Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0577

Level of harm – Potential for minimal harm

Residents Affected – Many

Allow residents to easily view the nursing home’s survey results and communicate with
advocate agencies.

Based on observation, interview and record review, the facility failed to post the most
recent survey results in a place readily accessible to residents, family members and the
public. Furthermore, the facility failed to maintain survey reports with respect to any
surveys, certifications and complaint investigations made during the three preceding
years, and any plan of correction in effect with respect to the facility and/or post
notice in a prominent location of the availability of the reports for any individual to
review upon request. The census was 72 with 20 residents in certified beds.
Observations of the front desk of the facility, on 7/11/18 at 10:00 A.M., 7/12/18 at 6:15
A.M., 7/13/18 at 11:30 A.M. and 7/16/18 at 6:15 A.M., showed a 4 inch by 6 inch posting,
which showed the most recent survey results could be found in the library. The posting did
not indicate the previous two years of survey, certifications and complaint investigation
results were available upon request.
Observations of the facility library on 7/11/18 at 5:03 P.M., 7/12/18 at 10:30 A.M.,
7/13/18 at 7:00 A.M., and 7/16/18 at 9:00 A.M., showed a binder labeled State Survey
Results on the top shelf of a credenza approximately 68 inches high. Review of the binder,
showed the statement of deficiencies and plans of correction from the (YEAR) annual survey
and licensure. The binder did not contain any additional information regarding the results
of any complaint investigations completed since the annual survey and licensure or any
survey, certifications and complaint investigation results from (YEAR) or (YEAR).
During the Resident Council interview on 7/12/18 at 10:00 A.M., four residents, in
certified beds, whom the facility identified as alert and oriented, stated they did not
know where the survey results were located or what they entailed.
Review of the Resident Census and Conditions of Residents, completed by the facility on
7/12/18, showed 13 of 20 residents in certified beds used a wheelchair for mobility all or
most of the time.
During an interview on 7/16/18 at 9:30 A.M., the administrator said she was not aware of
the need to post the availability of the previous two years of survey, certifications and
complaint investigation results were available on request. She was not aware the current
location of the survey results binder was not accessible to all residents. The
administrator is responsible for maintaining the survey binder.

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure allegations of abuse
were reported to the Department of Health and Senior Services (DHSS), for an incident
involving one resident and a staff member when the resident alleged the staff member
slapped him/her. (Resident #20) The facility census was 72 with 20 residents in certified
beds.
Review of the facility’s undated Abuse Prohibition policy, showed the following:
-Purpose: To ensure the safety and well-being of all residents, to ensure all allegations
or cases of suspected abuse or neglect are handled immediately and in an appropriate
manner, to creativity all residents’ injuries of unknown origin are investigated and

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
handled appropriately and reported to the Complaint Register Unit as necessary;
-Procedure:
-All employees will be screened for history of abuse, neglect or mistreatment of
[REDACTED]. This includes attempting to obtain previous employment references, review of
license as appropriate, criminal record checks and employee disqualification registry
check;
-Employees will be trained during orientation, through in service training’s and ongoing
education on appropriate interventions, reporting allegations, what constitutes abuse,
recognizing signs of abuse or signs that may lead to abuse, and annually a refresher
course will be completed;
-Profile adequate staff to meet the needs of residents, supervision of staff to identify
inappropriate behaviors, assess and monitor residents with needs and behaviors that may
lead to conflict or neglect;
-When there is suspicion of abuse an investigation will be initiated;
-An investigation form will be completed by the charge nurse. If the charge nurse
suspects abuse/neglect, the Director of Nursing (DON) will be notified immediately. The
DON will continue the investigation to determine cause and resolution of occurrence. If
the DON concurs with the charge nurse, the administrator will be notified immediately;
-The facility ensures that all allegations will be reported immediately, but no later
than 2 hours if there is serious bodily harm, and no later than 24 hours if there is not
serious bodily harm. In addition to reporting to the administrator and other officials,
such as the State Survey Agency, and in compliance with the policy on Elder Justice Act
Issues as outlined in the facility’s compliance manual;
-If during the investigation a specific employee is suspected, they will be put on leave
of absence until the investigation is completed;
-Any occurrence that needs to be reported to the Complaint Register Unit and any other
agencies as required will be reported by the DON or the Administrator. The following may
be self reported:
-An unexplained injury which require medical attention;
-A resident to resident altercation which resulted in injury;
-Financial exploitation of a resident;
-Any allegation of abuse;
-Elopement of a resident in which a resident leaves the facility without any staff
knowledge;
-Incidents of neglect;
-Suspicious deaths.
Review of Resident #20’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/15/18, showed the following:
-admission date of [DATE];
-Severe cognitive impairment;
-Required staff assistance for toileting, walking and dressing;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed a nurse’s notes on 6/14/18 at 3:30 A.M.,
which showed the following:
-Around 1:30 A.M., Nurse G informed by certified nurse aide (CNA) H the resident was very
agitated and cursed at the CNA. The resident yelled he/she did not want CNA H in his/her
room and he/she fired the CNA;
-Nurse G able to calm the resident down and walked with him/her to his/her bed;
-The resident said CNA H slapped him/her on the left side of the face and caused his/her
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
head to hit the wall. The resident said it hurt;
-Nurse G assessed the resident and did not note any injury;
-Nurse G was able to calm the resident and get him/her back to bed;
-Nurse G did not document if the DON or Administrator were informed of the abuse
allegation;
-No further notes regarding the allegation.
Further review of the resident’s medical record, did not show any additional information
regarding the alleged abuse allegation.
Review of the facility’s (MONTH) (YEAR) incident/accident log, provided on 7/11/18, showed
no documentation regarding the abuse allegation.
During an interview on 7/13/18 at 10:53 A.M., the administrator and DON said they were
unaware of the incident. If a resident makes an allegation of abuse, staff should notify
the DON or administrator immediately.
During an interview on 7/16/18 at 7:21 A.M., Nurse G said since the resident did not have
an injury, and it was the night shift, he/she left a note for the DON and informed the
on-coming nurse of the resident’s allegation. If the resident had an injury, he/she would
have notified the DON and the resident’s doctor. Nurse G also made CNA H write a statement
regarding the allegation. The nurse’s note and the CNA’s statement were left under the
door of the DON’s office.
During an interview on 7/16/18 at 9:30 A.M., the DON said she did not have any record of a
statement from the CNA. The administrator said DHSS should have been contacted regarding
the abuse allegation.

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow their policy by
thoroughly investigating a resident’s allegation of physical abuse by a staff member.
(Resident #20) In addition, the facility failed to protect the resident and other
residents until an investigation was completed. This deficient practice has the potential
to affect all residents residing in the facility. The census was 72 with 20 residents in
certified beds.
Review of the facility’s undated Abuse Prohibition policy, showed the following:
-Policy: Every resident has the right to remain free from any type of abuse. In accordance
with facility abuse prohibition, each incident including but not limited to incidents of
unknown origin or any suspicion of abuse will be investigated. The investigation will be
started immediately following the reporting of the incident;
-Incident Report: Any incident occurring in the facility must be written on an incident
report and turned into the nursing supervisor. An incident is defined as anything out of
the ordinary whether or not an injury is a result. Every incident report and investigative
report will be investigated and a report will be completed as to the findings,
recommendations and plan of correction;
-Investigative report: Any unusual or suspicious findings or reports should be written on
the investigative report and turned into the nursing supervisor. The nursing supervisor
will review and sign the report and turn into both social services and the administrator
for review. Each area of the incident report and investigative report shall be thoroughly
completed and signed by the nurse with the input of all staff, residents and witnesses

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 3)
involved. Statements will be obtained. If there is reasonable suspicion of abuse or
neglect the nursing supervisor must be notified immediately;
-Procedure: The charge nurse will immediately handle the incident and complete and
investigation and/or incident report;
-Immediately secure the safety of the resident;
-Relocate resident to safe area;
-Suspend staff involved until investigation is complete;
-Complete and document a physical assessment of the resident;
-The investigation should consist of:
-Interviews with resident(s) involved, statements taken and documented;
-Interviews with staff member(s), statements taken and enclosed;
-Interviews with witnesses, statements obtained and documented;
-Police report made/obtained if necessary;
-Documentation requirements:
-Internal incident report filled out;
-Documented in chart;
-Completed internal investigation report;
-Documented plan of correction;
-Reporting requirements:
-The charge nurse shall notify the nursing supervisor immediately;
-The nursing supervisor will make sure the family and doctor have been notified;
-The nursing supervisor shall call the police if necessary;
-The administrator or his/her designee shall review the file, and will make the final
ruling on the plan of correction and agencies to be contacted;
-Social services will notify the ombudsmen and DHSS if necessary.
Review of Resident #20’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/15/18, showed the following:
-admission date of [DATE];
-Severe cognitive impairment;
-Required staff assistance for toileting, walking and dressing;
-[DIAGNOSES REDACTED].
Review of the resident’s medical record, showed a nurse’s notes on 6/14/18 at 3:30 A.M.,
which showed the following:
-Around 1:30 A.M., Certified nurse aide (CNA) H informed Nurse G the resident was very
agitated and cursed at the CNA. The resident yelled he/she did not want CNA H in his/her
room and he/she fired the CNA. CNA H was not the boss of the resident;
-Nurse G calmed the resident down and walked with him/her to his/her bed;
-The resident he/she was upset because CNA H slapped him/her on the left side of the face
and caused his/her head to hit the wall. The resident said it hurt;
-Nurse G assessed the resident and did not note any injury;
-Nurse G was able to calm the resident and get him/her back to bed;
-Nurse G did not document if the DON or Administrator were informed of the abuse
allegation.
Review of the resident’s medical record, showed no further notes regarding the alleged
incident.
During an interview on 7/16/18 at 7:21 A.M., Nurse G said he/she helped CNA H with
toileting the resident around 1:30 A.M. on 6/14/18. Nurse G left the room and
approximately five minute later, CNA H came to the nurse station and informed Nurse G the
resident was agitated and cursing and did not want CAN H to work with him/her. Nurse G
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
said he/she found the resident in the doorway of his/her room and said the CNA was fired
and was not the boss of him/her. Nurse G told the CNA to not work with the resident for
the rest of the shift. The resident repeatedly stated CNA H had slapped him/her on the
face. The resident was assessed and no injury was noted. The CNA was asked to make a
statement regarding the incident. The CNA continued to work with other residents during
the shift. The resident is confused at times, but since Nurse G was not in the room,
he/she cannot say what did or did not happen. Nurse G put the CNA’s statement under the
door of the DON office. The DON never followed up with Nurse G regarding the incident.
During an interview on 7/16/18 at 8:18 A.M., CNA H said he/she wrote a statement regarding
the incident on 6/14/18 and Nurse G placed it under the door of the DON’s office. Nurse G
assisted him/her with toileting the resident and then left the room. CNA H was trying to
assist the resident back to bed when the resident became very agitated and began cursing
at him/her and attempted to take off his/her brief. CNA H said he/she never got within
arm’s reach of the resident once Nurse G left. He/she went and got Nurse G and was
reassigned to other residents for the remainder of the shift. CNA H helped the resident
get dressed in the morning with no issue. CNA H has worked with the resident since the
incident with no issues. The DON never followed up with him/her regarding his/her
statement.
During an interview on 7/13/18 at 10:53 A.M., the administrator and Director of Nursing
(DON) said they were not aware of the resident’s allegation of abuse. Once the allegation
was made, one of them should have been contacted immediately. Staff should have been
removed and other residents should be interviewed. Despite the resident’s confusion, the
allegation should have been investigated.
During an interview on 7/16/18 at 9:30 A.M., the DON said she did not receive a statement
from CNA H regarding the incident. She denied ever being told about the resident’s
allegation. She was told the incident did not happen when she interviewed staff on
7/13/18. If she had known, she would have sent CNA H home and completed an investigation.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed created a comprehensive
individualized care plan for the use of all nursing staff for one of 12 sampled residents
(Resident #20). The census was 72 with 20 residents in certified beds.
Review of Resident #20’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/15/18, showed the following:
-admission date of [DATE];
-Severe cognitive impairment;
-Required staff assistance for toileting, walking and dressing;
-[DIAGNOSES REDACTED].
Review of Resident #20’s undated admission care plan, located in the resident’s medical
chart, and in use during the survey, showed the following:
-[DIAGNOSES REDACTED].
-Problems identified included: Fall risk, impaired skin integrity risk, elopement risk,
abnormal bleeding/hemorrhage risk, poor appetite and confused/delusional;
-Interventions to assist the resident included: Complete fall risk assessment, weekly skin

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
assessments, wander guard (device used to alert staff when resident approaches an exit
door) placed on resident, administer medications as needed, provide diet as ordered and
approach diet as ordered.
Review of the resident’s medical chart on all days of the survey, 7/11, 7/12, 7/13 and
7/16/18, showed only the admission care plan available for staff review.
During an interview on 7/16/18 at 9:30 A.M., the administrator said the resident should
have a comprehensive care plan which reflects the resident’s current needs by the 14th
day. The care plan should be completed by the MDS coordinator and should be kept in the
resident’s chart for staff use.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to revise
individual resident care plans timely to address weight loss and falls for three of 12
sampled residents (Residents #10, #6 and #9). The census was with 72 with 20 residents in
certified beds.
1. Review of Resident #10’s comprehensive Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 5/15/18, showed the following:
-[DIAGNOSES REDACTED].
-Severe cognitive impairment;
-Unable to ambulate;
-Limited assistance with meals;
-Extensive assistance to total dependence on staff for personal care and mobility.
Review of the medical record, showed the following:
-May, (YEAR) weight recorded as 138 pounds (#’s);
-June, (YEAR) weight recorded as 133.1#’s;
-July, (YEAR) weight recorded as 128.2#’s.
Review of the physician’s orders [REDACTED].
-An order to administer med pass plus (fortified nutritional shake) 120 cubic centimeters
(cc) twice a day;
-Weekly weights for one month due to weight loss.
Review of the care plan, dated 5/7/18 and last reviewed on 5/25/18, showed weight loss not
identified as a problem and no interventions listed.
Observation on 7/11/18 at 11:58 A.M., showed the resident seated at the dining room table,
alert, folded hand resting on his/ her cheek. A staff member placed a food filled fork to
the resident’s mouth and the resident took the fork and placed it on the table without
consuming the food.
Observation on 7/13/18 at 12:00 P.M., showed a certified nurse aide (CNA) fed the resident
lunch. After five bites he/she closed his/her mouth and refused to eat more.
Observation on 7/16/18 at 8:26 A.M., showed the Director of Nursing (DON) fed resident
his/her breakfast. He/she consumed approximately three bites of the meal.
During an interview on 7/16/18 at 9:30 A.M., the DON said she was not aware that the
information needed to be on the care plan but she knows it now.
2. Review of Resident #6’s quarterly MDS, dated [DATE], showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 6)
-Cognitively intact;
-Required assistance of one staff member for transfers and total dependence on staff for
locomotion and hygiene;
-Utilized walker and wheelchair for mobility;
-Unsteady balance during transitions and walking;
-[DIAGNOSES REDACTED].
-Sustained two falls without injury and one fall with injury since last assessment.
Review of the resident’s progress notes, showed the following:
-On 5/21/18 at 12:30 P.M., the resident fell to the floor while walking and had complaints
of pain to his/her shoulders and back. The resident sustained [REDACTED]. Resident will
now go to meals in his/her wheelchair since this seems to be a continual problem;
-On 5/25/18 at 4:15 A.M., staff responded to the resident’s roommate’s call light. The
resident was on the floor on his/her left side at the bedside. Resident said he/she was
getting up to go to the bathroom. Resident complained of pain to his/her left shoulder. No
other injuries noted;
-On 6/25/18 at 6:00 P.M., staff called to the resident’s room and found the resident on
the floor on his/her buttock in the corner of the room, leaning against the closet door.
Staff noted a small white scratch to the right wrist and a small purple bruise;
-On 6/26/18 at 2:00 P.M., the resident complained of lower back pain, but no bruising
noted. Slight [MEDICAL CONDITION] to the lower back noted, but resident has arthritis and
it is a rainy day, which can cause a flare up;
-On 6/27/18 at 7:45 P.M., the resident requested pain medication for back pain;
-On 6/28/18 at 2:00 P.M., the resident requested pain medication for back pain;
-On 7/2/18 at 2:00 P.M., received a new order to complete an x-ray on the resident’s lower
back due to pain and a previous fall;
-On 7/3/18 at 12:00 P.M., x-ray results showed resident sustained [REDACTED].
Review of the resident’s care plan, last updated on 6/25/18 and in use during the survey,
showed the following:
-Problem: At risk for falls related to [MEDICAL CONDITION] and scoliosis (sideways
curvature of the spine). A hand written note, dated 6/25/18, showed staff found him/her on
the floor, leaning against closet;
-Goal: Resident will remain free from injury for the next 90 days. A hand written note,
showed staff to continue to educate to wait for staff assistance, not reach for things on
his/her own or get out of wheelchair without assistance;
-Approach: Dated 4/26/18, Resident is a high fall risk due to feeling strong and capable,
but his/her legs give out without warning. He/she has been educated on the risk of not
asking or waiting for assistance. He/she has verbalized understanding, but will do it
anyway. Also, resident has his/her own bed and it is high and does not lower. It has been
suggested to use a facility bed. Resident has back problems and his/her bed is special for
his/her condition;
-Staff did not document any other falls sustained by the resident;
-Staff did not document any new interventions.
During an interview on 7/11/18 at 3:30 P.M., the resident said he/she fractured his/her
back in two places. He/she has to stay in bed mostly now. When he/she gets up, he/she can
transfer by himself/herself. He/she now uses the wheelchair to get around, but is doing
therapy and hopes to be able to walk again. He/she knows to use his/her call light, but
sometimes it can take a while to have someone respond.
3. Review of Resident #9’s quarterly MDS, dated [DATE], showed the following:
-Short and long term memory problems;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 7)
-Severely impaired cognitive skills for daily decision making;
-Extensive assistance of staff required for bathing, eating, dressing, personal hygiene
and toileting;
-Incontinent of bowel and bladder;
-One fall since the last assessment;
-[DIAGNOSES REDACTED].
Review of the resident’s care plan, updated 3/22/18 and in use during the survey, showed
the following:
-Problem: Activities of daily living (ADL) functional/rehabilitation potential-ability for
walking with walker has improved, still a high risk for falls related to difficulty when
standing and balance and will not further deteriorate in ability to ambulate with walker
and ability to transfer for next 90 days;
-Approaches: Make sure resident is ambulating with walker, do not rush resident and allow
extra time to complete ADLs, have consistent approach amongst caregivers, instruct use of
walker, provide adequate rest periods between activities, provide standby assistance when
ambulating with walker, report any further deterioration to physician.
Review of the resident’s nurses notes, showed the following:
-6/21/18 at 12:00 P.M., The resident was found on the floor in the dining area on his/her
right side with eyes open, near his/her wheelchair, fully clothed with shoes on. The floor
was free from debris. Passive range of motion performed and within normal limits. Resident
is alert and oriented to self and unable to describe the incident and denied pain or
discomfort. Neuro checks were initiated;
-7/6/18 at 4:40 P.M., the resident was in the dining room ambulating with a walker, lost
his/her balance and sat down on the floor. Staff witnessed the fall, stated the resident
did not hit his/her head and no apparent injuries noted.
Further review of the resident’s care plan showed the falls on 6/21/18 and on 7/6/18 not
documented and no additional interventions added.
4. During an interview on 7/16/18 at 9:30 A.M., the DON said the care plan should reflect
the resident’s current condition and care needs. Any staff member can update the care
plan. Every fall should be listed on the care plan with either a new intervention or the
decision to continue with existing interventions.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to administer
medication as ordered, obtain an order for [REDACTED].#21, #2, #15 and #8). The census was
72 with 20 residents in certified beds.
1. Review of Resident #21’s admission Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated [DATE], showed the following:
-Diagnoses included dementia, stroke and high blood pressure;
-Moderate cognitive impairment;
-Required extensive assistance by staff for all mobility and personal hygiene.
Review of the resident’s medical record, showed the following:
-An admission date of [DATE];
-A signed code status sheet, dated [DATE], showed the resident wished to withhold

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 8)
cardiopulmonary resuscitation (CPR, life saving measures in the even the heart stops
beating);
-A (MONTH) (YEAR) physician order [REDACTED].
-No order for code status;
-An order, dated [DATE], for [MEDICATION NAME] (medication for high blood pressure) 90
milligram (mg) tablet every eight hours;
-A (MONTH) (YEAR) medication administration record (MAR), showed the following:
-an order for [REDACTED].
-No documentation the medication had been given on the mornings of [DATE] through [DATE]
and [DATE] through [DATE];
-No documentation on the back of the MAR to indicate why the medication had not been
administered at those times;
-Review of the resident’s nurse’s notes, showed no documentation to indicate why the
medication had not been administered.
During an interview on [DATE] at 9:30 A.M., the Director of Nursing (DON) said she
expected staff to follow physician orders. If a medication is not given, an explanation
should be provided on the back of the MAR and in the nurse’s notes. If the MAR is blank,
then the medication was not given. The resident’s code status should be on the POS. She
completes regular chart audits.
2. Review of Resident #2’s quarterly MDS, dated [DATE], showed the following:
-Diagnoses included dementia and diabetes;
-Severe cognitive impairment;
-Dependent on staff for mobility and personal hygiene;
-Incontinent of urine.
Review of the POS, dated [DATE], showed an order to administer Z-pak (antibiotic) and take
as directed. No diagnosis listed for the use of the antibiotic.
Review of the POS, dated [DATE], showed an order to administer [MEDICATION NAME]
(antibiotic) 100 milligrams mg twice a day for 10 days. No diagnosis listed for the use of
the antibiotic.
Review of the POS, dated [DATE], showed an order to discontinue [MEDICATION NAME] and
administer [MEDICATION NAME] (antibiotic) 500 mg. twice a day for 10 days. No diagnosis
listed for the use of the antibiotic.
During an interview on [DATE] at 9:30 A.M., the DON said staff should include a [DIAGNOSES
REDACTED].
3. Review of Resident #15’s quarterly MDS, dated [DATE], showed the following:
-[DIAGNOSES REDACTED].>-Severe cognitive impairment;
-Required extensive assistance with all mobility and personal care;
-Incontinent of urine.
Review of the POS, dated [DATE], showed an order to obtain a urinalysis with culture.
Review of the laboratory reports, showed staff did not obtain the specimen until [DATE],
the lab did not receive the specimen until [DATE] and the culture completed on [DATE], at
which time the physician ordered a course of antibiotics to treat a urinary tract
infection
During an interview on [DATE] at 9:30 A.M., the DON said if there is a delay in obtaining
a specimen it could be due to the resident’s resistance to cooperate. She added that
sometimes a resident may refuse care. This should be documented.
4. Review of Resident #8’s admission MDS, dated [DATE], showed the following:
-Short and long term memory problems;
-Severely impaired cognitive skills for daily decision making;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
-Extensive assistance required for dressing, toileting, personal hygiene and bathing;
-Incontinent of bowel and bladder;
-Diagnoses included high blood pressure, diabetes, dementia, anxiety, depression and
[MEDICAL CONDITION] (a-fib, irregular heartbeat).
Review of the resident’s care plan, dated [DATE] and in use during the survey, showed the
following:
-Required a regular diet with finger foods, needed staff assistance with eating and will
maintain current weight;
-Approaches: Make sure resident receives nutritional health shake every day, obtain
dietary consult and follow recommendations, praise for good dietary compliance, provide
with as much control as possible in routines, food preferences and try different food
choices.
Review of the resident’s nutrition progress note, dated [DATE], showed the resident
weighed 150.2 pounds, down 6.6 pounds since readmission (4.25%). Suggestion to add super
cereal (oatmeal fortified with high calorie ingredients) every morning to maximize calorie
intake.
Observations of the resident, showed the following:
-On [DATE] at 8:17 A.M., the resident sat at the dining room table and a plate in front of
him/her contained an omelet, two bacon strips and a donut. The resident ate ,[DATE] of the
donut and drank 100% of a glass of orange juice. Staff did not serve the resident super
cereal;
-On [DATE] at 8:35 A.M., the resident sat at the dining room table with a plate of
scrambled eggs and staff did not serve him/her super cereal.
Review of the resident’s diet card showed he/she received a regular diet and was updated
[DATE], to receive a health shake with meals and at bedtime, with no mention of super
cereal at breakfast.
During an interview on [DATE] at 9:30 A.M., the DON said the registered dietician (RD)
sent recommendations to her by email. The physician should be contacted and if the
recommendation is approved, it became an order and was added to the resident’s diet. She
would look for follow up to the recommendation to add super cereal.
The facility did not provide additional information regarding the RD recommendation as
late as 2:30 P.M. on [DATE].

F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate care for residents who are continent or incontinent of
bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract
infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to provide proper
positioning of a supra pubic (SP, a small rubber tube surgically inserted through the
lower abdomen in to the bladder to drain urine) catheter drainage bag to prevent infection
and failed to obtain orders for the catheter, care of the catheter and the frequency of
which to change the catheter. The facility identified one resident with a SP urinary
catheter (Resident #21) who was chosen as one of 12 sampled residents. The census was 72
with 20 residents in certified beds.
Review of the facility’s undated Suprapubic Catheter Care policy, showed the following:
-Purpose: To prevent skin irritation around the stoma site (small opening for insertion of

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
the catheter) and to prevent infection of the resident’s urinary tract;
-Preparation:
-Review the resident’s care plan to assess for any special needs of the resident;
-Assemble the equipment and supplies as needed;
-General Guidelines:
-Observe the urine level for noticeable increases or decreases. If the level stays the
same, or increases rapidly, report to the supervisor;
-If the resident indicates his/her bladder is full or the need to void, report to the
supervisor;
-Check the urine for unusual appearance (color, blood, etc.);
-The urinary drainage bag must be held or positioned lower than the bladder at all times
to prevent the urine in the tubing and drainage bag from flowing back into the urinary
bladder;
-Check the resident frequently to be sure the tubing is free of kinks;
-Observe the resident for signs and symptoms of a urinary tract infection (UTI, an
infection in any part of the urinary system) and [MEDICAL CONDITION];
-Empty the collection bag at least every eight hours;
Review of Resident #21’s admission Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 6/26/18, showed the following:
-[DIAGNOSES REDACTED].
-Moderate cognitive impairment;
-Required extensive assistance by staff for all mobility and personal hygiene.
Review of the physician order [REDACTED].
-An order dated 7/3/18 to administer [MEDICATION NAME] (antibiotic) 500 milligrams twice a
day for seven days for a UTI;
-No order for a SP catheter, size or care.
During an interview on 7/12/18 at 9:08 A.M., the resident’s spouse said he/she noted the
resident’s urine with a cloudy appearance. He/she asked staff to look into it and a
specimen was obtained. The resident tested positive for a UTI. He/she is not sure staff
are consistently and properly cleaning the site and storing the bag in the appropriate
place. The resident did not have any UTIs when at home. The resident wears a leg bag
(designed to provide discreet storage of urine under clothing and are secured to the leg)
when not in bed. He/she applies the leg bag to the resident’s calf area, but the facility
staff apply it to the resident’s mid to upper thigh. The resident’s catheter was changed
yesterday.
Observation on 7/13/18 at 11:15 A.M., showed the urinary catheter drainage bag hung in a
plastic bag on the bathroom handrail. The uncovered connection port lay across the
drainage bag and the leg bag lay on top of the resident’s right thigh.
During an interview on 7/13/18 at 11:16 A.M., the resident said when he/she is in the
chair, the certified nurse aide (CNA) removes the drainage bag and connects the catheter
to a leg bag. He/she said the CNA always attaches the leg bag to his/her thigh but at home
they connected it to his/her lower leg.
During an interview on 7/13/18 at 11:20 A.M., CNA C said he/she always works a different
hall and this was his/her first day with the resident. He/she said the nurse did not
inform him/her that the resident had a catheter and he/she did not know how to perform
care for that particular kind of catheter.
Observation of the resident on 7/16/18 at 6:55 A.M., showed the resident in bed with
his/her eyes closed. The resident’s catheter drainage bag lay in a privacy bag which
rested directly on the floor.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0690

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 11)
Observation on 7/16/18 at 7:54 A.M., showed CNA D and Certified Medication Technician
(CMT) E washed their hands and donned gloves. Using a wet cloth, CMT E wiped the catheter
from the abdomen to the connection port and removed the drainage bag. With the same cloth,
he/she picked up the leg bag that lay uncapped on the bed, wiped the connection port with
the cloth and connected the port to the catheter. He/she then secured the leg bag to the
right thigh. CNA D took hold of the catheter drainage bag, drained the urine into the
toilet and placed the drainage bag in a plastic bag that hung on the grab bar. He/she did
not cover the connection port. The catheter insertion site to the lower abdomen did not
have a dressing. CNA D nor CMT E cleansed the catheter insertion site.
During an interview on 7/16/18 at 8:05 A.M., CNA D and CMT E said catheter care with a SP
catheter means to cleanse the insertion site with soap and water and leave it open to air.
If it would need a dressing, the nurse does that. They both said the connection port of
the drainage bags need to be covered when not in use.
During an interview on 7/16/18 at 9:30 A.M., the Director of Nursing said urinary catheter
bags should never be allowed to lay on the floor and when not in use, the drainage bag and
leg bag connection ports should be covered with a plastic cover. The connection port
should always be wiped with an alcohol pad prior to connecting to the catheter, not wiped
with a wet cloth. She said it is permissible to wear the leg bag on the thigh when the
resident is seated in a chair because she believed the bag would be below the bladder,
however if the resident is in bed the leg bag should be removed and changed to the gravity
drainage bag. She added that the insertion site should be cleansed daily with soap and
water and if there is any drainage around the site, the nurse should apply a gauze
dressing.

F 0730

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Observe each nurse aide’s job performance and give regular training.

Based on interview and record review, the facility failed to ensure certified nurse
assistants (CNAs) received the required 12 hours of in-service, based on performance
reviews, for five of five employee files reviewed of the CNAs who worked in the facility
more than one year. The facility showed they currently had 13 CNAs who worked in the
facility more than one year. The census was 72 with 20 residents in certified beds.
Review of the staff training records for five randomly sampled CNAs employed for more than
a year, showed the following:
-CNA I, date of hire (DOH) 7/3/01, with 10 hours of in-service education;
-CNA J, DOH 6/26/06, with 10 hours of in-service education;
-CNA K, DOH 1/2/15, with 9.5 hours of in-service education;
-CNA L, DOH 12/18/14, with 10.5 hours of in-service education;
-CNA M, DOH 4/3/17, with 9 hours of in-service education.
During an interview on 7/12/18 at 12:58 P.M., the Director of Nursing said she is
responsible for ensuring the required number of hours are completed. She determines what
the topics are based on what is happening in the building and what will help the staff.
She was not aware topics which did not pertain specifically to resident care could not
count towards the required 12 hours of in-service training.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0761

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure drugs and biologicals used in the facility are labeled in accordance with
currently accepted professional principles; and all drugs and biologicals must be stored
in locked compartments, separately locked, compartments for controlled drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to date insulin
flex pens (pre-filled insulin pens) once opened and failed to discard a vial of outdated
insulin on two of two medication carts for two flex pens and one vial of insulin. The
census was 72 with 20 residents in certified beds.
Review of the facility’s undated insulin pen storage policy, showed the following:
-Store unopened pens in the refrigerator;
-Once in use, mark the flex pen/vial with date of first use and store at room temperature;
-Always be sure the pen has a pharmacy label or resident name written on the pen. Do not
use a pen for more than one resident;
-Refer to insulin properties table or product information sheet for expiration date once
in use.
Review of the facility’s undated Insulin Handling and Storage Policy, showed the
following:
-Discard [MEDICATION NAME] (long acting) insulin 28 days after opening;
-Discard Humalog (rapid acting) insulin 28 days after opening;
-Discard [MEDICATION NAME] (rapid acting) insulin 28 days after opening.
1. Observation of the medication cart on the Meadows/Maple nursing unit on [DATE] at 10:54
A.M., showed the following:
-One undated [MEDICATION NAME] flex pen;
-Two undated Humalog insulin flex pens.
During an interview on [DATE] at 11:00 A.M., Licensed Practical Nurse (LPN) A said we’re
really bad about dating the insulin. He/she added that insulin should to be dated when
opened and thrown away at 30 days.
2. Observation of the medication cart on the Veranda nursing unit on [DATE] at 11:05 A.M.,
showed one vial of [MEDICATION NAME] insulin, dated [DATE], when opened and the written
expiration date read [DATE].
During an interview on [DATE] at 11:20 A.M., Registered Nurse (RN) B said he/she started
at the facility just four days ago but believed insulins were good for 30 days after
opened. If an insulin has expired, it is the nurses responsibility to destroy it.
3. During an interview on [DATE] at 11:00 A.M. the Director of Nursing said insulin vials
and pens are good for 30 days, then she said it really depends on the type of insulin.
When staff open a vial or pen of insulin, they should make sure it has the resident’s name
and date on it. If outdated or not dated, staff should destroy the flex pen/vial and get a
new one.

F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Ensure each resident receives and the facility provides food prepared in a form
designed to meet individual needs.

Based on observation and interview, the facility failed to ensure one of one resident on a
puree diet received food blended to the proper puree consistency. The census was 72 with
20 residents in certified beds.
Observations of the kitchen, showed the following:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0805

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
-On 7/12/18 at 8:40 A.M., Cook N said three residents had puree diets and he/she would
make three servings. Cook N placed 2 cups of cooked cabbage into a blender, added ½ cup of
the liquid from the cooked cabbage and turned the blender on. Cook N said he/she was not
using their usual blender because the blade was broken and a new blade was ordered two to
three weeks ago. Cook N spooned the cabbage from the blender onto three divided plates.
The texture was coarse and not a pudding-like consistency;
-Cook N placed cooked sweet potatoes in the blender, added ½ cup of milk, blended the
mixture, added more milk and continued to blend. Cook N spooned the blended sweet potatoes
on to three divided plates. The texture was not a smooth, pudding consistency and
contained lumps;
-Cook N placed three servings of cooked corned beef in the blender, added juice from the
cooked cabbage, blended, stirred and continued to blend the mixture for approximately 45
seconds. Cook N spooned the corned beef onto the three divided plates. The texture was
very coarse, not smooth and resembled mechanical soft texture.
During an interview while preparing the meal on 7/12/18, Cook N said it was the best we
can do right now because of the blender.
During an interview on 7/12/18 at 9:45 A.M., the Administrator and Dietary Manager (DM)
looked at one of the divided plates that contained the puree mixture and agreed the
texture was not acceptable and could not be served. The Administrator said she had not
heard of any residents having an issue with the puree. Cook N said any meat that is pureed
in the blender would come out like the corned beef.
During an interview on 7/13/18 at 11:00 A.M., the DM said Cook N told him about the
problem with the puree. That is when he ordered the new blade. After the observation on
7/12, they borrowed a blender like the one that was broken from another facility and would
use it until the new blade was received and theirs could be repaired.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

Based on observation and interview, the facility failed to date thawed meat and health
shakes to ensure freshness, for four of four days of the survey. This deficient practice
had the potential to affect all residents who ate at the facility. The census was 72 with
20 residents in certified beds.
1. Observations of the kitchen, showed the following:
-On 7/11/18 at 10:21 A.M. and 4:07 P.M., two boxes sat on a shelf in the walk-in
refrigerator and contained approximately 40 thawed, undated health shakes. Instructions on
the side of each individual carton showed Use within 14 days of thawing;
-On 7/12/18 at 7:09 A.M., the refrigerator in the Meadow kitchenette held a tray with 6
undated health shakes;
-On 7/13/18 at 12:06 P.M., The shelves in the walk-in refrigerator held four undated, 5
pound packages of thawed ground pork sausage, three undated, thawed large pork loins, two
large undated packages of thawed ground beef, two large undated packages of unidentified
thawed meat and at least eight 1 pound packages of undated, thawed bologna;
-On 7/16/18 at 7:27 A.M., 9:30 A.M. and 12:11 P.M., the shelves in the walk-in
refrigerator held four undated 5 pound packages of thawed ground pork sausage, three
undated, thawed pork loins, one large undated and unopened, thawed package of ground beef,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265808

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

07/16/2018

NAME OF PROVIDER OF SUPPLIER

GARDEN VIEW CARE CENTER AT DOUGHERTY FERRY

STREET ADDRESS, CITY, STATE, ZIP

13612 BIG BEND ROAD
VALLEY PARK, MO 63088

For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY
OR LSC IDENTIFYING INFORMATION)
F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 14)
one thawed large package of ground beef that had been opened and rewrapped, but not dated,
at least 8 undated, thawed packages of bologna and one box contained approximately 25 to
30 undated chocolate health shakes.
During an interview on 7/16/18 at 12:15 P.M., the dietary manager (DM) said the meat just
came in and was not frozen when it arrived. This surveyor explained the meat was in the
refrigerator on the previous Friday. The DM then said thawed meat was good for seven days.
The meat should have been dated when it was placed in the walk-in by the staff person who
put stock away. Health shakes arrived frozen and were good for one month.