Garden View Care Center
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 10 Google reviews

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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 detailsStrengths
- 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
Distribution · 11 analyzed
How They Respond to Reviews
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.”
“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.”
“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.”
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 15 measures
7
measures
7
measures
1
measures
Residents on antipsychotic medication
Residents whose walking got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents who lost too much weight
Residents with pressure sores (bedsores)
Residents vaccinated for pneumonia
Short-stay residents vaccinated for pneumonia
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2026Complaint8
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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.
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Apr 2, 2026Complaint12
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Egress Deficiencies
Have exits that are accessible at all times.
Egress Deficiencies
Install proper backup exit lighting.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Dec 8, 2025Routine19
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
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.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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.
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.
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.
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.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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.
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.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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, 2025Complaint5
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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.
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.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Oct 21, 2025Complaint1
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Apr 10, 2025Routine12
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
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.
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.
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.
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.
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.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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
Jun 2, 2026ComplaintClean
Fed violations: 18, State violations: 1
Apr 8, 2026ComplaintClean
Fed violations: 8, State violations: 1
Feb 16, 2026InspectionClean
Fed violations: 0, State violations: 0
Dec 18, 2025ComplaintClean
Fed violations: 0, State violations: 0
Dec 8, 2025InspectionClean
Fed violations: 24, State violations: 2
Oct 21, 2025ComplaintClean
Fed violations: 1, State violations: 0
May 15, 2025InspectionClean
Fed violations: 0, State violations: 0
Apr 10, 2025InspectionClean
Fed violations: 11, State violations: 0
Ownership & Operations
Who Operates This Facility
Garden View Care Center
for profit
Chain Affiliation
Campbell Street Services
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
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
10 reviews from families & visitors
Official Website
Visit arboretahealthcare.com
Medicare data downloads
Original nursing home datasets
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