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Nursing HomeMedicaid

Garden View Care Center

On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.

1200 West Nishna Road, Shenandoah, IA 5160150 bedsLicensed & Active
Google rating
3.3/5

based on 10 Google reviews

5
4
3
2
1
Garden View Care Center Nursing Home in Shenandoah, IA — Street View
Street View

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What this means for your family

While recent reviews suggest that new ownership is actively working to improve the facility, the history of medication errors and hygiene concerns is significant. If you are considering this facility, we strongly recommend requesting a tour to observe current cleanliness and asking management specifically about the protocols they have implemented to prevent the medication and care lapses reported in previous years.

Google Reviews

Google Reviews

10 reviews on Google
Garden View Care Center has a history of severe operational issues, including medication errors, poor hygiene, and neglectful care reported by families. While some recent reviews mention improvements under new ownership, the facility has faced significant criticism regarding basic resident care and administrative transparency.

Quality Themes

Tap a score for details
Food5.0Staff5.0Clean4.0ActivitiesN/AMeds1.0MemoryN/AComms2.0Value2.0

Strengths

  • Friendly, attentive nursing staff
  • Effective physical and occupational therapy
  • Recent management improvements

Concerns

  • Medication management and safety errors (mentioned by 2 reviewers)
  • Poor hygiene and lack of basic personal care (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2341.0'17(1)1.05.0'20(1)3.03.0'22(2)4.05.0'24(1)5.0'25(1)

Distribution · 11 analyzed

5
5
4
1
3
0
2
0
1
5

How They Respond to Reviews

10%response rate

This facility rarely responds to reviews.

Questions for Your Tour

  • 1With the recent changes in management, what specific steps have been taken to improve the consistency and oversight of medication administration?
  • 2Could you walk me through your daily protocols for ensuring residents receive regular hygiene assistance and personal care throughout the day?
  • 3I noticed there have been some challenges with communication in the past; what is the best way for families to stay updated on their loved one's health and daily status?
  • 4Given the importance of physical and occupational therapy here, how do you integrate these sessions into a resident's daily activity schedule?
  • 5How does your nursing team coordinate with local hospitals or emergency services to ensure a seamless response if a resident’s medical needs suddenly increase?
  • 6I see that management has been actively engaging with feedback recently; how do you incorporate family suggestions into your ongoing facility improvements?

Personalized based on this facility's data


Key Review Excerpts

2 nurses tried giving my mom the wrong pills and thank God my she caught it but other residents did not.

Long-term resident's family · 2021☆☆☆☆

He had holes in his socks, just slippers on, pj's and no coat. Now one knew where his winter coat was. His hair was a mess and he has cradle cap, like they don't wash his hair.

Long-term resident's family · 2022☆☆☆☆

A new company purchased the facility and has been working non stop to get the building and staff back up and running the way it is supposed to. The staff is very caring and attentive.

Visitor/Observer · 2025★★★★★
Source: 10 Google reviews

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 15 measures

Better Than Avg

7

measures

Worse Than Avg

7

measures

Mixed Results

1

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility33.0%
Worse than Avg
Here
33.0%
US
15.5%
IA
19.4%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility29.6%
Worse than Avg
Here
29.6%
US
15.3%
IA
17.5%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
IA
4.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

⚖️

Residents who lost too much weight

↓ Lower is better
This Facility11.2%
Worse than Avg
Here
11.2%
US
5.3%
IA
4.9%
🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility10.3%
Worse than Avg
Here
10.3%
US
4.9%
IA
4.3%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility98.6%
Better than Avg
Here
98.6%
US
93.4%
IA
93.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
IA
84.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

33deficiencies
4penalties
70 complaint-triggered
$168,858 in fines

Garden View Care Center has a concerning pattern with 91 deficiencies across 11 surveys, including 52 complaint-triggered violations where families filed reports about safety concerns. The facility has recurring problems with nursing staffing levels, resident protection from abuse and neglect, and medication management. While all deficiencies show correction dates, the persistent issues with staffing and safety across multiple complaint investigations suggest ongoing operational challenges that warrant careful consideration.

Apr 8, 2026Complaint
8
0865Potential for harm · WidespreadCorrected

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Apr 2, 2026Complaint
12
0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0271Potential for harm · WidespreadCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0281Potential for harm · WidespreadCorrected

Egress Deficiencies

Install proper backup exit lighting.

0372Potential for harm · WidespreadCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0711Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0321Potential for harm · PatternCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0511Potential for harm · PatternCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0291Potential for harm · IsolatedCorrected

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Dec 8, 2025Routine
19
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0695Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0730Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0835Potential for harm · WidespreadCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0865Potential for harm · WidespreadCorrected

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

0803Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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.

0805Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0867Potential for harm · PatternCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0636Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Dec 8, 2025Complaint
5
0600Immediate jeopardy · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0610Immediate jeopardy · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0725Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0726Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

0804Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Oct 21, 2025Complaint
1
0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Apr 10, 2025Routine
12
0026Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

0607Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0804Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

0865Potential for harm · PatternCorrected

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0887Potential for harm · PatternCorrected

Infection Control Deficiencies

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.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0661Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Federal Penalties

Fine

Dec 8, 2025

$41,474

Fine

Jul 25, 2024

$95,573

Payment Denial

Jul 25, 2024

32-day denial

Fine

Jul 20, 2023

$31,811

State Inspection History

State Inspections

Source: Iowa Dept. of Inspections, Appeals & Licensing

10total
81deficiencies
Jun 2, 2026Complaint
Clean

Fed violations: 18, State violations: 1

Apr 8, 2026Complaint
Clean

Fed violations: 8, State violations: 1

Feb 16, 2026Inspection
Clean

Fed violations: 0, State violations: 0

Dec 18, 2025Complaint
Clean

Fed violations: 0, State violations: 0

Dec 8, 2025Inspection
Clean

Fed violations: 24, State violations: 2

Oct 21, 2025Complaint
Clean

Fed violations: 1, State violations: 0

May 15, 2025Inspection
Clean

Fed violations: 0, State violations: 0

Apr 10, 2025Inspection
Clean

Fed violations: 11, State violations: 0

Ownership & Operations

Who Operates This Facility

Owner / Operator

Garden View Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

Campbell Street Services

Chain Size

20 facilities nationwide

Ownership & Management

Owners

Holdco, Ia, 10, LLC

Owner · Organization

Birchwood Healthcare Partners LLC

Owner (parent company) · Organization

Dole, Isaac

Owner (parent company)

Key personnel

Dole, IsaacManaging Control - Governing BodySatterfield, BrendaManaging Control - Governing BodyBirchwood Foundation LLCManagerBirchwood Healthcare Partners LLCManagerCampbell Street Ia 10 LLCManager
Source: Medicare provider data

Contact

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

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