Garden View Care Center

In the surveyor’s words

From the most serious findings on record at Garden View Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 5, 2022

  Based on observation, document review, and staff interviews, the facility's administrative staff failed to ensure that the facility staff failed to follow the van lift manufacturer's instructions when transporting 1 of 1 resident (Resident #1) who was injured in an accident involving the life to [CONDITION(S)]. The facility staff's failure to follow the lift manufacturer's instructions resulted in Resident #1's wheelchair rolling backwards out of the lift, resulting in Resident #1 striking their head against the ground, which resulted in Resident #1 developing potentially life-threatening bleeding in their brain. The facility's administrative staff identified 6 residents who required [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF600Dec 8, 2025

  Based on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to prevent neglect when Staff A refused to provide or delayed providing suctioning for Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck). Resident #34 stated Staff A, Licensed Practical Nurse (LPN) refused to suction him nearly nightly when he worked at the facility. The resident experienced psychosocial harm as evident by severe anxiety, fear of being unable to breath and dying. Staff A worked at the facility 9/17/25 - 11/12/25 on the overnight shift with the last day of training with a second nurse on 10/4/25. Schedule documented Staff A was the only nurse when working the overnight shift when scheduled. […]

• Immediate jeopardy, isolatedF610Dec 8, 2025

  Based on Electronic Health Records (EHR), document review, staff interviews, resident interview and policy review the facility failed to investigate the allegation of neglect, failed to separate Staff A, Licensed Practical Nurse (LPN) from Resident #34 and failed to take corrective actions to prevent further abuse/neglect of Resident #34. Resident #34 stated Staff A would refuse to provide or delayed providing suctioning to Resident #34 who was dependent on staff assistance for his tracheostomy (breathing tube in the neck) frequently. Resident #34 explained he would have to call the Certified Nursing Assistants (CNA's) with the call light 3 or 4 times before his tracheostomy would be suctioned by Staff A. […]

• Immediate jeopardy, isolatedF600Sep 11, 2024

  Based on observation, record review, policy, and staff interviews, the facility failed to prevent physical and verbal abuse of Resident #2 and Resident #5. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The investigation revealed the same CNA had a history of verbally and physically abusing Resident #2 and Resident #5 without being separated. This failure resulted in residents living at the facility exposed to the actual abuse and the potential of abuse therefore causing an Immediate Jeopardy to the health, safety, and security of the resident. […]

• Immediate jeopardy, isolatedF609Sep 11, 2024

  Based on observation, record review, policy, and staff interviews, the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of physical and verbal abuse of Resident #2 and Resident #5. On 8/26/24 between 5:00 pm and 5:30 pm, a CNA witnessed another CNA physically and verbally abuse Resident #2 and Resident #5. The CNA stated she reported the physical abuse of Resident #2 to a nurse on 8/26/24 between 5:00 pm - 5:30 pm. Neither the CNA nor the nurse reported the physical abuse to the state agency or the administration. The investigation revealed the same CNA had history of verbally and physically abusing Resident #2 and Resident #5 and those allegations were also not reported. […]