The state of Iowa has suspended a $47,500 fine it imposed on a southwestern Iowa nursing home for understaffing and physical and verbal abuse of residents.
Garden View Care Center in Shenandoah is short-staffed, but the facility’s director of nursing recently reported that management is pressuring her to make further cuts due to budget constraints, according to state inspectors, adding that she feels doing so is “unrealistic and dangerous.”
In recent years, Garden View has been run by an out-of-state real estate investment trust aimed at offering investors returns tied to the profits generated by dozens of nursing homes in Iowa and other states.
State inspectors recently investigated and substantiated four complaints about Garden View, accusing the facility of 10 federal and four state violations. Just three weeks before this investigation was completed, state inspectors, as part of a routine inspection of Garden View, accused the facility of nine federal and one state violations.
As a result of the two inspections, the Iowa Department of Inspection Appeals and Licensing proposed state fines totaling $47,500, which were put on hold. As in previous years, the federal Centers for Medicare and Medicaid Services can impose fines for any violations of federal regulations noted by state inspectors.
According to the inspector general’s report, Garden View employees reported that a coworker had verbally abused, threatened and physically abused at least two residents. The report provided job titles for most of the employees who allegedly witnessed or investigated the incidents, but did not provide the job titles of the accused employee or the coworker who received the internal report about the alleged abuse. Both employees were reportedly fired.
Inspector general’s reports from July and August listed the following allegations:
— Resident Abuse: One certified nursing assistant told inspectors she witnessed a coworker tell a resident, “Don’t talk to me like that, you little shit,” and then saw the coworker grab a male resident’s legs and violently throw him off the bed while he was getting ready for the day. The assistant said she would have injured her back if someone had treated her like that.
Another employee reported that the defendant’s staff told the resident, “Don’t hit me, because I’m never going to take care of you again.” After getting changed, the female resident suffered three “fingertip bruises” on her chest after the defendant’s staff violently pushed her off a chair.
— Failure to report abuse: Facility administrators allegedly admitted to failing to separate alleged abuse victims from accused staff members while the incidents were being investigated and to failing to properly report the incidents to the state.
— Staffing Shortages: The facility was found to not have enough staff on hand to ensure resident needs were met. Residents complained that it sometimes took more than an hour for staff to respond to calls. On 10 occasions in June and July 2024, the facility failed to have a required registered nurse on duty for at least eight consecutive hours each day.
According to inspectors, the facility’s head of nursing told inspectors she was “very concerned” about ongoing staffing issues because she was “being pressured to reduce staff” to stay within budget. The head of nursing reportedly explained that residents’ needs were very high and expectations of staff reductions were “unrealistic and dangerous.”
The head of nursing allegedly said she had been forced to make multiple cuts to evening and night staff and was left looking after 34 residents with just one nurse and one caregiver. “The nurses can’t complete wound treatments, they can’t process all the faxes for the doctors and prepare the patient charts,” she allegedly told inspectors.
A qualified licensed practical nurse raised similar concerns, reportedly telling inspectors that there were many nights when only she and one carer were on duty.
— No corrective actions: Inspectors noted that since facility manager Cindy Willis was hired in December 2019, the facility was cited for nursing staff shortages in April 2021, February 2024, July 2024 and August 2024. The facility was also cited in March 2020, twice in April 2023 and in July 2024 for not implementing infection prevention policies.
Willis allegedly told inspectors that she was not a nurse, that nursing at Garden View lacked consistent leadership and that no plan was developed or implemented to address repeated violations. Willis reportedly told inspectors that the facility had been run solely by an “interim” director of nursing for 20 of the previous 25 months.
— Bed Linens: The facility was also noted to not have enough bed sheets, blankets or incontinence pads, and inspectors observed one resident’s bed was unmade and had “dirty, stained sheets.”
— Infection Control: Residents’ medical records were stored in a basement with clear evidence of water ingress through windows and exterior walls. Leaks had sent dirt into the room, a “black, fuzzy substance had grown” on one wall, and boxes of medical records had been overturned, revealing signs of water damage. Willis, the facility’s manager, reportedly acknowledged that the facility had not analyzed whether a resident’s recent respiratory illness had been exacerbated by conditions in the basement.
Owners with ties to other problem homes
Garden View Care Center is operated by Arboreta Healthcare of Sarasota, Florida, which operates 21 nursing homes in Iowa as well as facilities in Nebraska, Texas, Florida and Georgia, according to state records.
Willis provided the Iowa Capital-Dispatch with a written statement saying Garden View is owned by Arboreta, which recently hired Campbell Street Services Senior Living as the property’s management company, effective Sept. 1. The statement went on to say that Campbell Street “takes any allegations seriously and has launched an investigation.”
But state regulatory records, county tax records and Securities and Exchange Commission filings show Garden View is owned by an affiliate of CareTrust, a San Clemente, California-based real estate investment trust.
CareTrust maintains a portfolio of care homes and seniors housing developments across the country. The company said in August it had $827 million in total investments due in 2024, with an average return for investors of 9.5%.
Over the past three years, CMS has assessed $145,906 in federal fines against Garden View, and the facility has received the lowest rating from CMS (one star on a five-star scale) in all three metrics used by the federal agency: staffing levels, inspection results and overall quality.
Another Iowa facility owned by CareTrust and managed by Arboreta, Grundy Care Center, also received the lowest rating from CMS after accusations of understaffing and mistreatment of residents.
Earlier this year, the head nurse at Grundy Home resigned after being forced to work shifts of more than 12 hours due to staffing shortages. A judge found she had faced intolerable working conditions at the home and she was subsequently awarded unemployment benefits.
“We don’t provide any training here. You just do it as you go,” an aide who worked at Grundy reportedly told state inspectors last year.
The facility was accused of failing to protect residents from abuse, putting them in immediate danger, and failing to stop male residents from soliciting sexual favours from female residents.
