Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden View Care Center Of Chesterfield during CMS and state inspections, most recent first.
The facility failed to follow its falls protocol by not completing and documenting required neuro checks, fall evaluations, fall risk assessments, skin evaluations, and 72-hour incident follow-up (IFU) monitoring after multiple resident falls. In several cases, residents with significant cognitive and physical impairments fell, some hitting their heads and sustaining lacerations and fractures, yet neuro checks were either not done or not fully documented, and IFU notes were missing on multiple shifts over several days. These lapses occurred despite facility policy and leadership expectations that unwitnessed falls or head strikes trigger 72 hours of neuro checks and shift-by-shift IFU documentation.
Two residents who were unable to perform their own ADLs did not receive timely incontinence care, resulting in prolonged exposure to urine-soaked briefs and clothing. Staff failed to follow infection control protocols during perineal care, including improper hand hygiene and glove changes, and did not thoroughly clean all affected skin areas. Both residents had significant medical conditions and were at risk for skin breakdown, with staff interviews confirming lapses in care frequency and infection prevention.
A resident with multiple risk factors for skin breakdown did not receive consistent pressure ulcer care, as weekly wound assessments and documentation were missing or incomplete, and wound care orders were not always present. Observations showed improper infection control and wound management by a CNA, including applying barrier cream with soiled gloves to an open wound. Staff interviews confirmed that required protocols for assessment, documentation, and notification were not followed.
The facility's admission policy required residents to waive liability for personal belongings, such as clothing and jewelry, unless deposited with management for safekeeping. This policy, developed by the facility's corporate attorney, was provided to all residents, potentially affecting all 84 residents, including 46 in certified beds. The Admissions Coordinator was unaware of this requirement, and administrators acknowledged the need for corporate review.
The facility failed to maintain hot water temperatures within the safe range of 105 to 120 degrees Fahrenheit in resident rooms and common areas. Observations revealed that water temperatures exceeded the maximum allowable temperature, reaching as high as 129 degrees Fahrenheit. The Maintenance Director acknowledged the difficulty in regulating the temperature due to the boiler gauges and the need for higher temperatures in the kitchen. Despite daily checks, the facility did not ensure effective regulation of water temperatures, leading to the deficiency.
The facility failed to ensure all CPR-certified staff received certification through a provider with hands-on practice and in-person skills assessment. During a review, it was found that 12 out of 21 shifts had issues with CPR certification, with the DON often being the only certified staff. The DON and other staff obtained CPR certification through an online-only provider, contrary to facility policy.
The facility failed to maintain resident dignity during feeding assistance, as staff stood over two residents with cognitive impairments while feeding them, rather than sitting at eye level. The staff engaged in conversations with each other instead of focusing on the residents, and did not ensure that the residents had swallowed their food before offering the next bite. Interviews confirmed the importance of sitting next to residents to maintain dignity and proper engagement.
A facility failed to follow physician orders for a resident's oxygen therapy, leading to inconsistent oxygen rates being administered. The resident, with moderate cognitive impairment and multiple diagnoses, received varying oxygen levels from 3.5 L to 5 L, instead of the ordered 4 L. Staff interviews revealed confusion about the correct rate, and the care plan did not address the resident's respiratory needs.
The facility failed to maintain an accurate system for recording controlled drugs, with multiple missed narcotic counts and lack of adherence to procedures. Despite a policy requiring shift change counts, discrepancies persisted, as confirmed by staff interviews.
The facility failed to provide quality laboratory services by allowing expired supplies, including blood sugar control solutions and COVID-19 test kits, to remain in use. The DON confirmed the expired items and removed them, while the Administrator expected staff to follow policies regarding expiration checks.
Failure to Complete Neuro Checks and 72-Hour Post-Fall Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with its own falls protocol and acceptable standards of practice following resident falls. The facility’s Falls Clinical Protocol required nurses to assess and document vital signs, recent injury (especially head injury), musculoskeletal function, cognition/level of consciousness, neurological status, pain, fall history, precipitating factors, medications, and diagnoses, and to identify falls as witnessed or unwitnessed. The protocol also required completion of incident reports, skin evaluations, fall risk assessments, neurological checks (neuro checks) for unwitnessed falls or when a resident hit their head, and incident follow-up (IFU) monitoring with documentation each shift for 72 hours post-fall. Interviews with the RN, Administrator, and DON confirmed that neuro checks and IFU documentation were expected for 72 hours after such falls, and that staff were expected to follow these policies. For one resident with a history of stroke, hemiplegia, and a prior thoracic spine fracture, who was cognitively intact and dependent on staff for transfers, the facility failed to complete required post-fall assessments and monitoring after two separate falls. In the first fall, the resident fell from the edge of the bed while being assisted by a CNA, hit the head on the floor, and sustained a forehead hematoma and laceration requiring hospital evaluation and sutures. After the resident returned from the hospital, neuro checks were initiated, but the neurological flow sheet showed blank entries for both day and evening shifts on a later date, and progress notes showed missing IFU documentation on multiple shifts over several days. In the second fall, the resident was found on the floor beside the bed after reportedly falling from a Broda chair, with a hematoma to the left forehead and no other immediate complaints. The record showed no skin evaluation, no fall risk evaluation, and no neuro checks completed after this fall, and progress notes lacked IFU documentation for multiple consecutive shifts following the incident. For a second resident with severe cognitive impairment, multiple sclerosis, altered mental status, hypertension, and dementia, who was dependent for transfers and had a documented prior fall, the facility again did not follow its fall protocol. After this resident was found on the floor next to the bed, having stated they fell while reaching for something on the bedside table, the medical record contained no documentation of neuro checks following the fall. Additionally, progress notes for several subsequent shifts over multiple days contained no IFU notes documenting post-fall monitoring. A third resident with severe cognitive impairment and diagnoses including dementia, hypertension, diabetes, kidney disease, and depression experienced a fall from the bed during in-bed care, resulting in multiple skin tears to both upper extremities and a laceration to the forehead, with EMS called and the resident sent out. When the resident returned with a nasal fracture, sutures to the eyebrow area, and skin tears with dressings, the progress notes again showed no IFU documentation on multiple shifts over several days. These documented omissions demonstrate repeated failures to complete and document required neuro checks, fall evaluations, fall risk assessments, skin evaluations, and 72-hour IFU monitoring after falls for multiple residents.
Failure to Provide Timely Incontinence Care and Adhere to Infection Control During Perineal Care
Penalty
Summary
Facility staff failed to provide timely and appropriate incontinence and perineal care to two residents who were unable to perform their own activities of daily living. Both residents were observed to have a noticeable odor of urine and were found in heavily urine-soaked briefs and clothing. Staff did not check or change these residents at least every two hours as required by the care plans and facility policy, resulting in prolonged exposure to moisture and soiled garments. Direct observations revealed that certified nursing assistants (CNAs) did not follow proper infection control procedures during perineal care. Staff were seen donning gloves without sanitizing their hands, failing to change gloves and sanitize hands when moving from dirty to clean tasks, and applying barrier creams with soiled gloves. In some instances, staff left the resident’s room with dirty gloves and linens, further breaching infection prevention protocols. The perineal care provided did not include thorough cleaning of all areas exposed to urine, such as the genitals, buttocks, and thighs, as required by facility policy and in-service training. The residents involved had significant medical histories, including severe cognitive impairment, mobility deficits, incontinence, and risk factors for pressure ulcers and skin damage. One resident was dependent on staff for all ADLs and had existing moisture-associated skin damage, while the other required maximum assistance and was at risk for pressure ulcers. Staff interviews confirmed that care was not provided as frequently as required, and that infection control practices were not consistently followed, placing residents at risk for further skin breakdown and infection.
Failure to Provide Consistent Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide pressure ulcer care consistent with professional standards of practice for a resident with significant risk factors, including severe cognitive deficiency, impaired mobility, incontinence, and multiple comorbidities such as diabetes, heart failure, and kidney disease. The resident developed a pressure ulcer on the right buttocks, but there was inconsistent documentation and assessment of the wound. Weekly skin and wound assessments were either missing or incomplete, and there was no evidence of timely or thorough evaluation and documentation of the pressure ulcer's status, as required by facility policy and national guidelines. Orders for wound care and assessments were not consistently present in the resident's records, and documentation from the outside wound care company was not uploaded into the electronic medical health record as expected. Direct care observations revealed further deficiencies in wound management and infection control. During incontinence care, a CNA failed to sanitize hands before donning gloves and used soiled gloves to apply barrier cream directly to the resident's open coccyx wound, which was not covered with a dressing. The CNA acknowledged that this practice risked cross-contamination and infection and that open wounds should be reported to a nurse for appropriate treatment, not managed by CNAs. The resident was noted to have a strong odor of urine and a heavily soiled brief, indicating inadequate incontinence management, which is a known risk factor for pressure ulcer development and deterioration. Interviews with staff and the administrator confirmed that nurses were expected to complete and document weekly skin and wound assessments, notify the physician and responsible parties of changes, and administer wound treatments per orders. However, these expectations were not met, as evidenced by missing documentation, lack of timely notification, and improper wound care practices. The administrator also stated that CNAs should not apply treatments to pressure ulcers and should report skin issues to nurses, but this protocol was not followed in practice.
Facility Admission Policy Requires Waiver of Liability for Personal Belongings
Penalty
Summary
The facility failed to ensure its admission policy did not require residents or potential residents to waive potential facility liability for losses of personal property. This deficiency was identified during a review of the facility's admission policy, which was last reviewed on January 9, 2025. The policy stated that the facility would not be responsible for personal belongings such as clothing, jewelry, money, or other valuables unless they were deposited with management for safekeeping. The policy also included a waiver of liability for personal belongings, which residents or their responsible parties were required to acknowledge and agree to upon admission. Interviews with the Admissions Coordinator and the facility's administrators revealed that all residents were provided with the same admission policy, regardless of their payor source. The Admissions Coordinator was unaware that the policy required residents to waive the facility's liability for lost personal items. The administrators acknowledged that the policy was developed by the facility's corporate attorney and agreed that the verbiage should be reviewed by corporate. This deficient practice had the potential to affect all residents, with a sample size of 12 and a census of 84, including 46 in certified beds.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within the safe range of 105 to 120 degrees Fahrenheit in resident rooms and common areas accessible to residents. Observations conducted on various dates revealed that the water temperatures in multiple locations, including resident bathrooms and common areas, exceeded the maximum allowable temperature, reaching as high as 129 degrees Fahrenheit. This was contrary to the facility's policy, which mandates that water temperatures should not exceed 120 degrees Fahrenheit to prevent scalding. The observations were made using calibrated digital thermometers, and the high temperatures were consistent across different rooms and units within the facility. The Maintenance Director acknowledged the difficulty in regulating the water temperature due to the tricky nature of the boiler gauges and the need for higher temperatures in the kitchen. Despite daily checks and logs of water temperatures, the facility failed to ensure that the mixing valves effectively regulated the water temperature before distribution throughout the facility. Interviews with the Maintenance Director and the facility's administration revealed that the water temperature checks were conducted weekly, with different areas being audited each time. However, the method of obtaining water temperatures was expected to be consistent, and the temperatures should not exceed 120 degrees Fahrenheit to prevent residents from burning themselves. Despite these expectations, the facility did not adequately control the water temperatures, leading to the deficiency noted in the report.
Deficiency in CPR Certification Compliance
Penalty
Summary
The facility failed to ensure that all staff certified in cardiopulmonary resuscitation (CPR) received their certification through a provider whose training includes hands-on practice and in-person skills assessment. During a review of one week of staff CPR certification, it was found that 12 out of 21 shifts had issues with CPR certification. The facility's policy required key clinical staff to obtain and maintain CPR certification through the American Red Cross or American Heart Association, which includes hands-on practice. However, the Director of Nurses (DON), a Registered Nurse (RN), and a Certified Medication Technician (CMT) had obtained their CPR certifications through an online-only provider. The facility's staffing sheets revealed that on multiple occasions, the DON was the only CPR-certified staff scheduled, and on some shifts, the DON and CMT were the only certified staff. Interviews with the DON and the Administrator revealed a lack of awareness that CPR certification must include hands-on practice and in-person skills assessment. The Administrator mentioned that the facility was in the process of connecting with a new provider for CPR certification, as their previous provider was no longer offering the certification.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect during feeding assistance. Observations revealed that an Activities Assistant (AA) stood over two residents while feeding them, rather than sitting at eye level, which is considered a dignity issue. The AA engaged in conversation with other staff members instead of focusing on the residents, and did not ensure that the residents had swallowed their food before offering the next bite. This behavior was observed with two residents who required feeding assistance due to conditions such as aphasia, Alzheimer's disease, and dementia. Interviews with staff, including a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN), confirmed that the residents were confused and required assistance with eating. The staff acknowledged that sitting next to residents during feeding is important for maintaining dignity and ensuring proper engagement. The facility's Administrator and Director of Nurses (DON) also stated that staff should be seated to observe residents' ability to chew and swallow, regardless of cognitive status, and should engage with residents during feeding assistance.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that respiratory services provided to a resident were consistent with professional standards of practice. Specifically, staff did not adhere to the physician's orders regarding the rate of oxygen for a resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer's disease, respiratory failure, stroke, and high blood pressure. The resident's care plan did not address their respiratory care needs, and there were discrepancies in the oxygen rate administered, which varied from 3.5 L to 5 L, contrary to the physician's order of continuous oxygen at 4 L. Interviews with staff revealed a lack of consistency and understanding regarding the correct oxygen rate, with different staff members providing conflicting information. The CNA and RN interviews highlighted that the oxygen rate should follow the physician's orders, and deviations could have harmful effects. The Director of Nursing and the Administrator confirmed that the expectation was for staff to follow physician orders and facility policies for oxygen therapy, indicating a failure in adherence to these protocols.
Inadequate Narcotic Reconciliation System
Penalty
Summary
The facility failed to establish a comprehensive system for recording the receipt and disposition of controlled drugs, leading to inaccuracies in narcotic reconciliation. The facility's policy required nursing staff to count controlled medications at the end of each shift, with both the oncoming and off-going nurses responsible for initialing the narcotic count book. However, a review of the narcotics book for the Magnolia/Aspen unit revealed multiple instances where the required shift change counts were not completed. Specifically, there were two missed counts for the 7 A.M. - 3 P.M. shift and five missed counts for the 11 P.M. - 7 A.M. shift. Additionally, on one occasion, there were no nurse signatures for the 11 P.M. - 7 A.M. shift. Interviews with staff highlighted a lack of adherence to the established procedures. A registered nurse acknowledged that the process for counting narcotics was not consistently followed, and the Director of Nursing (DON) confirmed that there had been ongoing issues with narcotic counts between shifts. Despite implementing a new process to count the number of packages at shift changes, discrepancies persisted. The facility's administrator expressed an expectation for nursing staff to adhere to the policy, but the report indicates that this expectation was not met, resulting in the deficiency.
Expired Laboratory and Medication Supplies Found in Facility
Penalty
Summary
The facility failed to ensure the provision of timely and quality laboratory services to meet the needs of its residents. This deficiency was identified through observation, interview, and record review, revealing that the facility did not maintain quality control over laboratory supplies and medication administration items. Specifically, the facility had expired Assure Dose Control Solution, which is used to calibrate blood sugar testing machines, as well as expired InteliSwab and BinaxNow COVID-19 rapid test kits. Additionally, other expired items such as OcuSoft Lid Scrub and alcohol prep pads were found in the nurse's medication cart. The Director of Nursing confirmed the presence of these expired items and removed them from the cart, acknowledging that expired supplies should not be left in the medication carts. The facility's policy mandates that all drugs and biologicals be stored safely and securely, and that expired items should be returned to the dispensing pharmacy or destroyed. The Administrator expressed an expectation that staff adhere to facility policies, which include checking expiration dates before administering medications or tests.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chesterfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delmar Gardens Of Chesterfield | 0.8 mi | ★★★★★ | 0 | 0 |
| Mason Pointe Care Center | 1 mi | ★★★★★ | 0 | 0 |
| Delmar Gardens West | 1 mi | ★★★★★ | 0 | 0 |
| Friendship Village Chesterfield | 1.2 mi | ★★★★★ | 1 | 0 |
| Westchester House, The | 1.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.