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Nursing HomeMedicaid Investigative

Garden View Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

700 Garden Path, O Fallon, MO 6336680 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.9/5

based on 72 Google reviews

Garden View Care Center Nursing Home in O Fallon, MO — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • Above-median deficiencies (16 vs median 10)

Bottom 25% in MO · Below recommended RN staffing · Above recommended total nurse staffing · $3,145 in fines · Abuse citation

Source: Medicare data

What this means for your family

Garden View shows strong results for short-term rehab and general nursing, with many families praising the therapy team. However, the recurring reports of slow response times and hygiene failures are concerning; we strongly recommend visiting unannounced and asking specifically about the ratio of staff to residents on the floor during evening and weekend shifts.

Google Reviews

Google Reviews

72 reviews on Google
Garden View Care Center receives polarized feedback, with many families praising the dedicated nursing and therapy staff for providing compassionate, high-quality care. However, significant concerns persist regarding inconsistent response times for basic needs, hygiene issues in some cases, and poor experiences within the memory care unit.

Quality Themes

Tap a score for details
Food6.0Staff7.0Clean6.0Activities8.0Meds4.0Memory3.0Comms7.0Value4.0

Strengths

  • Highly effective physical therapy team
  • Attentive and caring nursing staff
  • Clean and well-maintained facility
  • Strong communication during the admission process

Concerns

  • Slow response times for call lights and basic assistance (mentioned by 4 reviewers)
  • Inadequate hygiene and lack of regular bathing (mentioned by 3 reviewers)
  • Poor outcomes or mismanagement in memory care (mentioned by 3 reviewers)
  • Poor quality or cold food (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'17(3)'19(1)'21(4)'23(14)'25(19)'26(4)

Distribution · 74 analyzed

5
47
4
7
3
1
2
2
1
17

How They Respond to Reviews

33%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1We've heard wonderful things about your physical therapy team; could you tell us more about how they work with residents to maintain mobility?
  • 2How do you ensure that call lights are answered promptly, especially during the night shifts or busy meal times?
  • 3What specific protocols do you have in place to ensure consistent hygiene and regular bathing routines for all residents?
  • 4Can you describe your approach to medication management and how you monitor for any changes in a resident's health?
  • 5What kind of daily activities or social outings are available to keep residents engaged and active in the community?
  • 6In the event of a medical emergency after hours, what is the process for contacting physicians and coordinating urgent care?

Personalized based on this facility's data


Key Review Excerpts

The staff here treat our loved one like family. They know things about us, they notice us, they take their time, and they pick up on moods and needs because they aren't rushed.

Family member · 2025★★☆☆☆

My father's first night here was atrocious. We arrived at 4:15pm. It took 35 minutes for someone to come with a wheelchair to get him out of the car... we asked MULTIPLE times for someone to help my dad out of his soiled clothes... and we were told, 'Yeah just one second.'

Family member · 2025★★☆☆☆

My 88 year old mom was there for physical therapy... when she would call for someone to take her to the bathroom it would take over an hour, by then she had already had an accident and would have to lay in it the entire time.

Family member · 2025☆☆☆☆
Source: 72 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.47hrs
63%
Registered nurses for medical care
Total Nursing
4.65hrs
OK
All nurses + aides combined
Staff Turnover
53%
Lower is better (< 30% = good)
RN Turnover
50%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
1/ 5
Better Than Avg

5

measures

Worse Than Avg

9

measures

Mixed Results

3

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility30.9%
Worse than Avg
Here
30.9%
US
15.4%
MO
23.6%
St. charles
14.7%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility32.3%
Worse than Avg
Here
32.3%
US
19.4%
MO
17.9%
St. charles
19.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility4.1%
Better than Avg
Here
4.1%
US
12.1%
MO
16.7%
St. charles
13.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility26.0%
Worse than Avg
Here
26.0%
US
14.4%
MO
19.1%
St. charles
14.6%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility15.5%
Better than Avg
Here
15.5%
US
19.5%
MO
25.4%
St. charles
17.7%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility85.3%
Mixed vs Avgs
Here
85.3%
US
93.4%
MO
84.4%
St. charles
92.6%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility90.4%
Better than Avg
Here
90.4%
US
79.7%
MO
63.5%
St. charles
73.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility90.4%
Better than Avg
Here
90.4%
US
81.8%
MO
65.9%
St. charles
77.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.9%
Mixed vs Avgs
Here
1.9%
US
1.6%
MO
2.2%
St. charles
0.8%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

13deficiencies
2penalties
Above state avg (12.0)
13 complaint-triggered
$3,145 in fines

Garden View Care Center has concerning patterns of repeat complaints from families regarding abuse protection and safety issues, with recent investigations as late as November 2025. The facility consistently struggles with protecting residents from abuse and neglect, safety hazards, and fire/building safety compliance across multiple surveys. While the facility corrects deficiencies when cited, the recurring nature of serious safety and abuse protection problems suggests ongoing operational challenges that families should carefully consider.

Nov 5, 2025Complaint
2
0600Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

Mar 14, 2025Complaint
3
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0742Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Jan 16, 2025Routine
25
0026Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0363Potential for harm · WidespreadCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0920Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0222Potential for harm · PatternCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0271Potential for harm · PatternCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0311Potential for harm · PatternCorrected

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

0351Potential for harm · PatternCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0374Potential for harm · PatternCorrected

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0695Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0925Potential for harm · PatternCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0100Potential for harm · IsolatedCorrected

Construction Deficiencies

Meet other general requirements.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

0909Potential for harm · IsolatedCorrected

Environmental Deficiencies

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

0623Minimal · PatternCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Minimal · PatternCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Jun 23, 2023Complaint
8
0600Actual harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0561Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0686Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0725Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Jun 23, 2023Routine
23
0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0921Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0606Potential for harm · WidespreadCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

0607Potential for harm · WidespreadCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0881Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0882Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

0883Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

0211Potential for harm · PatternCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0222Potential for harm · PatternCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0311Potential for harm · PatternCorrected

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0578Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0947Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

0100Potential for harm · IsolatedCorrected

Construction Deficiencies

Meet other general requirements.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0732Minimal · WidespreadCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Sep 13, 2019Routine
18
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0363Potential for harm · PatternCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0372Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0920Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0803Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0582Minimal · PatternCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Federal Penalties

Fine

Jul 17, 2023

$3,145

Payment Denial

Jun 23, 2023

46-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Garden View Care Center

Organization Type

for profit

Ownership & Management

Owners

Larus Corporation

Owner · Organization

100%

G. William Weier and Patricia R. Weier Trust

Owner (parent company) · Organization

Richard Lawrence Winter Trust

Owner (parent company) · Organization

Weier, Patricia R.

Owner (parent company)

Winter, Richard

Owner (parent company)

Key personnel

Weier, GeorgeOfficer / DirectorWinter, RichardOfficer / DirectorLitle, CharlotteOfficer / DirectorLuaders, JodiOfficer / DirectorNieves, CourtneyOfficer / Director
Source: Medicare provider data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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