Garden View Care Center At Dougherty Ferry

Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to be able to file a grievance anonymously and failed to post information on how to file a grievance, in accordance with the facility's grievance policy. The sample was 12. The census was 83 with 44 residents in certified beds.Review of the facility's admission Agreement, undated, showed:-A list of key personnel included the name, title, phone extension, and email of Administrative staff;-A staff person shall be designated to receive grievances, and the residents shall be free to voice their recommendations and complaints to that person, an ombudsman or any person outside the facility. Such complaints, upon request, will be put in writing and followed up by the facility and the Division of Aging, if necessary;-The admission Agreement did not include how a grievance could be filed anonymously. No specific staff member was identified as the Grievance Officer and no contact information was provided for the Grievance Officer. During a group interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure staff utilized appropriate techniques during two-person Hoyer lift (mechanical lift) transfers to prevent potential accidents for four residents (Residents #23, #36, #34, and #14). The sample was 12. The census was 83 with 44 residents in certified beds.1. Review of Resident #23's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 4/2/26, showed-Severe cognitive impairment;-Diagnoses included generalized muscle weakness, other abnormalities of gait and mobility, and syncope and collapse (fainting and falling);-Totally dependent on assistance with transfers, with two or more staff;-Utilized wheelchair for mobility. Review of the resident's care plan, in use at the time of the survey, showed:-Focus: Has an activity of daily living (ADL) self-care performance deficit related to muscle weakness;-Goal: Will improve current level of function in through the review date;-Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, precautions for use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms (MDROs, microorganisms that are resistant to one or more classes of antimicrobial agents) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) when staff failed to wear a gown while providing direct care for two residents (Residents #5 and #1). The sample was 12. The census was 83 with 44 residents in certified beds.Review of the facility's EBP policy, revised November 2025, showed:-Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room);-Examples of high-contact resident care activities requiring the use of gowns and gloves for EBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their abuse policy by not reporting timely after an allegation of sexual abuse was made by one resident (Resident #12) of 12 sampled residents. The census was 82 with 46 in certified beds. Review of the facility's Freedom from Abuse, Neglect and Exploitation-Investigation and Reporting policy, revised November 2023, showed: -Policy Statement: At the facility, all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Reporting: All alleged violations involving abuse will be reported to the facility Administrator. Or his/her designee, to the following persons or agencies: -The State licensing/certification agency responsible for surveying/licensing the facility; -The resident's representative; -Law enforcement officials; -The resident's physician; -The facility medical director; -Suspected abuse, neglect, exploitation or mistreatment will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure they followed their abuse policy by failing to conduct a thorough investigation into one resident's (Resident #12) allegation of sexual abuse. The resident reported the incident to a family member on 1/20/24. The facility initiated an investigation but failed to interview other residents regarding the incident of abuse. The sample size was 12. The census was 82 with 46 in certified beds. Review of the facility's Freedom from Abuse, Neglect and Exploitation-Investigation and Reporting policy, revised November 2023, showed: -Policy Statement: At the facility, all reports of resident abuse shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; -Policy Interpretation and Guidance; -Role of the Administrator: -If an incident or suspected incident of resident abuse is reported, the Administrator will assign the investigation to the appropriate individual. All the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were encoded and transmitted timely for 4 (Residents #1, #5, #277, and #478) of 11 sampled residents whose MDS assessments were reviewed for timeliness of submission. Findings included: Review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed, All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system. The manual also indicated, Encoding Data: Within 7 days after completing a resident's MDS assessment or tracking record, the provider must encode the MDS data (enter the information…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff members wore face coverings in three of four common resident areas when the community transmission of COVID-19 was high. Findings included: Review of a facility policy titled, Coronavirus Disease (COVID-19)-Using Personal Protective Equipment, revised September 2022, revealed, If community transmission is high, staff will use surgical face coverings during all resident care encounters or in specific resident care areas of the facility. Review of the CDC COVID Data Tracker at https://covid.cdc.gov/covid-data-tracker/index.html#datatracker-home on [DATE] showed, St. Louis County, where the facility was located, had a high community transmission rate. Review of the CDC guidance document titled, Infection Control Guidance, updated 09/23/2022 and available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html revealed, Source control refers to use of respirators or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed not less than every three months for 2 (Resident #177 and Resident #478) of 11 sampled residents whose MDS assessments were reviewed for timeliness of completion. Findings included: 1. Review of a Resident Face Sheet revealed Resident #177 had diagnoses including dementia without behavioral disturbance and major depressive disorder. A review of the MDS 3.0 Resident Assessments list revealed an annual MDS was completed on 01/08/2022, and a quarterly MDS was completed on 04/08/2022. The next quarterly assessment would have been due in July 2022; however, there was no evidence to indicate an MDS assessment had been initiated since the quarterly assessment on 04/08/2022. During an interview on 11/16/2022 at 1:26 PM, the MDS Coordinator indicated she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide treatment and care in accordance with professional standards for wound care related to a skin tear for 1 (Resident #476) of 2 sampled residents reviewed for skin conditions. Review of physician's orders revealed no order for the wound care and observations revealed Resident #476 had a skin tear with a dressing that had been in place for five days. Findings included: Review of a facility policy titled, Wound Care, revised 10/2022, revealed, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The policy also indicated, Verify that there is a physician's order for this procedure and Dress wound. [NAME] tape with initials, time, and date and apply to dressing. Review of a Resident Face Sheet revealed the facility admitted Resident #476 on 11/01/2022. There were no listed diagnoses. Review of an admission Minimum Data Set (MDS), dated [DATE],…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, it was determined that the facility failed to ensure kitchen staff wore beard guards to prevent potential contamination of food prepared in one of one kitchen. Findings included: On 11/14/2022 at 12:00 PM, during an observation of the kitchen, Dietary Aide #1 was in the meal service area without a beard guard. The aide had a full beard and was wearing a surgical mask, which had facial hair sticking out the top on the sides of the mask. On 11/14/2022 at 12:13 PM, Dietary Aide #1 was observed in the kitchen prep area working with rolls that were uncovered. The aide's beard was still partially exposed. On 11/14/2022 at 12:21 PM, during an interview with Dietary Aide #1, he stated the facility provided staff with beard covers and that he should have been wearing one. On 11/15/2022 at 3:14 PM, during an interview with the Dietary Manager, he stated the kitchen staff wore hair nets and beard covers if they had long hair or beards and were in the kitchen. He indicated Dietary Aide #1 had a beard and should have been wearing a beard cover. He stated he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.