Inspection Reports for Garden View Care Center

The investigation was complaint-driven based on allegations of inadequate incontinence care and pressure ulcer management. The complaint was substantiated with findings of minimal harm and few residents affected.

The facility failed to provide timely incontinence and perineal care to residents, resulting in potential infection risks and dignity issues. Additionally, the facility failed to provide treatment consistent with professional standards for an existing pressure ulcer, failed to complete and document weekly skin and wound assessments, and failed to notify appropriate parties of wound status changes.

The facility was found deficient in multiple areas including failure to ensure staff treated residents with dignity during feeding assistance, maintaining safe hot water temperatures, admission policies requiring waiver of liability for personal property, CPR certification standards, respiratory care oxygen rate adherence, controlled substance monitoring, and expired laboratory supplies in medication carts.

The complaint investigation found that the resident required two-person assistance for transfers with a Hoyer lift. During the transfer, one CNA released the resident and turned away, causing the lift to tip over and pin the resident and CNA briefly. The resident sustained injuries including a purple swollen right ear, head pain, and stitches to the left eyebrow. The resident was sent to the hospital for evaluation and returned with no new orders. Interviews with involved CNAs and facility leadership confirmed the improper transfer technique and lack of documentation for two-person assistance.

The facility failed to use proper transfer techniques in accordance with the resident's plan of care, leading to a Hoyer lift tipping over and causing injury. The resident required two-person assistance for transfers, but one CNA released the resident prematurely during the transfer. The facility's policy lacked documentation requiring two-person assistance for Hoyer lift transfers. Interviews confirmed staff did not maintain proper hands-on assistance during the transfer.

The facility failed to ensure newly hired employees were screened against the CNA registry for abuse indicators, failed to use proper transfer techniques resulting in a resident and staff injury, and failed to provide pneumococcal vaccinations despite consent.

The facility was found deficient in multiple areas including failure to screen employees against the Employee Disqualification List prior to hire, incomplete resident assessments related to hospice care, inadequate care planning for hospice residents, failure to follow physician orders, unsafe storage of razors, infection control lapses during perineal care, improper catheter care, unlabeled resident personal items, and poor kitchen cleanliness.