Troubled Iowa Nursing Home Taking Steps to Improve Care

An Iowa nursing home, recently assessed with multiple care violations, says it is now 100 percent compliant and taking steps to turn things around.

Garden View Care Center is a facility based in Shenandoah, Iowa. It is one of 10 state facilities that has been placed on the Centers for Medicare and Medicaid Services (CMS) Special-Focus Facility (SFF) list.

SFF-listed nursing homes are facilities with a history of significant quality of care issues. The CMS nationally-ranked program was created to help stimulate improvement in facilities with a history of poor regulatory compliance records. The facilities are inspected and then ranked from one to five stars in each of the compliance measures, with one star being the lowest.

Garden View Care Center has received the lowest possible ratings in all three areas of care measured by CMS for:

• Quality of care
• Staffing levels
• Regulatory compliance

Cited for Multiple Violations in One Year

According to a report by the Iowa Capital Dispatch, Garden View was cited for more than 23 serious violations following an inspection in April 2021. The inspection was initiated following the state’s receipt of nine complaints. All but one of the complaints were substantiated and included failures to:

• Protect residents from abuse
• Maintain adequate staffing levels
• Provide residents with physician-prescribed supplemental oxygen
• Maintain sanitary conditions
• Develop resident care plans
• Adequately groom and bathe residents
• Change wound dressings
• Provide physical therapy
• Protect two residents from incidents that resulted in bone fractures

In addition to the violations, federal officials also fined Garden View $306,335. Despite these serious care issues, management at the facility reportedly states that they are taking significant measures to improve their quality of care and add to their staffing levels.

What Federal Inspectors Found

When state inspectors visited the facility in April, what they found was beyond concerning and unacceptable. Residents using call lights to get help sometimes had to wait two to three hours for a staff member to respond. Inspectors noted many residents had been left ungroomed and unbathed. One of the inspectors observed that a resident had been left lying naked in urine-soaked sheets, but reportedly even this was not a unique incident.

According to the facility’s own records, poor hygiene and grooming were a common occurrence because of inadequate staffing levels. Various employees who spoke with inspectors said they often saw residents lying in urine-soaked sheets at the beginning of their shifts. Day shift workers refused outright to bathe residents.

The situation was so bad that state officials initially informed the facility that residents were determined to be in “immediate jeopardy.” This is a term used to indicate a serious regulatory violation. That said, officials downgraded that assessment the next day after management’s stated plans to immediately correct the issues.

According to the Iowa Department of Inspections and Appeals, action to downgrade an immediate jeopardy status is only taken after a “corrective-action plan has been verified in compliance with CMS regulation.”

What Improvements Are Being Done?

B2 Communications, the Florida-based public relations firm working with management at Garden View, reported that the facility is getting a lot of questions. People, understandably, want to know what measures the facility is taking to improve their abysmal quality of care.

According to a written statement, new ownership took over the facility in June, and they are driving significant changes to help ensure these incidents do not occur in the future. The written statement claims “the problems have all been addressed and corrected, with some employees immediately suspended and then fired.”

The facility is owned by Shenandoah Properties, LLC, which is based in Jackson, Mississippi.

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