Inspection Reports for
Garden View Care Center at Dougherty Ferry
13612 BIG BEND RD, VALLEY PARK, MO, 63088-1447
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
15% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an allegation of sexual abuse made by one resident (Resident #12) at the facility.
Complaint Details
The complaint involved an allegation of sexual abuse made by Resident #12 on 1/20/24. The facility investigated but concluded the allegation was unsubstantiated. The resident denied the allegations and was cognitively impaired with dementia. The facility did not report the incident to DHSS and failed to interview other residents or suspend the accused CNA during the investigation.
Findings
The facility failed to timely report the alleged sexual abuse and did not conduct a thorough investigation, as they failed to interview other residents and did not suspend the accused staff member. The allegation was ultimately determined to be unsubstantiated, but the facility did not report the incident to the Department of Health and Senior Services (DHSS) as required.
Deficiencies (2)
Failed to timely report suspected abuse after an allegation of sexual abuse by Resident #12.
Failed to conduct a thorough investigation into the allegation of sexual abuse, including failure to interview other residents and failure to suspend the accused staff member.
Report Facts
Residents sampled: 12
Census: 82
Total licensed capacity: 46
Safety checks frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Certified Nursing Assistant | Accused staff member in sexual abuse allegation; provided shower to resident on day in question; was not suspended during investigation |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Notified of allegation; reported to Director of Nursing and Administrator; did not suspend accused staff member |
| Director of Nursing (DON) | Director of Nursing | Reported to Social Worker and Administrator; unaware incident should have been reported to DHSS; concluded investigation within two hours |
| Administrator | Administrator | Oversaw investigation; decided not to report allegation to DHSS; stated resident was newly admitted and family was not concerned |
Inspection Report
Deficiencies: 5
Date: Nov 16, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to Minimum Data Set (MDS) assessments, wound care, food safety, infection prevention and control, and other care standards at Garden View Care Center at Dougherty Ferry.
Findings
The facility failed to complete and transmit timely MDS assessments for multiple residents, did not provide wound care according to physician orders for a resident with a skin tear, failed to ensure kitchen staff wore beard guards, and failed to ensure staff wore face coverings properly in resident areas during high COVID-19 community transmission.
Deficiencies (5)
Failure to ensure quarterly Minimum Data Set (MDS) assessments were completed timely for sampled residents.
Failure to encode and transmit MDS assessments timely for multiple residents.
Failure to provide appropriate wound care treatment and obtain physician orders for a skin tear on Resident #476.
Failure to ensure kitchen staff wore beard guards to prevent food contamination.
Failure to ensure staff wore face coverings properly in resident areas during high community transmission of COVID-19.
Report Facts
Residents sampled for MDS assessment review: 11
Residents with late MDS assessments: 4
Days late for discharge MDS transmission: 41
Days late for admission MDS transmission: 16
Dates dressing was not changed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Observed wound care treatment and commented on treatment procedures for skin tear |
| Licensed Practical Nurse #2 | LPN | Provided statements about wound care protocol and PPE training |
| Registered Nurse #1 | RN | Provided statements about wound care treatment procedures |
| MDS Coordinator | Discussed late MDS assessments and training | |
| Director of Nursing | DON | Discussed expectations for MDS assessments, wound care, and infection control |
| Dietary Aide #1 | Dietary Aide | Observed not wearing beard guard in kitchen |
| Dietary Manager | Dietary Manager | Discussed PPE training and beard guard expectations |
| Activity Assistant #1 | AA | Observed wearing surgical mask below nose while feeding resident |
| Dietary Aide #2 | Dietary Aide | Observed wearing surgical mask below nose while interacting with residents |
| Certified Nursing Assistant #1 | CNA | Observed not wearing mask in resident common area |
| Administrator | Administrator | Provided statements on expectations for MDS, wound care, and infection control |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 11, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident dignity, hospice care orders, personal care, safety, food preparation, food storage, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during meal service, incomplete hospice care orders, inadequate perineal care, unsecured razors in common areas, improper preparation of pureed food, failure to date fresh meat and use facial hair restraints in dietary, and lapses in infection control practices such as improper hand hygiene and storage of personal items.
Deficiencies (7)
Failure to ensure staff treat residents with respect and dignity by not removing soiled tablecloths and referring to residents as feeders.
Failure to ensure residents receiving hospice care had current physician orders and laboratory tests as ordered.
Failure to provide acceptable and thorough perineal care to a resident.
Failure to prevent resident access to razors in common spa rooms.
Failure to prepare mechanically altered food in a manner that preserved nutritive value, including use of water instead of recommended liquids.
Failure to ensure fresh meat was dated when placed in the walk-in refrigerator and dietary workers with beards wore facial hair restraints.
Failure to ensure staff used acceptable infection control practices during perineal care, improper storage of resident toothbrushes and commingling of used combs and brushes.
Report Facts
Residents in certified beds: 18
Current census: 65
Number of residents sampled: 8
Number of residents affected in hospice care deficiency: 4
Number of residents affected in perineal care deficiency: 1
Number of residents affected in razor access deficiency: all
Number of residents affected in food preparation deficiency: 2
Number of residents affected in food storage and hygiene deficiency: all
Number of residents affected in infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Mentioned in relation to dignity issue and razor storage | |
| Administrator | Interviewed regarding dignity issues, hospice orders, and razor storage | |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity issues, hospice orders, perineal care, razor storage, infection control |
| [NAME] X | Dietary Manager | Interviewed regarding pureed food preparation and food storage |
| CNA A | Certified Nurse Aide | Observed and interviewed regarding perineal care and infection control |
| CNA B | Certified Nurse Aide | Observed and interviewed regarding perineal care and infection control |
| Dietary Aide I | Dietary Aide | Observed not wearing facial hair restraint |
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