Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Valley Retirement Village during CMS and state inspections, most recent first.
Dietary staff did not consistently use or have access to standardized recipes when preparing pureed meals for four residents, resulting in food being prepared without proper guidance for nutritional value, portion size, or palatability. Staff relied on their own judgment for measurements and serving sizes, and there was confusion about the number of pureed portions needed. The facility's policy required standardized recipes for all menu items, but this was not followed.
A resident with multiple complex medical conditions and a recent amputation did not have her discharge needs identified or an appropriate discharge plan created. Despite her clear desire to return to the community and significant barriers to safe discharge, there was no documentation of social service notes, progress notes, or a discharge plan. Staff confirmed that discharge planning and documentation were not completed as required.
A resident with a history of muscle weakness and impaired mobility did not receive ongoing support to maintain ambulation after discharge from PT. Despite documented ability to ambulate short distances with assistance, there was no evidence of a restorative or walking program, and staff were unclear about responsibilities for ambulation. The care plan lacked instructions for ambulation, and communication between therapy and nursing was insufficient, resulting in the resident not receiving services needed to maintain ADL abilities.
A resident who was dependent on staff for personal hygiene and had a care plan directing regular shaving was observed over several days with prominent, unshaven facial hair, despite expressing a preference to be clean shaven and being unable to shave independently. Staff interviews indicated shaving was done on shower days or by request, but the resident remained unshaven until several days later, demonstrating a failure to provide timely ADL care.
A resident with dementia and hemiparesis experienced multiple falls, some with injury, due to the facility's failure to consistently implement and update fall prevention interventions. Required safety measures such as Dycem pads and brake extenders were not always in place on the resident's wheelchair, and staff did not reliably document or follow through on therapy orders or adapt interventions to the resident's worsening cognitive impairment.
A resident with a PICC line did not receive a dressing change every five days as ordered, and the IV antibiotic administered was not labeled with required information. Documentation of the dressing change was missing, and staff confirmed the dressing was overdue and the medication bag was unlabeled.
A resident with vascular dementia and major depressive disorder experienced a breakdown in medication management when staff failed to promptly implement and document provider orders following a consultant pharmacist’s medication review. Conflicting documentation, lack of staff understanding of the medication review process, and unclear facility policies led to confusion over dose changes for an antidepressant, placing the resident at risk of unnecessary medication use.
Failure to Use Standardized Recipes for Pureed Diets
Penalty
Summary
The facility failed to provide food prepared in accordance with standardized recipes for four residents on pureed diets. Observations revealed that dietary staff did not have access to or did not use recipes for pureed menu items, including Orange Chicken, Lo Mein noodles, and apple pie. Staff members confirmed they could not find the necessary recipes and sometimes relied on their own judgment for preparation and portion sizes. During meal preparation, staff pureed apple pie using a recipe intended for apple crisp and did not follow measurement guidelines, instead pouring apple juice directly from the container. The temperature of the pureed apple pie was recorded at 80 degrees, and there was confusion among staff regarding the correct serving size for desserts. Interviews with dietary staff indicated that recipes were not always used to ensure proper nutritional value or portion sizes for residents on pureed diets. One staff member reported not always using recipes and relying on usual serving amounts. Additionally, there was a discrepancy in the number of pureed desserts prepared, as only three portions were plated for four residents, with the explanation that one resident was transitioning to a regular diet. The facility's policy required the use of standardized recipes for all menu items, including pureed and therapeutic diets, but this was not consistently followed.
Failure to Develop and Document Discharge Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that the discharge needs of a resident were identified and that an appropriate discharge plan was created. The resident, who had a complex medical history including a recent surgical amputation, acute osteomyelitis, cellulitis, morbid obesity, COPD, muscle weakness, unsteadiness, a Stage 4 pressure ulcer, venous insufficiency, peripheral vascular disease, and hypertension, required substantial to maximum assistance with activities of daily living. Despite her cognitive intactness and clear communication of her desire to return to the community, the facility did not document a comprehensive discharge plan or progress notes addressing her needs and preferences for discharge. The resident expressed significant concerns about her ability to live independently, including financial limitations, housing challenges, and the need for her support animal. She reported that no one at the facility was assisting her with discharge arrangements, and she was not provided with information about when Medicare coverage would end. The resident also stated that she would leave the facility against medical advice if necessary, as she could not afford to remain once Medicare stopped paying. She indicated that her previous living situation required repairs and that she faced barriers to public housing due to her criminal record and the presence of her service animal. Interviews with facility staff confirmed that discharge planning documentation was lacking. The social services staff member responsible for discharge planning acknowledged that there were no social service admission notes, progress notes, or a documented discharge plan in the resident's record. The administrator confirmed that discharge planning should begin at admission and be updated regularly, but was unaware that this had not occurred for the resident. The facility's discharge policy did not address the discharge planning process, contributing to the lack of appropriate planning and documentation.
Failure to Maintain Resident's Ambulation and ADL Abilities Post-Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received services to maintain their abilities in activities of daily living (ADL). The resident had a history of right shoulder dislocation, muscle weakness, and unsteady gait, and was documented as having intact cognition. Assessments indicated the resident was dependent on staff for most ADLs but was independent with wheelchair mobility. Physical therapy records showed the resident participated in gait training and was able to ambulate short distances with assistance, with a goal to increase ambulation distance. However, after discharge from therapy, there was no evidence in the electronic health record of a formal or informal walking or restorative program to maintain the resident's ambulation abilities. Observations and interviews revealed that the resident expressed a desire to continue therapy and questioned why it had been discontinued. Staff interviews indicated confusion regarding who was responsible for restorative care and ambulation, with some staff unaware of the resident's ambulation abilities or care plan requirements. The care plan lacked specific instructions for staff to ambulate the resident, and staff reported only performing such activities if directed by the care plan. Therapy staff stated that recommendations for maintaining function were typically communicated to nursing, but in this case, nursing staff reported not receiving any such recommendations after therapy discharge. The facility's policy required providing care and services to maintain or improve residents' ADL abilities, including mobility and ambulation, in accordance with assessed needs and preferences. Despite this, the resident did not receive ongoing support to maintain ambulation after therapy ended, and there was a lack of communication and documentation regarding the continuation of restorative activities. This resulted in the resident not receiving necessary services to maintain functional abilities as required.
Failure to Provide Timely Assistance with Personal Hygiene (Shaving)
Penalty
Summary
Staff failed to provide adequate assistance with activities of daily living (ADLs) for a resident who required maximal help with personal hygiene, including shaving. The resident had a history of muscle weakness, lower extremity impairment, and was dependent on staff for dressing, footwear, transfers, and hygiene tasks. The care plan directed staff to shave the resident on bath days and as needed, but observations over several days showed the resident had prominent, unshaven facial hair and reported a preference to be clean shaven. The resident stated he could not shave himself and could not recall the last time he was shaved. Interviews with staff revealed that shaving was typically performed on scheduled shower days or upon resident request, and that staff were busy, sometimes leaving shaving to licensed nurses if not completed by CNAs. The administrative nurse expected staff to shave residents daily and as needed, regardless of cognitive status. Despite these expectations and the resident's dependence on staff, the resident was observed multiple times with unshaven facial hair until it was finally removed after several days, indicating a failure to provide consistent and timely ADL care as required by the care plan and facility policy.
Failure to Implement and Maintain Effective Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to ensure an environment free from accident hazards and did not fully implement or update fall prevention interventions for a resident with a history of multiple falls. The resident had diagnoses of vascular dementia and hemiparesis/hemiplegia, with documented moderate to severe cognitive impairment, impaired mobility, and a history of falls. The care plan included several interventions such as keeping the environment clutter-free, ensuring appropriate footwear, using Dycem pads and brake extenders on the wheelchair, and encouraging the use of call lights for assistance. Despite these interventions, the resident experienced repeated falls, some resulting in injury, and the interventions were not consistently implemented or adjusted in response to the resident's changing condition and repeated incidents. Multiple fall notes documented that the resident was often found on the floor without appropriate footwear or non-skid socks, and sometimes without the use of the call light. The resident's wheelchair was at times not equipped with the required Dycem pad or brake extenders, and staff interviews revealed uncertainty about whether these interventions were in place or needed. Maintenance staff could not confirm that brake extenders had been installed, and there was no documentation of some interventions being completed. Additionally, the resident's cognitive impairment was well known among staff, who acknowledged that the resident would not reliably remember to use the call light or follow safety instructions, yet interventions were not modified to address this. The facility also failed to follow through on a physician's order for a physical therapy evaluation after a fall, with no evidence that the evaluation was completed or that a refusal was documented. Staff interviews and record reviews confirmed gaps in documentation and implementation of prescribed interventions. The facility's own policies required the maintenance and supervision of assistive devices and documentation of their use in the care plan, but these were not consistently followed for this resident.
Failure to Perform Timely PICC Dressing Change and Label IV Medication
Penalty
Summary
Staff failed to provide adequate care and services for a resident with a peripherally inserted central catheter (PICC) by not performing the required dressing change every five days and not labeling the intravenous (IV) antibiotic medication administered through the PICC. The resident, who had diagnoses including cellulitis, paraplegia, and a stage 4 pressure ulcer, was dependent on staff for multiple activities of daily living. The care plan and physician orders specified that the PICC dressing should be changed every five days and that medications should be administered as ordered, with staff monitoring for signs of infection. Record review and observations revealed that there was no documentation of the PICC line dressing being changed as required, and the dressing observed was two days overdue. Additionally, the IV Vancomycin bag being administered was not labeled with the resident's name, dosage, route, preparation date, or expiration date. Staff interviews confirmed the missed dressing change and the lack of labeling on the IV medication. Facility policy required proper care and labeling to prevent complications, but these procedures were not followed.
Failure to Implement Pharmacist Medication Review Recommendations and Provider Orders
Penalty
Summary
The facility failed to implement provider orders based on the Consultant Pharmacist’s (CP) monthly medication review (MRR) and did not ensure a medication review system that prevented duplication or omissions for a resident with vascular dementia and major depressive disorder. The resident’s medical record showed a history of moderately to severely impaired cognition, use of a wheelchair, and dependence on staff for daily activities. The resident was prescribed venlafaxine for depression, and the care plan included monitoring for side effects and routine evaluation for possible dose reduction. During the CP’s MRR, a recommendation was made to reduce the venlafaxine dose in accordance with federal guidelines. The physician responded in writing to decrease the dose, and a prescription was sent to the pharmacy. However, the electronic health record (EHR) lacked evidence that staff acknowledged or acted on this order promptly, and there was no progress note documenting the medication change. Later, conflicting documentation appeared, with the physician indicating disagreement with the dose reduction and referencing previous unsuccessful attempts at gradual dose reduction (GDR). The resident’s medication administration record eventually reflected a dose change, but the process was marked by confusion and lack of clear communication among staff and providers. Interviews with facility staff revealed a lack of understanding regarding the MRR process and the presence of two separate MRR forms from different providers for the same medication issue. The facility’s drug regimen review policy did not specify nursing responsibilities related to the MRR, contributing to the breakdown in communication and implementation of provider orders. This deficient practice placed the resident at risk of receiving unnecessary medications due to the failure to properly coordinate and document medication regimen changes.
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 citations issued around you in the last 12 months — including the immediate-jeopardy cases — 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 Garden City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ranch House Senior Living Llc | 2 mi | ★★★★★ | 0 | 0 |
| Kearny County Hospital Ltcu | 21.3 mi | ★★★★★ | 0 | 0 |
| The Shepherd's Center | 29.7 mi | ★★★★★ | 24 | 0 |
| Bethel Home | 34.6 mi | ★★★★★ | 0 | 0 |
| Park Lane Nursing Home | 35 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Garden Valley Retirement Village.
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.