(A report from the Iowa Capital Dispatch) – A southwest Iowa nursing home cited for more than two dozen regulatory violations this year has been added to the federal government’s list of the nation’s worst care facilities. The Centers for Medicare and Medicaid Services has added the Garden View Care Center in Shenandoah to its list of Special-Focus Facilities.

In February 2025, state inspectors cited Garden View for 15 federal violations, including failure to meet professional standards, overall quality of care, insufficient nursing staff, a lack of competent nursing staff, infection-control issues and the use of unnecessary drugs.

Inspectors reported that on Feb. 12, 2025, the home, which had 37 residents, had no nurse on duty in the afternoon, and no one on staff certified to provide CPR if needed. A worker explained that a nurse from a temp agency had reported for work at 6 p.m. on Feb. 11, and remained on duty until roughly 2 p.m. Feb. 12, when she was told to go to the hotel where she was staying and get a few hours of sleep before reporting back for work at around 5 p.m.

The Garden View Care Center in Shenandoah, Iowa. (Photo via Google Earth)

The nurse’s departure allegedly left the home without a nurse in the building for three hours, despite the presence of several high-risk residents, including individuals who were on dialysis or needed airway suctioning or had COVID-19. “The administrator told staff he is a nurse but not currently licensed,” the inspectors wrote in their report.

State records indicate no fines or penalties were imposed as a result of the inspectors’ findings.

In April 2025, state inspectors returned and cited the home for 11 additional violations related to abuse-and-neglect policies, resident discharges, pharmacy services, medication errors, food quality and infection control. Again, no fines or penalties were imposed.

In the fall of 2021, CMS added Garden View to its special-focus eligibility list after the home was cited for 23 regulatory violations and fined $306,335 by the federal government. According to inspectors’ reports, the staff had withheld one woman’s dinner, with one worker telling a colleague the woman had no right to a meal because of how big she was. Another employee allegedly reported seeing a coworker pull a woman out of a room and drag her backward across the floor into another room while cursing at the resident.

In 2024, the state proposed, but held in suspension, $47,500 in fines against the home for inadequate staffing and the physical and verbal abuse of residents.

According to state inspectors, the home’s director of nursing informed them she was being pressured by management to cut staff due to budget constraints, adding that she felt doing so was “unsafe.”

Between October 2022 and July 2024, CMS imposed $241,479 in federal fines against the facility. Garden View is currently owned by a for-profit, limited liability company called Greenside Healthcare Properties, according to CMS. In addition to Garden View, the other Iowa care facility currently designated a Special-Focus Facility is Pine Acres Rehabilitation and Care Center in West Des Moines.

The other Iowa homes on the eligibility list, and the corrected number of consecutive months they’ve appeared on the list, are:

— Greater Southside Health and Rehabilitation Center in Des Moines, 38 months.

— Harmony West Nursing and Rehabilitation Center in West Des Moines, 23 months.

— Harvest Acres Nursing and Rehabilitation Center in Keota, eight months.

— Clarion Wellness and Rehabilitation Center, seven months.

— Caring Acres Nursing and Rehabilitation Center in Anita, five months.

— Pioneer Valley Living and Rehabilitation Center, Sergeant Bluff, four months.

— Aspire of Washington, four months.