Garden View Care Center

In the surveyor’s words

From the most serious findings on record at Garden View Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 1, 2026

  Based on interview and record review, the facility failed to ensure the safety of one resident (Resident #1) with a history of falls, in a review of five sampled residents, when staff did not routinely check on the resident at least every two hours per the facility's expectations throughout the night. On the morning of 5/30/26, staff found the resident on the floor in his/her room with the door closed for an undetermined amount of time with dried blood on his/her hair, face, and hands. The resident was admitted to the hospital following evaluation. […]

• Actual harm, isolatedF600Jun 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #22), in a review of fifteen sampled residents, remained free from verbal abuse, when Certified Nurse Aide (CNA) U used curse words directed toward and within hearing distance of the resident. CNA U's language made the resident feel hurt and abused. The resident was tearful after the incident. The facility census was 29. The facility learned of the allegation of staff to resident abuse when staff reported the concern on 06/14/23. Administration suspended CNA U pending the investigation. The facility reported the incident to DHSS timely and conducted a thorough investigation, speaking with residents and staff and later terminated CNA U's employment. […]

• No harm, potential for more than minimal, widespreadF812Jan 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff maintained areas throughout the kitchen in a clean and sanitary manner, failed to ensure ice machines in the kitchen and nourishment centers were clean and in good repair, failed to ensure staff properly wore hair and beard restraints while in the kitchen, and failed to cover food/drink items when transporting meal trays to residents' rooms. The facility census was 48. 1. Review of the facility policy, Sanitation, dated November 2024, showed the following: -All utensils, counters, shelves and equipment shall be kept clean and maintained in good repair; -Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime; -The food… […]

• No harm, potential for more than minimal, widespreadF880Jan 16, 2025

  Based on observation, interview, and record review, the facility failed to ensure staff washed their hands after each direct resident contact and when indicated by professional standard of practice during personal care for four residents (Residents #1, #4, #6, and #11), in a review of 14 sampled residents. The facility failed to complete Tuberculin Skin Tests (TST) and/or annual evaluations as required to rule out Tuberculosis (TB) (a communicable disease that affects the lungs characterized by fever, cough, and difficulty breathing) for three of ten new employees reviewed (Registered Nurse I, Laundry Staff J and Dietary Staff K). […]

• No harm, potential for more than minimal, widespreadF606Jun 23, 2023

  Based on interview and record review, the facility failed to ensure individuals employed by the facility did not have a federal indicator for misconduct. Review of Licensed Practical Nurse (LPN) B's employee file showed he/she had a federal indicator for misconduct. LPN B was employed by the facility as a charge nurse with access to all residents. The facility census was 29. Review of the facility policy, Background Screening Investigation, revised November 2015, showed the following: -Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on direct access employees; -For the purposes of this policy direct access employee means any individual who has access to a resident or patient of a long term care facility or provider… […]