Garden View Post Acute Rehabilitation

In the surveyor’s words

From the most serious findings on record at Garden View Post Acute Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF558Feb 27, 2026

  Based 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. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including difficulty walking, history of falling, displaced intertrochanteric fracture of right femur (broken hip occurring at the top of the right thigh bone), hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the… […]

• No harm, potential for more than minimal, patternF641Feb 27, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF686Feb 27, 2026

  Based 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. Findings: a. […]

• No harm, potential for more than minimal, patternF689Feb 27, 2026

  Based 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.Findings: a. […]

• No harm, potential for more than minimal, patternF726Feb 27, 2026

  Based 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.Findings: During a concurrent record review and interview on 2/26/2026 at 10:20 am with the Director of Staff and Development (DSD), CNA 4's employee file was reviewed. The DSD stated CNA 4 was a full-time employee in the facility since 11/11/2024. The DSD stated CNA 4 did not have a skills competency on file for 11/2025. […]