 2023

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

C December 2, 2022 Tag F0850 Corrected Jan 2023

Administration Deficiencies

Hire a qualified full-time social worker in a facility with more than 120 beds.

No actual harm, minimal potential

C December 2, 2022 Tag F0623 Corrected Jan 2023

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

No actual harm, minimal potential

D December 2, 2022 Tag F0698 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0697 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0692 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0690 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0689 Corrected Jan 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0688 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0684 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0677 Corrected Jan 2023

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0657 Corrected Jan 2023

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0645 Corrected Jan 2023

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0637 Corrected Jan 2023

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0609 Corrected Jan 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D December 2, 2022 Tag F0580 Corrected Jan 2023

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.