Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dysphagia was not supervised during meals and was served a whole hot dog, contrary to her mechanically altered diet order. Staff failed to follow care plan interventions and did not document required supervision, resulting in the resident consuming inappropriate foods without monitoring.
Several residents with dysphagia and other nutritional concerns were served foods that did not meet their prescribed mechanically altered or pureed diets, including one resident who was given a whole hot dog instead of a ground version, and others who received lumpy pureed foods or inappropriate snacks. Staff did not consistently verify diet orders or understand the differences between diet textures, leading to the provision of foods that did not align with physician orders or professional standards.
Surveyors identified multiple deficiencies in food storage, preparation, and sanitation, including dirty kitchen equipment, food and condiment packets on the floor, dead insects in storage areas, and a dishwasher that did not reach the required temperature. These issues had the potential to affect most residents who consume food PO.
Surveyors observed that linen carts in multiple units were torn, opened, or not fully covered, leaving linens exposed to potential contaminants. This occurred while several residents were under transmission-based precautions for conditions such as COVID-19, MRSA, ESBL, and Shingles. The Infection Preventionist confirmed the issue during a follow-up tour.
Two residents experienced a lack of dignity in their care, including delayed responses to call lights, staff displaying negative attitudes, and CNAs failing to offer assistance or handling a post-surgical resident roughly despite his requests and reports of pain. The DON acknowledged these issues and agreed that residents were not treated with dignity.
Two residents with cognitive impairment and significant physical limitations did not have their call bells within reach as required by their care plans. Observations showed that the call bells were placed out of reach or on the floor, and staff did not consistently ensure accessibility, despite the residents' dependence on staff for assistance.
Two residents voiced concerns during Resident Council meetings about the poor condition and lack of maintenance of the outdoor patio and courtyard, including issues such as old plants, debris, and safety hazards. Despite these grievances being raised, there was no documentation or follow-up, and observations confirmed the area was not maintained to the same standard as the rest of the grounds, with litter, leaks, and misuse of planters noted.
A resident receiving Seroquel and Oxcarbazepine for mood was not monitored for behaviors as required, despite psychiatric notes indicating the need for such monitoring. The DON confirmed that staff did not document behavior monitoring in the electronic medical record.
Surveyors found that the facility did not accurately complete MDS assessments for three residents by failing to document weights taken within the required 30-day period before the assessment reference date. In some cases, outdated weights were used, and in others, the standard code for missing information was not applied when no recent weight was available. These issues were confirmed by the MDS Coordinator.
Nursing staff did not follow physician orders for wound care for a resident with stage 4 pressure ulcers and osteomyelitis. An LPN cleansed both wounds with Dakin's-soaked gauze instead of using normal saline or wound cleanser and patting dry as ordered. The ADON confirmed the care did not comply with the prescribed wound care protocol.
A resident did not receive appropriate care to maintain or improve ROM or mobility, and the facility did not ensure necessary interventions were provided unless a decline was medically justified.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate. These deficiencies were observed in the care practices for residents requiring assistance with continence management and catheter maintenance.
A resident with severe cognitive impairment and multiple diagnoses had family members, including those designated as POA and HCS, repeatedly request a copy of the admission contract. Despite multiple follow-up emails, the BOM failed to respond or provide the requested records, having forwarded the request to the wrong staff. Staff interviews revealed inconsistent handling and lack of documentation regarding the records request.
Two residents experienced delays in receiving prescribed medications upon admission to the facility. One resident with Type 1 Diabetes did not receive insulin or the antibiotic Zosyn timely, with nearly 24-hour delays due to lack of specific dosing and order confirmation issues. Another resident with Diabetes faced similar delays, with short-acting insulin administered 15 hours after admission and long-acting insulin 21 hours later. The ADON confirmed these delays during interviews.
A resident with severe cognitive impairment and multiple medical conditions developed a pressure injury under a knee immobilizer due to a failure in monitoring skin integrity. The facility's policy required weekly skin assessments, but a 14-day gap occurred, during which the injury developed. Staff were unclear about whether the immobilizer could be removed for skin checks, leading to the oversight.
Failure to Provide Supervision and Appropriate Diet During Meals
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for three of nine sampled residents, specifically in the areas of nutrition and fall prevention. One resident with a history of cerebral infarction, hemiplegia, severe cognitive impairment, and dysphagia was not supervised during meals as required by her care plan. Despite being on a mechanically altered diet due to swallowing difficulties, she was served a whole hot dog by a CNA, which she consumed without staff supervision. The resident had also previously been given inappropriate foods such as potato chips and Goldfish crackers by staff, contrary to her dietary requirements. Observations and record reviews revealed that the resident's care plan and physician orders specified the need for a mechanically altered diet and supervision during meals to monitor for signs of aspiration or choking. However, documentation in the electronic medical record showed no evidence of supervision being provided during meals over a two-week period. During direct observation, the resident was left alone with her meal and was not monitored by staff, even when she was offered and consumed foods not consistent with her prescribed diet. Interviews with staff confirmed that the CNA provided the resident with a whole hot dog and did not ensure it was prepared according to the resident's dietary needs. The dietary manager was unaware that the hot dog was for this resident and confirmed that no ground hot dogs were prepared that day. Further, the resident was observed eating without supervision on another occasion, and staff interviews indicated a lack of adherence to protocols for verifying diet orders and providing required supervision during meals.
Failure to Provide Foods in Appropriate Texture for Residents with Swallowing Disorders
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents with swallowing difficulties and other nutritional concerns. Four out of five sampled residents were affected, including individuals with diagnoses such as dysphagia, cerebral infarction, malnutrition, and muscle weakness. In one instance, a resident with severe cognitive impairment and a physician-ordered mechanically altered diet was served and consumed a whole hot dog, which was not prepared according to her dietary requirements. Staff involved did not verify the appropriateness of the food texture, and the kitchen did not prepare the hot dog in the required ground form, despite the menu specifying a ground hot dog for those on mechanically altered diets. Additionally, staff provided this resident with snacks such as potato chips and Goldfish crackers, which were not suitable for her prescribed diet. Other residents on pureed diets were observed receiving foods that did not meet the required texture standards. One resident received soup containing whole grains of rice and intact corn kernels, and another was served pureed foods that were lumpy and not homogenous, as required for a pureed diet. Observations in the kitchen confirmed that some pureed foods, such as baked ham, were not consistently smooth and contained small lumps. Staff interviews revealed a lack of understanding regarding the differences between diet textures and the importance of matching meal tickets and physician orders. The facility's policies and professional standards, including those from the National Dysphagia Diet Task Force and the International Dysphagia Diet Standardization Initiative, were not consistently followed. There were discrepancies between diet orders in the electronic medical record and the meal ticket software, leading to confusion among staff. Staff members were not always aware of the specific dietary needs of residents or the consequences of serving inappropriate food textures, resulting in the provision of foods that posed a risk to residents with swallowing difficulties.
Deficient Food Storage, Sanitation, and Equipment Maintenance in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and sanitation practices. During a tour of the main kitchen, the reach-in cooler was found to have gaskets with dark brown/black streaks and spots, and the bottom of the gasket was torn with pieces of rubber hanging down. In the dry food storage area, a bag of pasta was found on the floor behind the lowest shelf, and two large dead insects were observed on the floor, one near the pasta and another under the area where cookies were stored. A yellow condiment packet was also found on the floor. Muffin pans and the storage rack for clean serving scoops and baking sheets were noted to have brown, yellow, and black residues, and the baking sheets themselves had visible residue as well. Additionally, the low-temperature dishwasher did not reach the required wash cycle temperature of 120°F, only reaching 100°F. The Vulcan fryer contained food residue and was not clean at the time of inspection. The CDM confirmed these findings during the tour. These deficiencies had the potential to affect 63 out of 66 residents who consume food by mouth.
Improper Storage of Linens Exposes Linens to Contamination
Penalty
Summary
The facility failed to ensure the proper storage of linens in three out of three observed linen carts. On the day of the survey, four residents were under transmission-based precautions for conditions including COVID-19, MRSA, ESBL, and Shingles. During multiple observations, linen carts in the [NAME] Wing, East Wing, and North Unit were found to be either torn, opened, or not fully covered, resulting in exposed linens. Additionally, a glove was found on the floor next to one of the linen carts. The Infection Preventionist acknowledged that the linen carts were torn and uncovered, which exposed the linens to potential contaminants.
Failure to Maintain Resident Dignity During Care and Assistance
Penalty
Summary
Two residents were not provided care and services in a manner that maintained their dignity. One resident, who was cognitively intact, reported that when using the call light for assistance, it sometimes took over 30 minutes for staff to respond. Upon arrival, staff would occasionally tell her she would have to wait because they were busy, and some staff appeared to be stressed or had negative attitudes. The resident expressed that this treatment made her feel disrespected and not good. The DON agreed that this did not reflect dignified treatment. Another cognitively intact resident described two incidents where he felt disrespected by CNAs. In one instance, a CNA watched him struggle to pick up an item from the floor without offering assistance. In another, during ADL care, the resident, who had a recent hip surgery, reported being handled roughly by CNAs who did not allow him time to move at his own pace and grabbed his surgical hip area, causing pain. Despite informing the CNAs of his pain, they continued without adjusting their approach, and their facial expressions did not change, making the resident feel unheard. The DON was not previously aware of these complaints but stated that CNAs should handle all residents gently, regardless of surgical history.
Failure to Maintain Call Bell Accessibility for Cognitively Impaired Residents
Penalty
Summary
The facility failed to maintain the call bell within reach for two residents who were cognitively impaired and required significant assistance with activities of daily living. For the first resident, who had diagnoses including non-Alzheimer's dementia, muscle weakness, and a history of polio, the care plan specifically required the call bell to be within reach due to her dependence on staff for most ADLs. Observations revealed that the call bell was placed out of her reach, coiled above her right shoulder, and later found on the floor. The resident expressed that she needed the call bell within reach and had needed help in recent days. Staff entered the room but did not ensure the call bell was accessible, only noticing and correcting the issue after it was pointed out. The second resident, who had renal insufficiency, diabetes, hemiplegia, and muscle weakness, also had a care plan intervention requiring a reachable call bell. During interviews and observations, the resident was unable to locate her call bell, which was found dangling between the mattress and the floor, and later behind the bed close to the wall. The resident stated she did not know where her call bell was and agreed it would be beneficial to have it within reach. These findings demonstrate that staff did not consistently follow care plan interventions to ensure the call bell was accessible to residents who were dependent on staff for assistance.
Failure to Address Resident Grievances Regarding Patio Maintenance
Penalty
Summary
The facility failed to promptly address grievances voiced by two cognitively intact residents regarding the condition of the outdoor patio and courtyard area. One resident reported making recommendations during Resident Council meetings about improving the patio with additional plants and mulch, noting that the concern was voiced approximately five months prior but no action had been taken. The resident stated that the issue was documented but not followed up on. Another resident agreed with these concerns, adding that the outdoor area was not maintained as it used to be, with old plants, fallen debris on walkways, and safety concerns about tripping hazards. Both residents indicated that the issue had been raised during Resident Council meetings, but there was no documentation of the concern in the meeting minutes for the relevant period. Observations of the patio and courtyard area revealed several maintenance issues, including areas of dirt and rocks with minimal vegetation, litter such as milk cartons and used masks, and a planter being used as a trash receptacle. The roof over the screened patio was noted to have several leaks, and trees and shrubbery were growing out of the overhanging awning. Staff interviews confirmed that residents had voiced concerns about the patio needing improvement and that the area was not maintained to the same standard as the rest of the facility grounds. The Maintenance Director acknowledged the misuse of the planter and the overall poor condition of the patio area.
Failure to Document Behavior Monitoring for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure proper behavior monitoring for a resident who was prescribed psychotropic medications, specifically Seroquel and Oxcarbazepine, both administered twice daily for mood management. Record review showed that although psychiatric progress notes documented the need to monitor for agitation, aggression, combativeness, refusal of care, refusal of medications, and symptoms of depression, there was no evidence of staff behavior monitoring documented in the resident's record. During an interview, the DON confirmed that nurses are expected to document behaviors on behavior monitoring forms in the electronic medical record, but acknowledged that such documentation was missing for this resident.
Inaccurate MDS Weight Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three out of five sampled residents in relation to their nutritional status, specifically regarding the documentation of resident weights. According to the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) guidelines, the most recent weight within 30 days of the Assessment Reference Date (ARD) should be used for MDS entries. In the case of one resident with multiple diagnoses including malnutrition and dementia, the MDS recorded a weight from a week prior to the ARD, despite a more recent weight being available on the ARD itself. The MDS Coordinator confirmed that the incorrect, earlier weight was entered instead of the most current one. For two other residents, the MDS assessments documented weights that were not obtained within the required 30-day window prior to the ARD. In one instance, the weight entered was from 41 days before the ARD, and there were no documented weights within the appropriate timeframe. The correct procedure, as outlined in the RAI manual, would have been to use the standard code for no information and document the rationale in the medical record. In the third case, the weight recorded in the MDS was from several months prior to the ARD, again not meeting the 30-day requirement. These findings were confirmed through interviews with the MDS Coordinator, who acknowledged the discrepancies.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
Nursing staff failed to follow physician orders for wound care for a resident with a history of osteomyelitis and two stage 4 pressure ulcers, one located on the right buttock and the other on the left hip. The facility's wound treatment management policy requires that wound treatments be provided in accordance with physician orders, specifying the cleansing method, type of dressing, and frequency of dressing change. Physician orders for this resident directed staff to cleanse both pressure ulcers with normal saline or wound cleanser, pat dry, apply wet to dry gauze with Dakin's solution at 1/4 strength, and secure with bordered gauze daily. During an observed wound care session, an LPN cleansed both wounds using Dakin's-soaked gauze, rather than following the prescribed method of cleansing with normal saline or wound cleanser and then patting dry before applying the Dakin's solution. The Assistant Director of Nursing confirmed that the wound care provided did not adhere to the physician's orders as required by facility policy.
Failure to Provide Care to Maintain or Improve Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that the resident received necessary interventions to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. This deficiency was based on observations and findings that the required care and services to address the resident's ROM or mobility needs were not provided as expected.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care practices for residents requiring assistance with bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Timely Respond to Resident Record Requests
Penalty
Summary
The facility failed to respond in a timely manner to requests for a resident's records, specifically for a resident with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression. The resident's family, including individuals designated as Power of Attorney (POA) and Health Care Surrogates (HCS), made multiple attempts to obtain a copy of the admission contract, which they did not possess and did not recall signing. Despite repeated requests via email to the Business Office Manager (BOM), there was no documented response or provision of the requested records. The BOM acknowledged forwarding the request to the wrong staff members and did not provide a rationale for failing to respond to the family's emails. Interviews with facility staff revealed inconsistent awareness and handling of the records request. The Medical Records Clerk described a process for handling such requests but had no documentation of receiving or processing the family's requests. The Administrator stated there were no requests from the family and cited restrictions on releasing records to individuals not designated as POA or HCS, despite evidence that the requests came from appropriately designated family members. Email records confirmed multiple follow-up attempts by the family, with no timely or appropriate response from the facility.
Delayed Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure the timely provision of medications for two residents upon their admission. Resident #1, who was admitted with Type 1 Diabetes, did not receive insulin or the antibiotic Zosyn as prescribed. The hospital discharge paperwork for Resident #1 lacked specific insulin dosing, which required clarification from the physician. Despite an order for Novolog FlexPen being entered by the pharmacy, it was not confirmed by nursing staff until 14 hours later, resulting in a delay of nearly 24 hours before insulin was administered. Similarly, the antibiotic Zosyn was not administered until nearly 24 hours after admission, with no documented reason for the delay. Resident #2, also admitted with Diabetes, experienced a delay in receiving insulin. The pharmacy ordered a substitute for the prescribed insulin due to insurance coverage, but the nursing staff did not confirm the order until 15 hours after admission, delaying the first dose of short-acting insulin. The long-acting insulin was also delayed, with the first dose administered 21 hours after admission. The Assistant Director of Nursing confirmed these delays during interviews, acknowledging the lack of timely medication administration for both residents.
Failure to Monitor Skin Under Immobilizer Leads to Pressure Injury
Penalty
Summary
The facility failed to assess a resident's skin under a knee immobilizer, leading to the development of a pressure injury. The resident, who was transferred from a hospital with a left knee immobilizer due to a fracture, was not properly monitored for skin integrity under the immobilizer. The facility's policy required weekly skin assessments, but there was a 14-day gap between documented assessments, during which a pressure injury developed. Staff interviews revealed confusion about whether the immobilizer could be removed for skin checks, with some CNAs stating they were told not to remove it, while others indicated they would follow orders regarding its removal. The resident had a severe cognitive impairment and multiple medical conditions, including a fracture of the lower end of the left femur, pleural effusion, and chronic obstructive pulmonary disease. The pressure injury was discovered after drainage was noticed on the resident's linen. The Director of Rehabilitation stated that the immobilizer could be removed for skin care unless there were specific orders not to do so. The resident's physician confirmed that the pressure injury was preventable and emphasized the importance of checking skin integrity and circulation under immobilizers, which he assumed was standard practice for the nursing staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 50 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vero Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hidden Lakes Senior Living Community | 0.8 mi | ★★★★★ | 12 | 0 |
| Sea Breeze Rehab And Nursing Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Vero Beach Care Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Palm Garden Of Vero Beach | 1.4 mi | ★★★★★ | 3 | 0 |
| Willowbrooke Court At Indian River Estates | 5.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Garden View Health And Rehabilitation Center.
100% money-back within 48 hours.
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.