Garden View Post Acute Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to readmit one of ten sampled residents (Resident 1) to the first available bed in a private room when the General Acute Care Hospital 2 (GACH 2) contacted the facility regarding Resident 1's readmission to the facility on 3/10/2026. This deficient practice resulted in Resident 1 remaining in GACH 2 from 3/10/2026 through 5/7/2026, a total of 59 days, following an inquiry from GACH 2 for Resident 1 to be readmitted to the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor one of ten sampled residents (Resident 6) in accordance with facility's policy and procedure (P&P) titled, Change in Condition, after discovering an incident on 5/4/2026 that involved Resident 6 and Resident 7. This deficient practice resulted in Resident 6 receiving inadequate care and had the potential to negatively affect Resident 7's psychosocial well-being. a. During a review of Resident 6's admission Record, dated 5/6/2026, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of two sampled residents (Residents 1 and 50). These failures had the potential to result in Residents 1 and 50 not receiving care or receiving delayed services to meet the residents' needs and could result in a fall or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment and care screening too) reflected accuracy of assessments for two of two sampled residents (Resident 5 and Resident 106) by failing to: a. Ensure Resident 5 was coded in the MDS dated [DATE] taking Rivaroxaban (anticoagulant-blood thinner).b. Ensure Resident 106 was coded in the MDS dated [DATE] as discharged home with home health. These deficient practices resulted in inaccurate reporting to the Centers of Medicare and Medicaid (CMS, a federal agency that administers the Medicare program and works with state governments to administer the Medicaid and health insurance portability standards) agency and had the potential to negatively affect the resident's care planning and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatment to prevent pressure ulcer (PU/PI - an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure) development and promote healing for three of four sampled residents (Residents 7, 9, and 46) by failing to: a. & b. Ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries) for Residents 7 and 9 were set to alternating pressure and set correctly to the residents' weights. c. Ensure the LALM was set correctly for Resident 46's weight. These failures had the potential to cause pressure ulcers, worsen, and prevent healing for residents with skin and pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services in accordance with physician's order and to implement its Policy and Procedure (P&P) on fall management for two of three sampled residents (Residents 6 and 72) by failing to:a. Ensure cushion alarm (safety device designed to alert caregivers immediately when a person at risk of falling would stand up or leave a seated/lying position) for Resident 6 was connected in bed and in the wheelchair.b. Ensure Resident 72 was provided with adequate supervision and had an environment free of accident hazards. These failures placed Residents 6 and 72 at risk for injury from fall and recurrent falls.

Inspectors wroteBased on interview and record review, the facility failed to conduct competencies for two of five sampled staff (Certified Nurse Assistant 4 (CNA 4) and Licensed Vocational Nurse 2 (LVN 2). These failures had the potential for the residents in the facility not to receive appropriate nursing care and services from CNA 4 and LVN 2.

Inspectors wroteBased on interview and record review, the facility failed to provide dental care and services to two of three sampled residents (Resident 3 and Resident 72) in accordance with the facility's policy and procedure (P&P) titled, Quality of care. This failure had the potential to result in the residents' poor oral health and reduce quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 66) was assisted with eating at eye level and called by Resident 66's legal (official name recognized by government on documents), proper and preferred name. These failures had the potential for Residents 66 to lose dignity and individuality.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and clean areas for residents. This failure had the potential to negatively affect the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its facility's Policy and Procedures (P&P) on the use of cushion pad alarms (safety devices designed to alert caregivers immediately when a person at risk of falling stand up or leave a seated/lying position) for one of one sampled resident (Resident 12). This failure placed Resident 12 at risk of injury and psychological distress related to the use of cushion pad alarms.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of six sampled residents' (Resident 108) order for Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) included a specific indication for a specific diagnosed condition and the hours of sleep was monitored, as indicated in the facility's policy titled Chemical Restraints and Psychotropic (medications that alter chemical levels in the brain which impact mood and behavior) Medication Management. This deficient practice had the potential to result in the use of unnecessary psychotropic drug, which may result in significant adverse (harmful) consequences to Resident 108.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the resident's care plan for one of three sampled residents (Resident 72). This failure had the potential to compromise Resident 72's safety and prevent the provision of necessary care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide required assistance during activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily) for one of one sampled resident (Resident 51). This failure placed Resident 51 at risk of physical injury during bed mobility and overall decline in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition/medication directly to the stomach) site in accordance with the physician's order for one of one sampled resident (Resident 51). This failure had the potential for complications related to tube feedings for Resident 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident 109) was free from significant medication error by failing to administer Morphine Sulfate Contin (MS Contin- controlled medication used for pain) Oral Tablet Extended Release (ER-long acting) 15 milligrams (mg- unit of measurement) at the correct administration time. The medication was administered too early than the ordered scheduled time of administration. This failure had the potential to place Resident 109 at risk for adverse side effects related to overdosing, such as lethargy, respiratory depression (slow breathing and carbon dioxide retention) and hypotension (low blood pressure).

Inspectors wroteBased on observation , interview and record review , the facility failed to maintain medication related equipment and storage areas in a clean and appropriate manner, resulting in the presence of contaminated equipment and unsecured, loose medication pills in the medication room. This deficient practice had the potential to cause contamination, medication errors, and unsafe conditions for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and follow infection prevention procedures to prevent the transmission of infectious organisms for one of four sampled residents (Resident 80) by failing to ensure the resident's nasal cannula (NC- a flexible tube with two small prongs that sits in the nostrils to deliver oxygen) was not touching the floor. This deficient practice had the potential to result in infection to Resident 80.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and maintain dignity for two of two sampled residents (Residents 138 and 238) by failing to: a. Close Resident 138's privacy curtain and Resident 138's body was exposed and can be seen from the hallway. b. Close Resident 238's privacy curtain and Resident 238's upper extremities were exposed when Minimum Data Set Nurse (MDSN) checked the resident's surgical site. These deficient practices violated Residents 138 and 238's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of residents' needs for four of four sampled residents (Residents 13, 20, 39, and 57). For Residents 13, 20 and 57, the call light (device that allows the resident to request assistance from nursing staff) was not within reach. For Resident 39, the resident did not know how to use the call light and the purpose of the call light was not explained to the resident. These failures had the potential for the residents not to receive care or receive delayed services to meet the residents' needs and could result in a fall or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents with indwelling catheter (including Foley Catheter- a soft flexible tube inserted into the bladder to drain urine, nephrostomy tube- a thin, flexible tube that drains urine from the kidney into a bag outside the body, and suprapubic catheter- a catheter inserted through a hole in the abdomen and then directly into the bladder) in accordance with the facility's Policy and Procedure (P&P) for four of five sampled residents (Residents 19, 26, 32 and 78) by failing to: a. Ensure Resident 19's Foley Catheter (FC) tubing was kept secured and monitored for the presence of white sediments (visible particles) in the urine. b. Ensure Resident 26's Suprapubic Catheter (SC) tubing was kept secured and the suprapubic catheter site dressing clean and dry. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bedrails (a bar that runs along the side of a bed) and grab bars (a bar or loop that helps the resident move in and out of the bed) for two of two sampled residents (Residents 33 and 51) by failing to: a. Ensure the use of appropriate alternatives to grab bars were attempted and did not meet the needs of the resident before its installation for Resident 51. b. Ensure the use of appropriate alternatives to bedrails were attempted and did not meet the needs of the resident. In addition, the facility failed to ensure the use of siderails was consented before its installation for Resident 33. These failures placed Residents 33 and 51 at risk for entrapment and injury from the use of bedrails or grab bars.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure on infection control by failing to: a. Ensure one of one Certified Nurse Assistant (CNA 2) wore the required personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while providing care for a resident on enhanced barrier precaution (EBP, a set of infection control practices that use PPE to reduce the spread of multidrug-resistant organisms [MDROs}]) for one of one sampled resident (Resident 34). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an effective communication method for one of one non-English speaking sampled resident (Resident 138). This failure had the potential for Resident 138 not to receive necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazard for one of two sampled residents (Resident 40) by failing to ensure Resident 40's bed was in the lowest position. This deficient practice had the potential to place Resident 40 at risk for recurrent fall with injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the nasal cannula (NC) tubing (an oxygen delivery device) for one of two sampled residents (Resident 64). This failure had the potential to result in infection for Resident 64.

Inspectors wroteBased on interview and record review, the facility failed to act upon the consultant pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication use) recommendation for one of five sampled residents (Resident 40). This deficient practice had the potential for Resident 40 to receive unnecessary medication and adverse (harmful) consequences related to medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to identify and document specific indication for the use of Mirtazapine (antidepressant- medication to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning]) for one of five sampled residents (Resident 20) as indicated in the facility's policy titled Psychotropic Medications This deficient practice had the potential to result in unnecessary psychotropic drug use which could result in significant adverse (harmful) consequences to Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep an electric fan (a powered machine used to create a flow of air to cool and ventilate rooms and control humidity) in a safe, operating, and sanitary condition for one of one sampled resident (Resident 4). This failure had the potential to affect Resident 4's quality of life and health.

Inspectors wroteBased on interview and record review, the facility failed to post actual number of nursing staff who worked on 1/2/2025, 1/3/2025, 1/5/2025 for one of one sampled Nursing Station. This failure resulted in inaccurate information to the residents and family members and had the potential to affect the quality of care provided to the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan (CP - a document that describes a resident's needs and how the nursing home will meet them) for one of three residents (Resident 1) by failing to ensure Resident 1 had a care plan for Resident 1's oral/dental status. This failure had the potential for Resident 1 to not receive the care and services needed to address Resident 1's edentulous (the complete loss of all natural teeth) mouth.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received proper treatment and care for foot health by failing to arrange Resident 1's consult with a podiatrist (a medical professional who specializes in the diagnosis and treatment of foot, ankle, and lower limb disorders) in a timely manner. This failure resulted in a delay of the provision of foot care and treatment for Resident 1 which could result in podiatric complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure to provide information regarding Advance Directives (AD, legal document that provide instructions for medical care which go into effect when a person becomes disabled) to two of two sampled residents (Resident 82 and 47). This deficient practice had the potential for facility staff to provide care and treatment against the resident's will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss Mattress (LAL mattress, a pressure reducing device that helps prevent skin breakdown) settings for four of four sampled residents (Residents 68, 66, 31 and 32) were carried out as ordered by the physician and/or as recommended by the manufacturer. a. For Resident 68, the facility failed to ensure the LAL setting was according to the resident's weight as ordered by the physician and as recommended by the manufacturer. b. For Resident 66, the facility failed to ensure the LAL setting was according to the resident's weight as ordered by the physician and as recommended by the manufacturer. c. For Resident 31, the facility failed to ensure the LAL mattress setting was accurate. d. For Resident 32, the facility failed to ensure the LAL mattress setting was accurate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free of accident hazard for two of four sampled residents (Residents 50 and 32) by failing to: a. Utilize bilateral landing mats for Resident 50 who had history of fall, as ordered. b. Ensure Resident 32's pad alarm ( a pad placed under a resident while on the bed and sends an alarm to alert staff when the resident gets up from pad) was turned on while the resident was in bed for fall prevention, as ordered. These deficient practices had the potential to result in serious consequences of fracture (break in the bone) and/or bleeding that may accompany a fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform a Gradual Dose Reduction (GDR, an attempt to decrease or discontinue) for two of five sampled residents (Residents 55 and 41) in accordance with the facility's Policy and Procedure titled, Psychotropic Drug Use. a. There was no GDR completed for Resident 55 who received Remeron (a medication to treat depression [a feeling of severe sadness or hopelessness]) with no symptoms of depression for 11 months. b. There was no GDR completed for Resident 41 who received Risperdal (a medication to treat schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real]) since 1/21/2021. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention and control program practices were implemented for two of two sampled residents (Residents 41 and 20), by failing to: a. Ensure the facility administered antibiotics (medicine that fights infection) to Resident 41 with adequate indication for its use. For Resident 41, the criterion was not met for the use of antibiotics based on Mc Geer's criteria (the criteria that define infections for surveillance purposes were selected to increase the likelihood that the events captured by application of the definitions are true infections). This deficient practice had the potential for Resident 41 to develop antibiotic resistance (when bacteria/germs develop the ability to defeat medications designed to kill them). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 65) who was at risk for fall by failing to ensure Resident 65's call light was within reach as indicated in the facility's Policy and Procedure titled, Call Light, and Resident 65's plan of care. This deficient practice had the potential for Resident 65 not to receive and/or receive delayed assistance when needed that could potentially result in falls and/or accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 14) reviewed for communication/sensory was assessed accurately. For Resident 14, the admission assessment for hearing was not accurately assessed to reflect Resident 14's hearing problem. This deficient practice had the potential risk for Resident 14's hearing problem not identified and worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an effective communication method to one of one non-English speaking sampled resident (Resident 185). This deficient practice had the potential for Resident 185 to not be able to express needs which may result in Resident 185 not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 14) reviewed for communication/sensory was provided necessary treatment and/or services for resident's difficulty in hearing. Resident 14 had problems with hearing and was not addressed. This deficient practice had the potential risk for Resident 14's hearing problem to get worse. Cross reference F641.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of five sampled residents (Resident 22) with indwelling catheter (foley catheter - a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure, titled Catheter Drainage Bag and the resident's care plan for foley catheter. This deficient practice had the potential for Resident 22 to not receive care or delayed care and treatment for urinary tract infection (UTI, condition in which bacteria invade and grow in any part the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct oxygen flow rate was administered to one of one sampled resident (Resident 25) This deficient practice had the potential to result in complications associated with oxygen (odorless and colorless reactive gas) therapy (treatment that provides extra oxygen to breathe in).

Inspectors wroteBased on interview and record review, the facility failed to supervise medical care by a licensed physician according to the facility ' s policy and procedure (PP) titled, Physician Services, for one of four sampled residents (Resident 1) by failing to: 1. Ensure Medical Doctor 1 (MD 1) provided care after attempting to be notified by RN 1 and RN 2 to resume Resident 1 ' s home medications in a timely manner for the following medications: a. Xarelto 20 (medication to treat and prevent blood clots (an important process that prevents excessive bleeding when a blood vessel is injured]) milligram (mg, unit of measurement) by mouth one time a day for atrial fibrillation (a type of irregular heartbeat). b. Rhopressa Ophthalmic Solution eyedrop (medication to treat loss of vision), instill one (1) drop in both eyes at bedtime for glaucoma (nerve connecting the eye to the brain is damaged). c. [...]