Inspection Reports for
Garden View Care Center at Dougherty Ferry
13612 BIG BEND RD, VALLEY PARK, MO, 63088-1447
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
68% occupied
Based on a June 2024 inspection.
Occupancy rate over time
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
Complaint Investigation
Deficiencies: 5
Date: Jun 12, 2024
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident (Resident #12) at Garden View Care Center at Dougherty Ferry.
Complaint Details
The complaint investigation was triggered by an allegation of sexual abuse made by Resident #12. The allegation was not substantiated after investigation. The facility failed to report timely and conduct a thorough investigation. The resident denied the allegations and no employee was identified as an alleged perpetrator. Social Services will continue to monitor and support residents' psychosocial needs.
Findings
The facility failed to follow their abuse policy by not reporting timely after an allegation of sexual abuse was made by one resident. The facility also failed to conduct a thorough investigation into the allegation of sexual abuse. The census was 82 with 46 certified beds.
Deficiencies (5)
F609: The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately and investigated thoroughly. The facility did not report timely after an allegation of sexual abuse by Resident #12 and failed to conduct a thorough investigation.
F610: The facility failed to ensure all alleged violations were thoroughly investigated and prevented further potential abuse during the investigation. The investigation into Resident #12's sexual abuse allegation was incomplete and failed to interview other residents.
A4065: The facility failed to store controlled substances under double lock for two medication rooms. The medication refrigerator was unlocked and contained multiple boxes of lorazepam concentrate.
A8023: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents and requiring reports to the department. See deficiency cited at F610.
A8025: The facility failed to report allegations of abuse or neglect to the Department of Health and Senior Services or Department of Mental Health when needed. See deficiency cited at F609.
Report Facts
Sample size: 12
Census: 82
Certified beds: 46
State licensed beds: 36
Inspection Report
Life Safety
Census: 82
Capacity: 120
Deficiencies: 3
Date: Jun 12, 2024
Visit Reason
The inspection was a life safety code survey conducted to evaluate the facility's compliance with fire protection and safety regulations, including sprinkler system maintenance, corridor door integrity, and oxygen storage safety.
Findings
The facility failed to maintain sprinkler heads free of debris and obstructions, maintain corridor doors to prevent propping open, and properly store oxygen cylinders according to NFPA codes. These deficiencies had the potential to affect residents and staff in multiple smoke compartments.
Deficiencies (3)
K353 Sprinkler System - The facility failed to maintain sprinkler heads free of debris and obstructions and ensure escutcheon plates were properly installed, affecting four of eight smoke compartments.
K363 Corridor Doors - The facility failed to maintain corridor doors to prevent propping open, impacting three of eight smoke compartments and potentially impeding fire safety.
K923 Gas Equipment - The facility failed to maintain oxygen cylinder storage according to NFPA code, including segregation of full and empty cylinders and securing combustible materials, affecting two of eight smoke compartments.
Report Facts
Facility capacity: 120
Census: 82
Certified beds census: 46
Number of smoke compartments affected by sprinkler deficiency: 4
Number of smoke compartments affected by corridor door deficiency: 3
Number of smoke compartments affected by oxygen storage deficiency: 2
Inspection Report
Life Safety
Census: 56
Capacity: 120
Deficiencies: 5
Date: Nov 29, 2022
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety regulations and related requirements at Garden View Care Center at Dougherty Ferry.
Findings
The facility failed to meet several Life Safety Code requirements including issues with egress doors, fire alarm system testing and maintenance, portable fire extinguishers, smoke barrier walls, and emergency power generator testing. These deficiencies had the potential to affect residents and staff in multiple smoke compartments.
Deficiencies (5)
K222 Egress Doors: The facility failed to ensure that doors with delayed egress locking mechanisms released when the fire alarm was activated, affecting two of nine smoke compartments.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to ensure only authorized personnel could access, silence, and reset the main fire alarm panel, potentially affecting all residents.
K355 Portable Fire Extinguishers: Fire extinguishers were mounted more than five feet above the floor, violating NFPA 10 requirements and affecting occupants in eight of nine smoke compartments.
K372 Smoke Barrier Walls: The facility failed to maintain smoke barrier walls with the required fire resistance rating, affecting residents in eight of nine smoke compartments.
K918 Electrical Systems - Essential Electric System: The facility failed to complete monthly load testing and annual fuel testing of the emergency generator, potentially affecting all occupants during an emergency.
Report Facts
Deficiencies cited: 5
Census: 56
Total Capacity: 120
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
Complaint Investigation
Deficiencies: 5
Date: Nov 16, 2022
Visit Reason
A Recertification Survey and Complaint Survey was conducted from 11/14/2022 to 11/16/2022 to assess compliance with federal regulations for long term care facilities.
Complaint Details
The survey included a complaint investigation as indicated by the report title and content describing a Recertification Survey and Complaint Survey conducted from 11/14/2022 to 11/16/2022.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, with deficiencies cited related to quarterly assessments, encoding and transmitting resident assessments, quality of care including wound care, food safety, and infection prevention and control.
Deficiencies (5)
F638 Quarterly Assessment at Least Every 3 Months CFR(s): 483.20(c) The facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for 2 of 11 sampled residents.
F640 Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4) The facility failed to encode and transmit MDS assessments timely for 4 of 11 sampled residents.
F684 Quality of Care CFR(s): 483.25 The facility failed to provide treatment and care in accordance with professional standards for wound care related to a skin tear for 1 of 2 sampled residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary CFR(s): 483.60(i)(1)(2) The facility failed to ensure kitchen staff wore beard guards to prevent potential contamination of food prepared in one kitchen.
F880 Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) The facility failed to ensure staff wore face coverings in three of four common resident areas during high community transmission of COVID-19.
Report Facts
Number of sampled residents with late MDS assessments: 2
Number of sampled residents with late encoding and transmission of MDS assessments: 4
Number of sampled residents reviewed for wound care: 2
Number of sampled residents with wound care deficiency: 1
Number of common areas with staff not wearing face coverings: 3
Inspection Report
Plan of Correction
Census: 45
Deficiencies: 2
Date: Jul 20, 2021
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Garden View Care Center at Dougherty Ferry following a state survey conducted on 07/20/2021.
Findings
The facility failed to provide appropriate care to one resident by not ensuring adequate bathing care and failing to coordinate with hospice for bathing assistance. The resident also refused treatment and staff performed care against the resident's wishes.
Deficiencies (2)
19 CSR 30-85.042(67) Nursing Care per Res Condition: The facility failed to provide adequate bathing care and coordinate with hospice for one resident dependent on staff for personal hygiene needs.
19 CSR 30-88.010(13) Right to Plan Care/Refuse Treatment: The facility failed to provide one resident the opportunity to refuse treatment and performed a shower against the resident's wishes.
Report Facts
Sample size: 4
Census: 45
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices. No deficiencies were cited, indicating the complaint was not substantiated.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited as a result of this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 24, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted from 08/20/2020 through 08/24/2020 to assess compliance with CMS and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with related CMS and CDC requirements.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 05/20/2020 through 05/27/2020 to assess compliance with CMS and CDC recommended practices and emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
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 |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Jul 11, 2019
Visit Reason
The document is a Plan of Correction submitted by Garden View Care Center at Dougherty Ferry following a survey conducted from 7/9/19 to 7/11/19. It addresses deficiencies cited during the inspection.
Findings
The facility failed to ensure residents were treated with dignity and respect, failed to ensure hospice care orders and laboratory tests were obtained, failed to provide acceptable perineal care, failed to prevent access to razors in common areas, failed to prepare mechanically altered food properly, and failed to maintain infection control practices including proper storage of resident toothbrushes.
Deficiencies (7)
F550 Resident Rights/Exercise of Rights: The facility failed to ensure staff treated each resident with respect and dignity and provide care in a manner that promotes quality of life by failing to remove soiled tablecloths during meal service and by referring to residents who need assistance at meals as feeders.
F658 Services Provided Meet Professional Standards: The facility failed to ensure physician's orders for hospice care and laboratory tests were obtained for sampled residents receiving hospice care.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide acceptable and thorough perineal care to one of two residents observed, including improper cleansing techniques and failure to change gloves appropriately.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to prevent resident access to razors in three common spa rooms, posing a potential hazard to residents able to move freely.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to prepare mechanically altered food in a manner that preserved nutritive value, affecting residents on a pureed diet.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to ensure fresh meat was dated when placed in the walk-in refrigerator and failed to ensure dietary workers with beards wore facial hair restraints when preparing and serving food.
F880 Infection Prevention & Control: The facility failed to maintain infection control practices including proper storage of resident toothbrushes, commingling of used combs and brushes, and failure to ensure staff used acceptable infection control practices during perineal care.
Report Facts
Census: 65
Certified beds: 18
Inspection Report
Life Safety
Census: 65
Capacity: 120
Deficiencies: 4
Date: Jul 11, 2019
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety and emergency preparedness regulations at Garden View Care Center at Dougherty Ferry.
Findings
The facility failed to maintain three of ten delayed egress doors so they could be opened without excessive force and failed to remove delayed egress signage on two exit doors. The facility also failed to ensure fire drills were completed on each shift quarterly at unexpected times, failed to assess electrical receptacles annually, and failed to maintain two oxygen storage rooms with a system for identifying full and empty oxygen cylinders.
Deficiencies (4)
K222 Egress Doors: The facility failed to maintain three of ten delayed egress doors so they could be opened without excessive force and failed to remove delayed egress signage on two exit doors. This affected residents in four of nine smoke compartments including those using the main dining room.
K712 Fire Drills: The facility failed to ensure fire drills were completed on each shift, quarterly, at unexpected times and under varying conditions for one of four quarters reviewed. This deficiency had the potential to affect all occupants.
K914 Electrical Systems - Maintenance and Testing: The facility failed to assess electrical receptacles in resident rooms for physical integrity, grounding circuit continuity, polarity, and retention force on an annual basis. This deficiency had the potential to affect all residents.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain two oxygen storage rooms with a system for identifying full and empty oxygen cylinders. This deficiency had the potential to affect residents in two of nine smoke compartments.
Report Facts
Facility capacity: 120
Census: 65
Residents in certified beds: 18
Delayed egress doors: 10
Delayed egress doors failed: 3
Fire drills required: 12
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Jul 16, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident and a staff member, as well as to investigate compliance with regulatory requirements related to abuse reporting and care planning.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate an allegation of physical abuse by a staff member toward Resident #20. The resident alleged being slapped by a CNA, and the facility did not notify the Department of Health and Senior Services or complete a thorough investigation in a timely manner. The CNA involved is no longer employed at the facility.
Findings
The facility failed to post the most recent survey results in an accessible location, failed to report allegations of abuse timely, and did not thoroughly investigate a resident's allegation of physical abuse by a staff member. Additionally, the facility failed to develop and implement comprehensive care plans and ensure proper medication administration and food safety.
Deficiencies (11)
F577: The facility failed to post the most recent survey results in a place readily accessible to residents, family members, and the public.
F609: The facility failed to ensure allegations of abuse were reported immediately and investigated thoroughly, including an incident involving a resident alleging a staff member slapped him/her.
F610: The facility failed to investigate, prevent, and correct alleged abuse and report investigation results to appropriate officials within required timeframes.
F656: The facility failed to develop and implement comprehensive, person-centered care plans for sampled residents, including timely revisions.
F657: The facility failed to revise individual resident care plans timely to address weight loss and falls for sampled residents.
F658: The facility failed to meet professional standards in medication administration, including obtaining timely orders and following dietary recommendations for sampled residents.
F690: The facility failed to ensure proper care and positioning of residents with urinary catheters and failed to prevent urinary tract infections.
F730: The facility failed to ensure certified nurse assistants received required 12 hours of in-service training annually.
F761: The facility failed to properly label and store insulin pens, including discarding outdated medications.
F805: The facility failed to ensure food was prepared and served in a form meeting individual resident needs, including serving pureed food with proper consistency.
F812: The facility failed to maintain food safety, including proper storage temperatures and handling of thawed items.
Report Facts
Resident census: 72
Certified beds: 20
Deficiencies cited: 11
In-service training hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse G | Interviewed resident and assessed injury related to abuse allegation; did not document notifying DON or Administrator. | |
| CNA H | Alleged by resident to have slapped him/her; did not document incident properly. | |
| Director of Nursing | DON | Responsible for investigation and reporting of abuse allegations; failed to follow up on abuse allegation properly. |
| Administrator | Interviewed regarding survey results posting and abuse allegation; responsible for monitoring corrective actions. | |
| Cook N | Observed preparing meals and food safety issues. | |
| Dietary Manager | DM | Observed food service and responsible for food safety monitoring. |
| Licensed Practical Nurse B | LPN | Interviewed about insulin medication handling. |
| Registered Nurse B | RN | Interviewed about insulin medication handling. |
Inspection Report
Life Safety
Census: 72
Capacity: 120
Deficiencies: 3
Date: Jul 16, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically focusing on sprinkler system installation, electrical systems, and oxygen storage safety.
Findings
The facility failed to provide sprinkler coverage in a connected outside electrical room, lacked a remote manual stop station for the emergency generator, and failed to properly secure oxygen tanks in storage rooms. These deficiencies had the potential to affect occupants in multiple smoke compartments.
Deficiencies (3)
K351 Sprinkler System - Installation: The facility failed to provide sprinkler coverage in a connected outside electrical room. This deficient practice could affect occupants in one of nine smoke compartments.
K918 Electrical Systems - Essential Electric System: The facility failed to provide a remote manual stop station for the emergency generator. This deficient practice could affect all occupants in the building.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly secure oxygen tanks in one of two oxygen storage rooms. This deficient practice could affect occupants in one of nine smoke compartments.
Report Facts
Deficiencies cited: 3
Census: 72
Total Capacity: 120
Certified Beds: 20
Viewing
Loading inspection reports...
