Garden View Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 9, 2025

  Based 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),… […]

• Immediate jeopardy, isolatedF805Jul 9, 2025

  Based 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. […]

• Actual harm, isolatedF684Jul 6, 2022

  Based on record review and interview, it was determined, the facility staff failed to provide timely and necessary care and services to respond to a medical emergency. The failure affected 1 of 3 sampled residents (Resident #2), who experienced a choking episode and was subsequently intubated by emergency personnel and admitted to the hospital for Acute Respiratory Failure and [CONDITION(S)], (lack of oxygen). The findings included: Clinical record review conducted on [DATE] revealed Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Jul 9, 2025

  Based 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).The findings included:During the initial tour of the Main Kitchen on 06/23/25 at 9:15 AM, accompanied by the CDM (Certified Dietary Manager) and the RD (Registered Dietician), the following was observed:1. The gaskets on the door of the reach in cooler had dark brown/black streaks and spots on the rubber pleats. The bottom of the gasket attached to the door was torn. Pieces of the rubberized material that were still attached to the door hung downward. […]

• No harm, potential for more than minimal, widespreadF880Jul 9, 2025

  Based on observation, and interview, the facility failed to ensure the proper storage of linens in 3 of 3 linen carts.The findings included:On 06/25/2025, it was revealed the facility had four residents under transmission-based precautions due to various health concerns, including positive COVID-19 status, Methicillin-resistant Staphylococcus aureus (MRSA), which is a type of staph bacteria resistant to many commonly used antibiotics, Extended-spectrum beta-lactamase (ESBL) production, which refers to enzymes that make certain bacteria resistant to many beta-lactam antibiotics, and Shingles.On 06/25/2025 at 11:09 AM, an observation revealed that the linen cart in the [NAME] Wing was torn and opened, exposing the linens inside. […]