Garden View Care Center
1200 West Nishna Road · Shenandoah, IA · 51601 · 7122464515
50 certified beds For profit - Limited Liability company Chain: Campbell Street Services
Why this verdict
- On the federal Special Focus list of the most persistently poor performers.
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (2 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
Red flags
Special Focus Facility
CMS has designated this facility one of the most persistently poor performers in the country — it is under increased inspection and enforcement.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
2 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
5 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$137,047 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: not rated Inspections: not rated Staffing: not rated Quality measures: not rated
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | 3 · $168,858 |
Inspection citations (93 in the current record)
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Potential for harm · D April 8, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has no plan of correction · Resident Rights
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Potential for harm · D April 8, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has no plan of correction · Resident Rights
-
Potential for harm · E April 8, 2026 · found via complaint
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.
Deficient, Provider has no plan of correction · Resident Rights
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Potential for harm · D April 8, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has no plan of correction · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 8, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has no plan of correction · Quality of Life and Care
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Potential for harm · E April 8, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has no plan of correction · Resident Assessment and Care Planning
-
Potential for harm · F April 8, 2026 · found via complaint
Have a plan that describes the process for conducting QAPI and QAA activities.
Deficient, Provider has no plan of correction · Administration
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Potential for harm · E April 8, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Deficient, Provider has no plan of correction · Infection Control
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Immediate jeopardy · J December 8, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J December 8, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected December 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G December 8, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 29, 2025 · Quality of Life and Care
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Actual harm · G December 8, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected December 29, 2025 · Quality of Life and Care
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Potential for harm · D December 8, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected January 8, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 8, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected January 8, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 8, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 8, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 8, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected January 8, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 8, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 8, 2026 · Resident Assessment and Care Planning
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Potential for harm · D December 8, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 8, 2026 · Quality of Life and Care
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Potential for harm · D December 8, 2025
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.
Corrected January 8, 2026 · Quality of Life and Care
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Potential for harm · D December 8, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected January 8, 2026 · Quality of Life and Care
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Potential for harm · F December 8, 2025
Observe each nurse aide's job performance and give regular training.
Corrected January 8, 2026 · Nursing and Physician Services
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Potential for harm · D December 8, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected January 8, 2026 · Pharmacy Service
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Potential for harm · E December 8, 2025
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.
Corrected January 8, 2026 · Nutrition and Dietary
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Potential for harm · E December 8, 2025
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected January 8, 2026 · Nutrition and Dietary
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Potential for harm · E December 8, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 8, 2026 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 8, 2025 | Fine | $41,474 |
| July 25, 2024 | Fine | $95,573 |
| July 25, 2024 | Payment Denial | 32 days |
| July 20, 2023 | Fine | $31,811 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165531 · certified since April 1, 2004. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.