Garden View Care Center at Dougherty Ferry

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF585Apr 17, 2026

  Based on interview and record review, the facility failed to maintain an effective grievance process for residents and family members to be able to file a grievance anonymously and failed to post information on how to file a grievance, in accordance with the facility's grievance policy. The sample was 12. The census was 83 with 44 residents in certified beds.Review of the facility's admission Agreement, undated, showed:-A list of key personnel included the name, title, phone extension, and email of Administrative staff;-A staff person shall be designated to receive grievances, and the residents shall be free to voice their recommendations and complaints to that person, an ombudsman or any person outside the facility. […]

• No harm, potential for more than minimal, patternF640Nov 16, 2022

  Based on record review, interviews, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments were encoded and transmitted timely for 4 (Residents #1, #5, #277, and #478) of 11 sampled residents whose MDS assessments were reviewed for timeliness of submission. Findings included: Review of the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, revealed, All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Quality Improvement and Evaluation System (QIES)… […]

• No harm, potential for more than minimal, patternF880Nov 16, 2022

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff members wore face coverings in three of four common resident areas when the community transmission of COVID-19 was high. Findings included: Review of a facility policy titled, Coronavirus Disease (COVID-19)-Using Personal Protective Equipment, revised September 2022, revealed, If community transmission is high, staff will use surgical face coverings during all resident care encounters or in specific resident care areas of the facility. Review of the CDC COVID Data Tracker at https://covid.cdc.gov/covid-data-tracker/index.html#datatracker-home on 11/16/2022 showed, St. […]

• No harm, potential for more than minimal, isolatedF689Apr 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff utilized appropriate techniques during two-person Hoyer lift (mechanical lift) transfers to prevent potential accidents for four residents (Residents #23, #36, #34, and #14). The sample was 12. The census was 83 with 44 residents in certified beds.1. Review of Resident #23's quarterly Minimum Data Set, a federally mandated assessment instrument completed by facility staff, dated 4/2/26, showed-Severe cognitive impairment;-Diagnoses included generalized muscle weakness, other abnormalities of gait and mobility, and syncope and collapse (fainting and falling);-Totally dependent on assistance with transfers, with two or more staff;-Utilized wheelchair for mobility. […]

• No harm, potential for more than minimal, isolatedF880Apr 17, 2026

  Based on observation, interview, and record review, the facility failed to follow acceptable standards of practice for infection control when staff failed to use Enhanced Barrier Precautions (EBP, precautions for use during high-contact resident care activities to reduce transmission of multidrug-resistant organisms (MDROs, microorganisms that are resistant to one or more classes of antimicrobial agents) as recommended by the Centers for Disease Control and Prevention (CDC) and as required by the Centers for Medicare and Medicaid Services (CMS) when staff failed to wear a gown while providing direct care for two residents (Residents #5 and #1). The sample was 12. […]