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Complaint Investigation

Garden View Care Center

November 5, 2025 · O Fallon, MO · 700 Garden Path
Citations 2
CMS Rating 1/5
Beds 80
Provider ID 265321
Healthcare Facility
Garden View Care Center
O Fallon, MO  ·  View full profile →
Inspection Summary

GARDEN VIEW CARE CENTER in O FALLON, MO — inspection on November 5, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

Review of an email communication from the administrator to the state agency on 11/20/25 at 8:44 A.M. and 8:55 A.M., showed she said the facility had a policy with a questionnaire that they would complete if they had two residents who wanted to engage or were attempting on multiple occasions to engage in sexual contact.

The facility would first contact resident families to make them aware and discuss the next steps.

Then, the facility would follow their capacity to consent policy, and the questionnaire would be completed by the social worker on both residents and would be scanned into the resident's electronic medical record. If both residents were deemed to have the capacity to consent, the facility would still call and speak with their power of attorney. If one or both residents were deemed incapable of consenting to sexual activity, then families would be notified, and interventions would be put into place to avoid those residents from attempting to do this.

The questionnaire was put into place about five years ago. In the situation with Resident #11 and Resident #7, BIMS scores (brief interview for mental status, an assessment of cognition function rated from a 0 to 15, where 0 - 7 is severe impairment) were assessed (Resident #11 with a three and Resident #7 unable to assess) to determine if they had the capacity to consent and to determine if the assessment needed to be initiated.

Since neither had the capacity to consent, the assessment form was not initiated, and an immediate discharge was determined as the remedy for Resident #11's inappropriate behaviors.

The facility has not had the occasion to put it into practice because they had not had residents express interest in being sexually active. #2658020

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center

700 Garden Path O Fallon, MO 63366

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited GARDEN VIEW CARE CENTER in O FALLON, MO for a deficiency under regulatory tag F-F0609 during a complaint investigation conducted on 2025-11-05.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of GARDEN VIEW CARE CENTER.

Correction Status: Deficient, Provider has plan of correction.

The facility reported correction as of 2025-12-19.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in O FALLON, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GARDEN VIEW CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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