Assisted living

Garden View Care Center

0.00 reviews · 0 verifiedShenandoah, IALic. 165531

Signals

JKLRecent citation with immediate-jeopardy / high severity (J/K/L)Source: CMS Health Citations

SFFSpecial Focus: SFFSource: CMS Provider Information

ABUSECMS abuse icon presentSource: CMS Provider Information

DENYCMS payment denial (32 days)Source: CMS Penalties

FINECMS fine: $95,573Source: CMS Penalties

FINECMS fine: $41,474Source: CMS Penalties

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Provided by facility

About

Garden View Care Center in Shenandoah, Iowa, has faced significant regulatory scrutiny, being cited for 23 violations this year and fined over $300,000 by federal officials. The facility has received the lowest ratings from CMS in quality of care, staffing levels, and regulatory compliance. Reports indicate serious issues with resident care, including inadequate staffing, failure to provide necessary medical treatments, and unsanitary conditions. The home is currently eligible for inclusion on the Special-Focus Facility List due to its poor performance and history of serious quality issues.

Amenities

TherapiesOn-Site Rehabilitation Services

Outside AmenitiesGarden

CMS Care Compare

Staffing (PBJ)

3.34 total HPRDRN 0.53 · weekend 83%Oct 2025 – Dec 2025

Survey history

13 inspections109 deficiencies on record

Federal IDs

CCN 165531

Unbeatable ratings come only from verified family, staff, and professional reviews on this site. CMS stars, staffing, and citations are public regulatory signals — useful for context, not blended into our score.

Recent inspections

Health surveyApr 2026 · CMS8 deficiencies

F-550SS D — Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F-558SS D — Reasonably accommodate the needs and preferences of each resident.
F-584SS E — Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-609SS D — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F-677SS D — Provide care and assistance to perform activities of daily living for any resident who is unable.
F-842SS E — Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F-865SS F — Have a plan that describes the process for conducting QAPI and QAA activities.
F-880SS E — Provide and implement an infection prevention and control program.

Fire safetyApr 2026 · STATE FIRE MARSHAL12 deficiencies

E-15SS F — Address subsistence needs for staff and patients.
E-41SS F — Implement emergency and standby power systems.
K-271SS F — Have exits that are accessible at all times.
K-281SS F — Install proper backup exit lighting.
K-291SS D — Install emergency lighting that can last at least 1 1/2 hours.
K-321SS E — Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K-345SS D — Have approved installation, maintenance and testing program for fire alarm systems.
K-363SS D — Install corridor and hallway doors that block smoke.
K-372SS F — Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K-511SS E — Have properly installed electrical wiring and gas equipment.
K-711SS F — Provide a written emergency evacuation plan.
K-761SS E — To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Health surveyDec 2025 · CMS24 deficiencies

F-600SS J — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-605SS D — Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
F-610SS J — Respond appropriately to all alleged violations.
F-636SS D — Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F-656SS D — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-657SS D — Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F-658SS D — Ensure services provided by the nursing facility meet professional standards of quality.
F-684SS G — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F-686SS D — Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F-688SS D — Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F-690SS D — Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F-695SS G — Provide safe and appropriate respiratory care for a resident when needed.
F-725SS F — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-726SS F — Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F-730SS F — Observe each nurse aide's job performance and give regular training.
F-755SS D — Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F-803SS E — 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.
F-804SS D — Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F-805SS E — Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F-812SS E — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Health surveyOct 2025 · CMS1 deficiencies

F-677SS D — Provide care and assistance to perform activities of daily living for any resident who is unable.

Health surveyApr 2025 · CMS11 deficiencies

F-607SS E — Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F-625SS D — 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.
F-656SS D — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-661SS D — Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
F-688SS D — Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F-755SS D — Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F-760SS D — Ensure that residents are free from significant medication errors.
F-804SS E — Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F-865SS E — Have a plan that describes the process for conducting QAPI and QAA activities.
F-880SS E — Provide and implement an infection prevention and control program.
F-887SS E — Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Fire safetyApr 2025 · STATE FIRE MARSHAL1 deficiencies

E-26SS F — Establish roles under a Waiver declared by secretary.

Health surveyFeb 2025 · CMS15 deficiencies

F-657SS D — Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F-658SS E — Ensure services provided by the nursing facility meet professional standards of quality.
F-684SS E — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F-686SS D — Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F-689SS D — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-725SS D — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-726SS D — Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F-727SS E — Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F-732SS E — Post nurse staffing information every day.
F-757SS D — Ensure each resident’s drug regimen must be free from unnecessary drugs.
F-761SS D — 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.
F-835SS E — Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F-842SS D — Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F-865SS E — Have a plan that describes the process for conducting QAPI and QAA activities.
F-880SS E — Provide and implement an infection prevention and control program.

Health surveySep 2024 · CMS10 deficiencies

F-584SS E — Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-600SS J — Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F-609SS J — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F-610SS J — Respond appropriately to all alleged violations.
F-656SS E — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-689SS J — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-725SS E — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-842SS F — Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F-865SS F — Have a plan that describes the process for conducting QAPI and QAA activities.
F-880SS E — Provide and implement an infection prevention and control program.

Health surveyJul 2024 · CMS9 deficiencies

F-657SS E — Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F-684SS D — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F-689SS G — Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-698SS D — Provide safe, appropriate dialysis care/services for a resident who requires such services.
F-725SS F — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-727SS F — Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F-812SS E — Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F-880SS D — Provide and implement an infection prevention and control program.
F-883SS D — Develop and implement policies and procedures for flu and pneumonia vaccinations.

Health surveyApr 2024 · CMS5 deficiencies

F-609SS D — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F-622SS D — Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F-661SS D — Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
F-684SS D — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F-842SS D — Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Health surveyFeb 2024 · CMS6 deficiencies

F-656SS D — Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F-677SS D — Provide care and assistance to perform activities of daily living for any resident who is unable.
F-688SS D — Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
F-725SS E — Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F-727SS E — Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F-732SS C — Post nurse staffing information every day.

Health surveyAug 2023 · CMS4 deficiencies

F-558SS D — Reasonably accommodate the needs and preferences of each resident.
F-609SS D — Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F-684SS G — Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F-921SS E — Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Showing 12 of 13 inspections.

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Ownership

Operated by CAMPBELL STREET SERVICES (privately held) since 2004.

Feb 2025
operator transition — BIRCHWOOD HEALTHCARE PARTNERS LLC
INDIRECT OWNERSHIP INTEREST (NOT APPLICABLE) — BIRCHWOOD HEALTHCARE PARTNERS LLC
Feb 2025
operator transition — HOLDCO, IA, 10, LLC
DIRECT OWNERSHIP INTEREST (NOT APPLICABLE) — HOLDCO, IA, 10, LLC
Feb 2025
operator transition — DOLE, ISAAC
INDIRECT OWNERSHIP INTEREST (NOT APPLICABLE) — DOLE, ISAAC

Contact

1200 West Nishna Road
Shenandoah, IA 51601

Get directions →

7122464515 iowacapitaldispatch.com/2021/10/13/iowa-nursing-home-is-named-one-of-the-nations-worst

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