Inspection Reports for
Garden View Care Center of O’Fallon
700 Garden Path, O'Fallon, MO 63366, MO, 63366
Back to Facility Profile16 Reports
Inspection Report — Mar 14, 2025
Complaint Investigation
Date: Mar 14, 2025
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident at Garden View Care Center.
Complaint Details
The complaint investigation was substantiated. The facility failed to report and investigate allegations of physical abuse involving Resident #1 and a Certified Nurse Aide. The resident had a history of trauma and mental health diagnoses that were not adequately addressed.
Findings
The facility failed to immediately report allegations of physical abuse of a resident and did not conduct a timely and thorough investigation of the abuse allegations. The facility also failed to ensure appropriate treatment and services for a resident with mental health diagnoses and trauma history.
Deficiencies (6)
F609 Reporting of Alleged Violations: The facility failed to immediately report allegations of physical abuse of a resident to the state agency as required by regulations.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to conduct a timely and thorough investigation of an allegation of physical abuse involving a resident and a staff member.
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to ensure a resident with major depressive disorder and trauma history received appropriate treatment and care planning to address behavioral and psychosocial needs.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with the resident's condition as evidenced by previous deficiencies.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents.
A8025 Report A/N to DHSS/DMH When Needed: The facility failed to immediately report suspected abuse or neglect to the Department of Health and Senior Services and Department of Mental Health as required.
Report Facts
Deficiencies cited: 6
Inspection Report — Jan 16, 2025
Complaint Investigation
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to provide written notices of transfer or discharge, bed hold policy notifications, inadequate care for dependent residents, failure to ensure resident safety, and other regulatory concerns.
Complaint Details
The complaint investigation substantiated multiple deficiencies related to failure to provide required notices, inadequate care for dependent residents, failure to ensure resident safety, improper medication management, and poor infection control practices.
Findings
The facility failed to provide timely written notices of transfer or discharge to residents and their representatives, failed to provide written notice of bed hold policy, did not provide necessary care for dependent residents, failed to ensure resident safety regarding falls and bed rails, and did not maintain effective infection control and food safety practices.
Deficiencies (11)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide a written notice of transfer to the resident and/or the resident's representative for six residents transferred to the hospital.
F625 Notice of Bed Hold Policy Before/Upon Transfer: The facility failed to provide a written notice of the bed hold policy within 24 hours of transfer to the hospital for four residents.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary care and services for incontinence and oral care for two residents requiring assistance.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure resident safety by not transferring one resident as directed, not following fall policy after a resident's fall, and not implementing interventions to prevent further falls.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to properly store, change, and date respiratory equipment for two residents requiring oxygen therapy.
F700 Bedrails: The facility failed to assess risk and provide safe bed rails for one resident, resulting in unsafe conditions.
F761 Label/Store Drugs and Biologicals: The facility failed to ensure proper labeling, storage, and destruction of medications, including expired drugs and medications of discharged residents.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain clean kitchen and dining areas, including uncovered food, dirty equipment, and improper food labeling.
F880 Infection Prevention & Control: The facility failed to ensure staff washed hands properly, used gloves correctly, and completed required tuberculosis testing and infection control audits.
F909 Resident Bed: The facility failed to ensure safe bed rails and proper maintenance of bed frames for one resident.
F925 Maintains Effective Pest Control Program: The facility failed to maintain an effective pest control program, with evidence of insects and inadequate pest control measures.
Report Facts
Number of sampled residents: 14
Number of residents affected: 6
Number of residents affected: 4
Number of residents affected: 2
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 2
Number of residents affected: 3
Number of residents affected: 1
Number of residents affected: 1
Inspection Report — Jan 16, 2025
Life Safety
Date: Jan 16, 2025
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and emergency preparedness at Garden View Care Center.
Findings
The facility was found deficient in multiple areas including emergency preparedness policies, fire safety equipment maintenance, egress door functionality, fire drills, and smoke barrier integrity. Several deficiencies had the potential to affect residents, staff, and visitors across multiple smoke compartments.
Deficiencies (24)
E026: The facility failed to develop policies describing its role in providing care at alternate care sites under a section 1135 waiver. The certified census was 48.
K100: The facility failed to ensure two gas dryers in the laundry had no excess lint buildup, posing a fire hazard. Total capacity was 120 and census was 48.
K222: The facility failed to ensure delayed egress door hardware was functional and properly signed, affecting 18 residents in two smoke compartments. Capacity was 120 and census was 48.
K271: The facility failed to keep five of nine exterior emergency exit pathways clear of ice and snow, potentially affecting 36 residents and others. Capacity was 120 and census was 48.
K311: The facility failed to maintain fire-resistant barriers between floors, with unsealed openings and missing ceiling tiles affecting 19 residents. Capacity was 120 and census was 48.
K324: The facility failed to ensure proper operation of the kitchen range hood by allowing gaps between baffle filters, affecting occupants in one smoke compartment. Capacity was 120 and census was 48.
K345: The facility failed to maintain the fire alarm system active during testing and failed to activate the fire alarm monthly, affecting all occupants in seven smoke compartments. Capacity was 120 and census was 48.
K351: The facility failed to install sprinkler heads in accordance with NFPA 13, affecting 11 residents in two smoke compartments. Capacity was 120 and census was 48.
K353: The facility failed to maintain sprinkler heads free from debris and corrosion and failed to maintain the sprinkler system properly, affecting 24 residents in four smoke compartments. Capacity was 120 and census was 48.
K363: The facility failed to maintain corridor doors to resist passage of smoke, with gaps and missing hardware affecting 48 residents in six smoke compartments. Capacity was 120 and census was 48.
K372: The facility failed to maintain smoke barrier doors properly, with unsealed holes and missing seals affecting 22 residents in four smoke compartments. Capacity was 120 and census was 48.
K712: The facility failed to conduct fire drills at unexpected times and failed to maintain a fire drill schedule, affecting all occupants in seven smoke compartments. Capacity was 120 and census was 48.
K920: The facility failed to ensure proper use of power cords and extension cords in resident rooms, affecting 40 residents in five smoke compartments. Capacity was 120 and census was 48.
A2007: The facility failed to properly fire-stop all openings between floors with suitable noncombustible material. Classification was Class II*.
A2017: The facility failed to maintain range hood certification and testing in accordance with NFPA 96. Classification was Class II*.
A2019: The facility failed to maintain complete fire alarm systems and monthly activation testing. Classification was Class II.
A2022: The facility failed to activate the fire alarm monthly as required. Classification was Class II*.
A2034: The facility failed to maintain sprinkler system testing and maintenance in accordance with NFPA 13. Classification was Class II*.
A2037: The facility failed to maintain exit requirements including egress doors and discharge from exits. Classification was Class II*.
A2054: The facility failed to maintain smoke section walls and doors properly. Classification was Class II*.
A2061: The facility failed to conduct required fire drills including evacuation drills. Classification was Class II*.
A2067: The facility failed to vent clothes dryers and clean lint traps regularly. Classification was Class II*.
A3001: The facility failed to substantially construct and maintain the building in good repair. Classification was Class II*.
A3030: The facility failed to maintain electrical wiring and equipment in accordance with NFPA 70. Classification was Class II*.
Report Facts
Residents potentially affected: 48
Residents potentially affected: 40
Residents potentially affected: 36
Residents potentially affected: 24
Residents potentially affected: 22
Residents potentially affected: 19
Residents potentially affected: 18
Residents potentially affected: 11
Residents potentially affected: 8
Residents potentially affected: 7
Residents potentially affected: 6
Residents potentially affected: 2
Inspection Report — Jun 23, 2023
Life Safety
Date: Jun 23, 2023
Visit Reason
The inspection was conducted as a Life Safety Code survey to assess compliance with fire safety regulations and related requirements at Garden View Care Center.
Findings
The facility was found deficient in multiple areas including buildup of lint in laundry dryers, obstructions in means of egress, improper delayed egress locking signage, failure to maintain fire resistance barriers, unsecured hazardous areas, inadequate sprinkler system maintenance, failure to conduct fire drills as required, improper electrical equipment use, and unsafe storage of oxygen cylinders. These deficiencies had the potential to affect residents, staff, and visitors.
Deficiencies (13)
K100: The facility failed to ensure two gas dryers in the laundry had no excess buildup of lint and debris, posing a fire hazard.
K211: The facility failed to keep the exit discharge from the main dining room free of obstructions, blocking the path of egress.
K222: The facility failed to ensure proper signage for delayed egress locking on emergency exit doors was posted and visible.
K311: The facility failed to maintain fire resistance barriers between the first floor and attic, allowing unsealed openings in ceilings.
K321: The facility failed to ensure doors to hazardous areas were self-closing or automatic closing, exposing combustible storage areas.
K324: The facility failed to ensure proper operation and cleanliness of the kitchen range hood and baffle filters, allowing grease buildup.
K353: The facility failed to maintain the sprinkler system, including heavy grease buildup on sprinkler heads and missing escutcheon plates.
K363: The facility failed to maintain corridor doors to resist passage of smoke and ensure positive latching, with multiple doors held open or damaged.
K372: The facility failed to maintain smoke barriers, with unsealed holes and missing drywall in smoke barrier walls.
K712: The facility failed to conduct fire drills at unpredictable times quarterly for each shift, missing required drills in the past year.
K920: The facility failed to ensure proper use of power strips and extension cords, with multiple violations of electrical safety standards.
K921: The facility failed to conduct annual electrical receptacle testing and maintain electrical equipment according to NFPA standards.
K923: The facility failed to adequately secure oxygen cylinders and separate full and empty cylinders in storage areas.
Report Facts
Number of sprinkler heads with heavy buildup: 6
Number of residents potentially affected by corridor door deficiencies: 23
Number of residents potentially affected by hazardous area door deficiencies: 19
Number of residents potentially affected by sprinkler head deficiencies: 15
Number of residents potentially affected by smoke barrier deficiencies: 21
Number of residents potentially affected by fire drill deficiencies: 7
Number of residents potentially affected by electrical equipment deficiencies: 29
Inspection Report — Mar 24, 2023
Plan of Correction
Date: Mar 24, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to residents' rights to be free from physical restraints and to ensure the facility was free of accident hazards, including supervision and devices to prevent falls.
Findings
The facility failed to ensure that staff did not use physical restraints improperly on residents and failed to provide adequate monitoring and interventions to prevent falls for three residents. Policies and care plans were reviewed and found lacking in addressing restraints and fall prevention adequately.
Deficiencies (3)
F604 Right to be free from physical restraints. The facility failed to ensure staff did not use physical restraints for convenience or discipline and did not have physician orders for restraints for Resident #1.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate monitoring and interventions to prevent falls for three residents, resulting in multiple falls with injuries.
A4075 Nursing Care per Resident Condition. Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies F604 and F689.
Report Facts
Deficiencies cited: 3
Inspection Report — Feb 16, 2023
Abbreviated Survey
Date: Feb 16, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted on 2/16/23 to assess compliance with infection control and professional standards.
Findings
The facility was found deficient in professional standards of care related to comprehensive care plans, ADL care for dependent residents, bowel/bladder incontinence care, and infection prevention and control. Deficiencies included failure to follow physician orders, inadequate showering and grooming assistance, improper catheter care, and lapses in infection control practices.
Deficiencies (8)
F658 Services Provided Meet Professional Standards: The facility failed to follow acceptable standards of practice for one resident by not obtaining a physician-ordered urinalysis and wound culture. The facility census was 26.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure residents unable to carry out ADLs received necessary services, including at least two showers per week. This affected two residents. The facility census was 26.
F690 Bowel/Bladder Incontinence, Catheter, UTI: The facility failed to properly secure an indwelling catheter to prevent contamination and ensure proper care. The facility census was 26.
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention program, including failure to wear facemasks, obtain wound cultures, and practice proper hand hygiene. The facility census was 26.
A4075 Nursing Care per Resident Condition: The facility failed to provide personal attention and nursing care consistent with residents' conditions, including failure to follow physician orders for one resident. The facility census was 31.
A4077 Residents Groomed/Dressed Appropriately: The facility failed to provide adequate assistance for bathing and grooming for three residents. The facility census was 31.
A4086 Infection Control/Communicable Disease: The facility failed to ensure staff wore masks, changed gloves, and washed hands properly for one resident. The facility census was 26.
A4088 Notify Responsible Party- Change in Condition: The facility failed to notify the responsible party of a resident's unreported fall with injuries. The facility census was 50.
Report Facts
Inspection Report — Oct 25, 2022
Annual Inspection
Date: Oct 25, 2022
Visit Reason
The inspection was an annual survey to assess compliance with infection prevention and control, antibiotic stewardship, and immunization requirements at Garden View Care Center.
Findings
The facility failed to maintain an effective infection prevention and control program, including improper cleaning and sanitizing of glucometers, inconsistent antibiotic stewardship practices, and failure to follow pneumococcal and influenza immunization policies for residents.
Deficiencies (4)
F880 Infection Prevention & Control: The facility failed to maintain an infection prevention program, evidenced by staff not properly cleaning and sanitizing glucometers between resident uses, risking transmission of blood-borne pathogens.
F881 Antibiotic Stewardship Program: The facility failed to consistently implement an antibiotic stewardship program, including inadequate tracking of infections and antibiotic use, and incomplete documentation in stewardship books.
F883 Influenza and Pneumococcal Immunizations: The facility failed to follow policies ensuring residents received required pneumococcal vaccines, including failure to offer and document vaccinations for eligible residents.
A4086 Infection Control/Communicable Disease: The facility failed to report communicable diseases within seven days as required by state regulations.
Report Facts
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Named in interviews regarding infection control supplies and policies |
| Director of Nursing | Director of Nursing (DON) | Named in interviews regarding infection control and antibiotic stewardship program |
| Registered Nurse | Registered Nurse (RN) | Observed during glucometer use and interviewed about supplies |
| Chief of Operations | Chief of Operations (COO) | Interviewed regarding antibiotic stewardship program documentation |
Inspection Report — Dec 21, 2021
Complaint Investigation
Date: Dec 21, 2021
Visit Reason
The inspection was conducted as a complaint investigation into allegations of quality of care issues and abuse at Garden View Care Center.
Complaint Details
The complaint investigation substantiated that Resident #1 was physically and verbally abused by CNA staff. The facility failed to prevent and properly investigate the abuse. The abuse was confirmed by interviews, observations, and record reviews.
Findings
The facility failed to provide care according to professional standards for one resident, including medication administration and assessment failures. The facility also failed to prevent and address physical and verbal abuse by staff toward a resident.
Deficiencies (3)
F684 Quality of care was not met as the facility failed to ensure staff provided care according to acceptable standards for one resident, including medication administration, assessment, and communication failures.
A8022 The facility failed to ensure one resident was free from physical and verbal abuse by a Certified Nurse Assistant, including hitting, slapping, and verbal threats.
A9105 The facility failed to obtain proper consent for electronic monitoring devices in resident rooms and failed to protect resident privacy.
Report Facts
Number of residents involved: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Named in findings for physical and verbal abuse of Resident #1 |
| CNA B | Certified Nurse Assistant | Named in findings for involvement in abuse incident and investigation |
| Director of Nursing | Administrator | Involved in investigation and corrective action planning |
Inspection Report — Oct 27, 2020
Routine
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted 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 — Jun 9, 2020
Routine
Date: Jun 9, 2020
Visit Reason
A COVID-19 focused emergency preparedness and infection control survey was conducted to assess compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR483.73 and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report — Sep 13, 2019
Life Safety
Date: Sep 13, 2019
Visit Reason
The inspection was a life safety code survey to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain fire safety barriers and sprinkler system maintenance, resulting in multiple unsealed gaps around sprinklers and doors, accumulation of dust and debris on sprinklers, and lack of self-closing doors in hazardous areas. These deficiencies had the potential to affect numerous residents across several smoke compartments.
Deficiencies (8)
K161: The facility failed to maintain fire resistance barriers by not repairing openings in ceilings around sprinklers, affecting 63 residents in six of seven smoke compartments.
K321: Hazardous areas were not protected by self-closing or automatic-closing doors, potentially affecting 30 residents and staff in two of seven smoke compartments.
K324: The facility failed to maintain the range hood free of grease and debris, risking occupants in one of seven smoke compartments.
K353: The sprinkler system was not maintained properly, with sprinklers covered in dust and debris, potentially affecting 62 residents in six of seven smoke compartments.
K363: Corridor doors did not resist smoke passage due to holes and lack of proper closure, potentially affecting 12 residents in two of seven smoke compartments.
K372: Smoke barriers were incomplete due to unsealed openings in walls, potentially affecting 53 residents in five of seven smoke compartments.
K741: Smoking regulations were not fully enforced, with combustible trash intermixed in designated smoking areas, potentially affecting occupants in two of seven smoke compartments.
K920: Electrical wiring was not maintained to prevent fire hazards, with extension cords and power strips improperly used, potentially affecting 55 residents in five of seven smoke compartments.
Report Facts
Number of smoke compartments affected: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Harold Mills | Administrator | Named in signatures and interviews related to inspection findings |
Inspection Report — Sep 13, 2019
Plan of Correction
Date: Sep 13, 2019
Visit Reason
The document is a Plan of Correction submitted by Garden View Care Center following a survey conducted on 09/13/2019. It addresses deficiencies cited during the inspection.
Findings
The facility was found non-compliant with several regulatory requirements including Medicaid/Medicare coverage notices, reporting of alleged violations, nursing care standards, medication administration, ADL care, nutrition, infection control, and food safety. Deficiencies involved failure to provide proper notices, report abuse allegations, follow nursing care plans, administer medications correctly, maintain safe environment, and ensure proper infection control.
Deficiencies (10)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide Medicaid-eligible residents with required notices regarding coverage and charges when Medicare services ended for two residents.
F609 Reporting of Alleged Violations: The facility failed to report two allegations of resident physical abuse to the state survey agency within required timeframes.
F658 Services Provided Meet Professional Standards: The facility failed to follow nursing care standards for one resident, including improper medication mixing and inadequate skin care.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide adequate personal hygiene and pericare for three residents unable to perform ADLs independently.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for residents requiring assistance.
F692 Nutrition/Hydration Status Maintenance: The facility failed to provide adequate hydration and nutrition to residents, including failure to offer fluids and monitor intake properly.
F761 Label/Store Drugs and Biologicals: The facility failed to secure medication carts and properly label and store medications, leaving carts unlocked and medications accessible.
F803 Menus Meet Resident Needs/Prep in Adv/Followed: The facility failed to meet nutritional needs of residents by not serving correct portion sizes and failing to prepare menus in advance.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain proper food safety, including storing food at unsafe temperatures and improper sanitation in the kitchen.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and use of gloves.
Report Facts
Inspection Report — Jan 14, 2019
Plan of Correction
Date: Jan 14, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations regarding care for residents whose needs cannot be met by the facility, specifically focusing on one resident with behavioral issues requiring private duty nursing care.
Findings
The facility failed to meet the regulation requiring care for residents whose needs cannot be met by the facility, as evidenced by the need for a private duty sitter for one resident with behavioral issues. The facility informed the resident's family that they must pay for a private sitter upon the resident's return from the hospital.
Deficiencies (1)
19 CSR 30-85.042(6) Care to Meet Resident Needs, Licensed Nurse: The facility admitted and continued to care for a resident whose needs could not be met by the facility, requiring the family to hire a private duty sitter for protective oversight.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding resident discharge and care requirements | |
| Administrator | Interviewed regarding facility's ability to take resident back and sitter requirements |
Inspection Report — Aug 2, 2018
Complaint Investigation
Date: Aug 2, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, and exploitation involving Resident #202 and other residents, including a physical abuse incident and failure to report verbal abuse.
Complaint Details
Complaint MO145098 involved allegations of abuse, neglect, exploitation, and mistreatment including physical and verbal abuse. The complaint was substantiated as the facility failed to prevent abuse and failed to report allegations timely.
Findings
The facility was found to have failed to ensure Resident #202 was free from physical abuse by a staff member, failed to report allegations of verbal abuse timely, and failed to protect residents from further potential abuse. Additional deficiencies related to food safety, infection control, and resident care were also cited.
Deficiencies (19)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure Resident #202 was free from physical abuse by a staff member who hit the resident causing injury.
F609 Reporting of Alleged Violations: The facility failed to report an allegation of staff verbal abuse within two hours to the state survey agency for Resident #13.
F610 Investigate/Prevent/Correct Alleged Violation: The facility failed to protect residents from further potential abuse after a staff member witnessed another staff member hit Resident #202 during personal care.
F623 Notice Requirements Before Transfer/Discharge: The facility failed to notify two residents and their representatives in writing of a transfer or discharge as required.
F677 ADL Care Provided for Dependent Residents: The facility failed to provide necessary personal care and hygiene to two residents unable to perform activities of daily living.
F804 Nutritive Value/Appear, Palatable/Prefer Temp: The facility failed to provide residents with palatable meals served at appropriate temperatures.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain sanitary food service areas and proper food handling procedures.
F880 Infection Prevention & Control: The facility failed to establish and maintain an infection prevention and control program including proper hand hygiene and glove use.
A4053 Written Orders; Restraints: The facility failed to follow physician's orders for medication and failed to place an off-loading shoe as ordered for residents.
A4074 Nursing Care per Resident Condition: The facility failed to safely transfer one resident and provide consistent nursing care.
A4085 Infection Control/Communicable Disease: The facility failed to implement acceptable infection control procedures to prevent the spread of infection.
A6012 Floor Surfaces: The facility failed to maintain clean and good repair floors and floor coverings.
A6015 Walls/Ceilings/Doors/Windows Clean: The facility failed to maintain clean walls, ceilings, doors, and windows.
A6019 List Fixtures, Vent Covers, Décor Cleanable: The facility failed to maintain clean light fixtures, vent covers, and wall-mounted fans.
A7002 Wash Hands/Arms & Clean Fingernails: The facility failed to ensure employees washed hands and kept fingernails clean.
A7015 Food-Protected, Temp, Need to Contact DHSS: The facility failed to maintain food at proper temperatures and protect food from contamination.
A7036 Food-120 Degrees/Above, 45 Degrees/Below: The facility failed to maintain food temperatures within safe ranges.
A7067 Nonfood Contact Surfaces, Cleaned as Needed: The facility failed to clean nonfood contact surfaces as necessary.
A8023 Develop/Implement A/N Policies: The facility failed to develop and implement policies to prevent abuse, neglect, and exploitation.
Report Facts
Resident sample size: 12
Resident sample size: 5
Deficiency counts: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nursing Assistant | Named in physical abuse incident involving Resident #202. |
| LPN H | Licensed Practical Nurse | Witnessed and reported on the incident involving Resident #202 and CNA J. |
| DON | Director of Nursing | Conducted investigation and provided statements regarding abuse allegations. |
| RN G | Registered Nurse | Witnessed and reported on the incident involving Resident #202 and CNA J. |
| CNA I | Certified Nursing Assistant | Witnessed and reported on the incident involving Resident #202 and CNA J. |
| Administrator | Facility Administrator | Provided statements and approved plan of correction. |
Inspection Report — Aug 2, 2018
Life Safety
Date: Aug 2, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related reference documents.
Findings
The facility failed to maintain all exits for immediate use, ensure emergency lighting at the emergency generator, inspect and test the sprinkler system quarterly, and maintain a continuous smoke barrier with a one-hour fire resistance rating. These deficiencies had the potential to affect residents, visitors, and staff in multiple smoke compartments.
Deficiencies (4)
K222 Egress Doors: The facility failed to maintain all exits so they were available for immediate use at all times in case of emergency, including a locked gate leading to an enclosed patio.
K291 Emergency Lighting: The facility failed to ensure emergency lighting was provided at the emergency generator, which was enclosed by a privacy fence lacking lighting.
K353 Sprinkler System - Maintenance and Testing: The facility failed to inspect and test the sprinkler system flow alarm quarterly as required, with no inspections completed during the third quarter of 2017 or the first quarter of 2018.
K372 Smoke Barrier: The facility failed to maintain a continuous smoke barrier with a one-hour fire resistance rating, including openings and unsealed gaps in the attic smoke barrier walls.
Report Facts
Inspection Report — Apr 19, 2018
Complaint Investigation
Date: Apr 19, 2018
Visit Reason
The inspection was conducted in response to a complaint regarding abuse and neglect of a resident at Garden View Care Center.
Complaint Details
Complaint MO141402 was substantiated based on findings of verbal and physical abuse by a CNA towards Resident #1, resulting in injury and bruising. The facility took corrective actions including removal and termination of the CNA involved.
Findings
The facility failed to ensure a resident was free from abuse when a staff member verbally abused and physically grabbed the resident, causing injury. The investigation confirmed inappropriate conduct by a CNA, resulting in a skin tear and bruising to the resident.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to ensure one resident was free from verbal and physical abuse by a staff member, resulting in injury to the resident's arm.
A8023 Develop/Implement Abuse/Neglect Policies: The facility did not develop and implement written policies to prohibit mistreatment, neglect, and abuse of residents as required.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse incident involving Resident #1 |
| Director of Nursing | Director of Nursing | Investigated the abuse incident and submitted a Self Reportable Incident |
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