Garden View Health and Rehabilitation Center

Inspectors wroteBased on observations, interviews, record reviews, and a policy review, the facility failed to ensure care and services to prevent accidents for 3 of 9 sampled residents reviewed for nutrition and falls, as evidenced by the failure to provide supervision while eating for Resident #37; failure to implement preventative measures to prevent a fall related injury for Resident #14; and failure to complete a post fall investigation to determine the cause of the fall for Resident #20. On 06/24/25 it was determined the facility failed to ensure adequate supervision for Resident #37, a resident with diagnoses of Cerebral Infarction (Stroke) and Dysphagia (difficulty swallowing), to prevent the likelihood of choking, aspiration (the accidental ingestion of food particles or fluids into the lungs), and/or death. [...]

Inspectors wroteBased on observations, interviews, record reviews, policy review, and review of professional standards of practice, the facility failed to prepare foods in a form to meet the individual needs for 4 of 5 sampled residents, Resident #37, Resident #10, Resident #15, and Resident #21, reviewed for nutritional concerns. This had the potential to affect 18 current residents who were on mechanically altered diets at the time of the survey. On 06/24/25 it was determined the facility failed to follow a physician ordered diet, that was mechanically altered, for Resident #37, a resident with diagnoses of dysphagia (difficulty swallowing), to prevent the likelihood of choking, aspiration (the accidental sucking in of food particles or fluids into the lungs), and or death. Resident #37, who was ordered to have a mechanically altered diet, was provided with a whole hot dog that she consumed. [...]

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 63 out of 66 residents who consume foods PO (by mouth).

Inspectors wroteBased on observation, and interview, the facility failed to ensure the proper storage of linens in 3 of 3 linen carts.

Inspectors wroteBased on record review and interview, the facility failed to provide care and services in a manner to maintain residents' dignity for 2 of 20 sampled residents, reviewed for dignity (Resident #118 and #218).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain the call bell within the reach of 2 of 20 sampled residents, reviewed for accommodation of needs (Resident #2 and Resident #40).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to promptly address grievances voiced for 2 of 20 sampled residents (Resident #10 and Resident #7).

Inspectors wroteBased on interviews and record reviews, the facility failed to respond to requests for resident's records in a timely manner for 1 of 2 sampled residents reviewed for records requests (Resident #69).

Inspectors wroteBased on record review and interview, the facility failed to ensure behavior monitoring for 1 of 4 sampled residents, Resident #119, reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on record reviews, interviews, and a review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI), the facility failed to accurately complete Minimum Data Set (MDS) assessments for 3 of 5 sampled residents, reviewed for nutrition (Resident #15, Resident #23 and Resident #37).

Inspectors wroteBased on policy review, observation, interview, and record review, the nursing staff failed to follow physician orders for wound care for 1 of 2 sampled residents, observed with pressure ulcers (Resident #119).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a resident with restorative therapy per physician's orders for 1 of 2 sampled residents reviewed for Range of Motion (ROM), (Resident #24).

Inspectors wroteBased on observation, interview, record review, and professional standards, the facility failed to ensure appropriate care and services to prevent an Urinary Tract Infection (UTI) for 2 of 2 sampled residents reviewed with indwelling urinary catheters, as evidenced by the failure to change the urinary drainage device collection bags using appropriate infection control techniques for Resident #36, and failure to ensure proper anchoring for the tubing of the indwelling urinary catheters for Residents #36 and #120.

Inspectors wroteBased on policy review, interview, and record review, the facility failed to ensure timely provision of medications for 2 of 3 sampled residents, as evidenced by the failure to provide insulin and an antibiotic timely upon Resident #1's admission to the facility, and failure to provide insulin timely upon Resident #2's admission to the facility.

Inspectors wroteBased on interview, policy review and record review, the facility failed to assess a resident's skin under a knee immobilizer to prevent a pressure injury for 1 of 5 sampled residents (Resident #1).

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure reconciliation of controlled medications for 4 of 4 sampled residents reviewed (Resident #22, #68, #37 and #6).

Inspectors wroteBased on interview and record review, the facility failed to ensure showers were provided per resident preference and as scheduled for 1 of 3 sampled residents reviewed for choices (Resident #13).

Inspectors wroteBased on record review and interview, the facility failed to ensure of an accurate Minimum Data Set (MDS) assessment related to medications for 1 of 5 sampled residents reviewed for unnecessary medications, (Resident #62).

Inspectors wroteBased on interview and record review, the facility failed to assess for a voiced change in condition for 1 of 23 sampled residents (Resident #118), and the nursing staff held blood pressure medications without ordered parameters and failed to notify the physician of the low blood pressure readings for 1 of 5 sampled residents (Resident #21).

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure proper catheter care and services for 2 of 5 sampled residents with indwelling urinary catheters (Residents #32 and #4), and failed to ensure proper peri-care (personal care provided after an incontinent episode of urination) for 1 of 1 sampled resident observed (Resident #16).

Inspectors wroteBased on observations and interview, the facility failed to maintain a safe, clean and homelike environment for 3 of 3 hallways observed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain an infection control program to ensure a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 5 of 8 sampled residents. Staff nurses C, D, and F, failed to properly clean and or disinfect the glucometer (device used to obtain a resident's blood sugar level) for Residents #15, #7, and #215. Staff G and E failed to clean nebulizer equipment as per facility policy, after use by Resident #25. Staff E touched pills with her bare hands while preparing the medications for Resident #25. Staff D utilized a syringe and water container that had fallen to the floor during tube feeding administration for Resident #43. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure showers were provided as per facility schedule and family request for 1 of 1 sampled resident (Resident #3).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure continued podiatry services for 1 of 1 sampled resident (Resident #34).

Inspectors wroteBased on interview and record review, the facility failed to ensure continued range of motion (ROM) services for 1 of 1 sample resident (Resident #3).

Inspectors wroteBased on record review and interview, the facility failed to ensure a safe transfer for 1 of 1 sampled resident, Resident #215, reviewed for falls, as evidenced by the facility's process/policy requiring 2-person assistance for all Hoyer transfers not being followed by Certified Nursing Assistants (CNA).

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure monitoring of medications related to following physician ordered parameters and medication administration for 3 of 5 sampled residents (Residents #47, #215 and #25).

Inspectors wroteBased on record review and interview, the facility failed to ensure documentation of behavior monitoring and monitoring of side effects for psychotropic medications 3 of 5 sampled residents (Residents #47, #215, and #36).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to properly secure medications for 1 of 3 medication carts (West Unit), and for 1 of 3 treatment carts (East Unit). The census at the time of the survey was 59, and the number of independently ambulatory residents was 4.

Inspectors wroteBased on personnel file review, interview, and policy review, the facility failed to complete a performance review of nurse aides at least once every 12 months for 3 of 3 sampled nurse aides (Staff H, I, and J).