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 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.
Current CMS list includes some errors
At any given time, no more than two nursing homes per state appear on CMS’ list of federally designated Special-Focus Facilities, although the list also includes hundreds of other nursing homes — typically, 10 per state — where ongoing quality-of-care violations have made them eligible for that status.
Once a home is designated a Special-Focus Facility, it receives additional oversight and assistance from the government that’s intended to improve resident care. The other homes that are merely deemed eligible do not receive that assistance. They appear on the list, some for as long as 10 years, and then drop off without ever receiving the federal help.
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.
However, CMS’ latest Special-Focus Facilities list, published by the agency on Sept. 24, 2025, appears to include several errors. Garden View, for example, is listed not only as one of Iowa’s two special-focus facilities, but also as one of Iowa’s 10 care facilities that are eligible for the status without actually being enrolled in the program.
Although CMS did not respond Monday to inquiries about discrepancies in its list, possibly due to the federal government shutdown, it appears the list of Iowa facilities with “eligible” status has not been revised or updated since July.
The data from CMS suggests Garden View has taken the place of Aspire of Gowrie in the list of special-focus facilities. The Gowrie home had been in the special-focus program for at least 22 months without graduating before it closed on July 23, 2025.
As for the Iowa facilities whose quality-of-care issues make them eligible for special-focus status, the two most recently added homes are The Ivy at Davenport, located in Scott County, and Parkview Manor in Reinbeck. Both were added to the list in July, although the new list suggests they made their debut on the list in late September.
And while The Ivy at Davenport has been on the list continuously only since July, that’s because the home was inexplicably dropped from the list, for one month, in June. In May, the home had logged its 20th straight month on the eligibility list. So while the current list suggests The Ivy has been eligible for special-focus status for only one month, it has actually been eligible for the better part of two years.
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.
