Garden View Care Center of Chesterfield

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment in accordance with acceptable standards of practice when facility staff failed to complete and document neurological assessments (neuro checks) following falls for two residents (Residents #1 and #2). The facility failed to complete and document a fall evaluation and fall risk evaluation for one resident (Resident #1) and failed to complete and document incident follow up (IFU) monitoring on each shift for 72 hours post-fall for three residents (Residents #1, #2, and #3). The sample was 3. The census was 79. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided two residents (Residents #1 and #4), who were unable to perform their own activities of daily living, the necessary services to maintain good personal hygiene when staff did not administer incontinence care in a timely manner. The facility also failed to ensure appropriate perineal care (Peri-care, washing the front and back of the hips, genitals, anal area and buttocks) was provided for infection control. The sample size was three. The census was 82. Review of the facility's Activities of Daily Living, Supporting policy, dated November 2024, showed: -Policy: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment consistent with professional standards of practice to an existing pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one resident (Resident #1) out of three sampled residents. The facility also failed to consistently complete and document assessments of the resident's skin and failed to assess and document the resident's pressure ulcer weekly. The census was 82. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014, showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its admission policy did not request or require residents or potential residents to waive potential facility liability for losses of personal property. This deficient practice had the potential to affect all residents. The sample was 12. The census was 84 with 46 in certified beds. Review of the facility's admission policy, reviewed 1/9/25, showed: -The facility shall not be responsible for clothing, jewelry, money, or other valuable retained by Resident except as described under the lost and found and denture policy of the facility; -Attached hereto and incorporated herein, included Exhibits C and F; -Exhibit C, admission Authorizations: -Waiver of liability - personal belongings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain hot water temperatures between 105 and 120 degrees Fahrenheit (F) in resident rooms and resident-accessible common areas. The sample was 12. The census was 84 with 46 in certified beds. Review of the facility's Safety of Water Temperatures policy, dated 2001, showed: -Policy Statement: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents; -Policy Interpretation and Implementation: -Water heaters that service resident rooms, bathrooms, and common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit (F), or the maximum allowable temperature per state regulation. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff certified in cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating) received their CPR certification through a provider whose training includes hands-on practice and in-person skills assessment. One week was reviewed for staff CPR certification (21 shifts), and problems were found with 12 shifts. The resident sample was 12. The census was 84 with 46 in certified beds. Review of the facility's Emergency Procedure - CPR policy, revised [DATE], showed: -Policy statement: Personnel have completed training on the initiation of CPR and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest; -Preparation for CPR included; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff treated residents with dignity and respect when staff stood over residents (Residents #32 and #23) while providing feeding assistance, and interacted with other employees rather than the resident receiving feeding assistance (Resident #32). The sample was 12. The census was 84 with 46 in certified beds. Review of #23's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/4/25, showed: -Resident rarely/never understood; -Partial/moderate assistance required for eating; -Diagnoses included aphasia (language disorder that affects how a person communicates), Alzheimer's disease, anxiety and depression. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Resident rarely/never understood; -Dependent for eating; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the respiratory services provided were consistent with professional standards of practice for one resident (Resident #9) when staff failed to follow the physician orders for the rate of the oxygen. The sample size was 12. The census was 84 with 46 in certified beds. Review of the facility's Departmental (Respiratory Therapy) - Prevention of Infection policy, revised November 2011, showed: -The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment including ventilators among residents and staff; -Change the oxygen cannula (a tubing that is placed in the nose) and tubing every seven days or as needed Review of the Resident #9's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff, dated 12/6/24, showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation. The facility failed to ensure accuracy and monitoring for controlled substances for one of one narcotic count books reviewed. The census was 84 with 46 in certified beds. Review of the facility's Controlled Substance policy, dated June 2024, showed: -Garden View Care Center(s) shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule 2 and other controlled substances, in accordance with state and federal laws; -Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse coming off duty. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure laboratory services to meet the needs of the residents by failing to ensure quality control solution for blood sugar testing machines, in house Covid tests, and other supplies used for laboratory testing and medication administration, stored in the nurse's medication cart, were not expired. The census was 84 with 46 in certified beds. Review of the facility's Centers for Medicare and Medicaid Services Clinical laboratory Improvement Amendment (CLIA) certificate of waiver, effective date [DATE] through [DATE], showed: -The facility name and address listed as the Laboratory name and address; -The above named laboratory located at the address shown hereon may accept human specimens for the purpose of performing laboratory examination or procedures. [...]

Inspectors wroteSee the deficiency cited at event ID G4IH12. Based on interview and record review, the facility failed to use a proper transfer technique in accordance with the resident's plan of care. A staff member failed to safely assist a resident during a Hoyer lift (mechanical lift) transfer and the Hoyer lift tipped over, landing on top of the resident and a Certified Nurse Aide (CNA). This affected one of five sampled residents (Resident #2). The census was 77. Review of the facility's policy on Safe Lifting and Movement of Residents, undated, showed the following: -Policy: Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for eight of 10 sampled employees hired since the last survey. The facility hired at least 200 new employees since the last survey. The census was 78. Review of the facility's Abuse Prevention Program, revised December 2016, showed the following: -Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms; -Policy Interpretation and Implementation: [...]

Inspectors wroteBased on interview and record review, the facility failed to use a proper transfer technique in accordance with the resident's plan of care. A staff member failed to safely assist a resident during a Hoyer lift (mechanical lift) transfer and the Hoyer lift tipped over, landing on top of the resident and a Certified Nurse Aide (CNA). This affected one of five sampled residents (Resident #2). The census was 77. Review of the facility's policy on Safe Lifting and Movement of Residents, undated, showed the following: -Policy: Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide the pneumococcal vaccine after consent was obtained for 1 (Resident #5) of 5 residents reviewed for immunizations.

Inspectors wroteBased on interview and record review, the facility failed to complete the required significant change in status assessment (SCSA) when four residents were admitted to hospice care (Residents #6, #14, #25 and #12). The facility identified six residents who received hospice care. Four of those six residents were sampled, and problems were found with all of them. The census was 65 with 28 residents in certified beds. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/19, showed the following: -Short and long term memory problems; -Severe cognitive impairment for daily decision making; -Total dependence on staff for personal hygiene, bathing, toilet use, dressing and transfers; -Did not have a condition or chronic disease that might result in a life expectancy of less than six months; [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered care plans that addressed hospice services and interventions for three residents (Residents #6, #14 and #13) that received hospice care. The census was 65 with 28 in certified beds. 1. Review of Resident #6's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/27/19, showed the following: -Short and long term memory problems; -Severe cognitive impairment for daily decision making; -Received hospice care; -Diagnoses included anemia, heart disease, high blood pressure, Alzheimer's disease, stroke, dementia, anxiety and depression. Review of the resident's hospice binder, kept at the nurses's station, showed the resident admitted to hospice care on 11/6/18. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up on a nutrition recommendation, failed to obtain an order for an indwelling catheter (small rubber tube inserted in the bladder to drain urine) (Resident #25), failed to administer medication as ordered (Resident #230) and failed to follow physician orders (Resident #5). Facility staff also failed to obtain physician signatures on order sheets (Residents #17, #6, #14, #23 and #2). The census was 65 and with 28 residents in certified beds. 1. Review of Resident #25's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/19, showed the following: -Severe cognitive impairment; -Dependent on staff for all mobility and personal care; -Nutrition approach: [...]

Inspectors wroteBased on observation and interview, the facility failed to prevent resident access to razors in four unlocked spa rooms. This had the potential to affect all residents who were able to move freely around the facility. The census was 65 with 28 residents in certified beds. 1. Observations of the Magnolia west spa, showed the following: -On 1/21/20 at 1:05 P.M., a box of disposable razors containing two razors rested on the rail on the left side of the shower. The door to the spa did not have a lock; -On 1/22/20 at 7:35 A.M., a box of disposable razors with two razors in an unlocked cabinet adjacent to the window. 2. Observations of the Magnolia south spa on 1/21/20 at 1:08 P.M., 1/22/20 at 7:44 A.M., 1/23/20 at 8:57 A.M., and 1/24/20 at 8:32 A.M., showed a box of disposable razors containing three razors in an unlocked cabinet adjacent to the window. The door to the spa was not locked. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff used acceptable infection control procedures during perineal care (peri-care, cleaning the front of the body from hips, between legs and the buttocks) for one of three observations, ensure proper placement of urinary catheter (small rubber tube inserted in to the bladder to drain urine) drainage bag to prevent contamination, and ensure resident toothbrushes in one shared resident room were clearly identified for each resident and ensure co-mingling of use did not occur for combs and hairbrushes in one shared spa room (Resident's #25 and #5). The sample size was 14. The census was 65 with 28 in certified beds. 1. Review of Resident #25's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/10/19, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the equipment and floor in the kitchen was kept clean and free of grimy build-up, for four of four days of observation. The census was 65 with 28 in certified beds. Observation of the kitchen on 1/21/20 at 11:30 A.M., 1/22/20 at 10:15 A.M., 1/23/20 at 2:35 P.M. and 1/24/20 at 10:40 A.M., showed the following: -A plastic tub stuck out from under the stove, contained grease. The grease drawer pulled out halfway from the stove, coated with and dripping grease; -The front, sides and control knobs of the convection oven dirty, streaked and with a build-up of grime; -The deep fat fryer cabinet next to the reach-in cooler, dirty and streaked, with a build-up of grease on the sides and front; -The floor between the deep fat fryer and the stove with spilled grease; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to ensure all employees were screened for the Employee Disqualification List (EDL), prior to hire, for five of 10 employees reviewed out of the 186 employees hired since the 12/27/18 inspection. The census was 65 with 28 residents in certified beds. 1. Review of the facility's undated Abuse Prohibition Policy, showed all employees will be screened for history of abuse, neglect or mistreatment of residents prior to hire. This includes attempting to obtain previous employment references, review of license as appropriate, criminal record checks and EDL checks. 2. [...]