No state fines for alleged abuse and ‘unsafe’ staffing levels at Iowa nursing home in Shenandoah

by Clark Kauffman, Iowa Capital Dispatch
September 18, 2024

The state of Iowa has suspended $47,500 in fines against a southwest Iowa nursing home cited for inadequate staffing and the physical and verbal abuse of residents.

According to state inspectors, although the Garden View Care Center in Shenandoah has insufficient staff on hand, the home’s director of nursing recently informed them she was being pressured by management to make further cuts in staffing due to budget constraints — adding that she felt doing so was “unrealistic and unsafe.”

Garden View is owned by an out-of-state real estate investment trust that is designed to provide investors with returns tied to the profits generated by dozens of nursing homes in Iowa and other states.

State inspectors recently investigated four separate complaints pertaining to Garden View and substantiated each of them. The home was cited for 10 violations of federal regulations and four violations of state regulations. Just three weeks before that investigation was completed, state inspectors cited the home for nine federal violations and one state violation as part of a routine inspection at Garden View.

As a result of the two inspections, the Iowa Department of Inspections Appeals and Licensing has proposed, but held in suspension, a total of $47,500 in state fines. As it has in the past, the federal Centers for Medicare and Medicaid Services may yet impose fines for the violations of federal regulations cited by the state inspectors.

According to the inspectors’ reports, employees of Garden View reported that a colleague of theirs had cursed at, threatened, and physically abused at least two residents of the home. Although the report identifies the job titles of most of the workers who allegedly witnessed or investigated the incidents, the job titles of the accused worker and a colleague who fielded internal reports of the alleged abuse – both of whom were reportedly fired — are not disclosed.

Among the allegations in the inspectors’ reports from July and August:

— Resident abuse: One certified nursing assistant told inspectors she observed a colleague telling a resident, “You are not going to talk to me like that, you f—-ing a——,” and saw the worker get one male resident ready for the day by grabbing the man’s legs and aggressively flinging them off the bed. The aide told inspectors that if someone had handled her in that fashion, it would have injured her back.

Another employee reported that the accused worker had told a resident, “Don’t f—-ing hit me. I’ll never take care of you again.” A female resident sustained three “fingertip bruises” to her chest after the accused worker aggressively pushed the woman down in her chair after changing her clothes.

— Failure to report abuse: The home’s administrator allegedly acknowledged she did not separate the alleged victims of the abuse from the accused worker while investigating the matter and that she failed to properly report the incidents to the state.

— Insufficient staffing: The home was cited for failing to provide adequate staffing to ensure the needs of residents were being met. Residents complained it sometimes took the staff an hour or more to answer their call lights. On 10 separate occasions in June and July 2024, the facility failed to have to have a registered nurse on duty, as required, for at least eight consecutive hours each day.

According to inspectors, the home’s director of nursing informed them she was “very concerned” about the ongoing staffing issues because she was “getting pressured to cut staff” in order to stay within a budget. The director of nursing allegedly explained that the needs of the residents were very high and the expectation to reduce staff was “unrealistic and unsafe.”

The director of nursing allegedly stated that she been forced many times to cut staff on the evening and overnight shifts, leaving just one nurse and one aide to care for three dozen residents. “The nurses are not able to get the wound treatments completed and can’t get through all the faxes to the doctors and do the charting,” she allegedly told inspectors.

A licensed practical nurse allegedly voiced similar concerns, telling inspectors there were many nights in which she and one aide were the only staff on duty.

— No corrective action: The inspectors noted that since the home’s administrator, Cindy Willis, was hired in December 2019, the home had been cited for insufficient nursing staff in April 2021, February 2024, July 2024 and August 2024. The home was also cited for failure to implement infection prevention policies in March 2020, twice in April 2023, and July 2024.

Willis allegedly told inspectors she was not a nurse and there had been no consistent leadership in nursing at Garden View, which meant plans to address the repeat violations had not been formulated or implemented. The home had been operating with only an “interim” director of nursing for 20 of the past 25 months, Willis reportedly told inspectors.

— Bed linens: The home was also cited for failing to have enough bed sheets, blankets and incontinence pads on hand, with an inspector observing that one resident’s bed had been left unmade and had “dirty, stained sheets” on it.

— Infection control: Medical records of residents were stored in a basement room that showed obvious evidence of water intrusion through a window and an exterior wall. The leaks had caused mudflows in the room and there was a “black fuzzy substance growing” on one wall, with boxes of overturned medical records showing signs of water damage. Willis, the home’s administrator, reportedly acknowledged the facility had not analyzed whether residents’ recent respiratory issues had been exacerbated by conditions in the basement.

Owners linked to other troubled homes

According to state records, Garden View Care Center is managed by Arboreta Healthcare of Sarasota, Fla., which manages 21 care facilities in Iowa, as well as homes in Nebraska, Texas, Florida and Georgia.

State and county records indicate Garden View is owned by the CareTrust real estate investment trust in San Clemente, California. CareTrust officials there did not return calls for comment.

CareTrust maintains a nationwide portfolio of nursing homes and senior housing developments. In August, the company said its 2024 investments totaled $827 million, with an average yield for investors of 9.5%.

In the past three years, CMS has imposed $145,906 in federal fines against Garden View. The home has the lowest possible ratings from CMS — one star on a five-star scale — on all three criteria used by the federal agency: staffing levels, inspection results and overall quality.

Another Iowa facility that’s owned by CareTrust and managed by Arboreta, the Grundy Care Center, has also been cited for staffing shortages and resident abuse, and it, too, has the lowest possible ratings from CMS.

Earlier this year, the Grundy home’s director of nursing resigned, citing staffing shortages that resulted in her working shifts of 12 hours or more. She was later awarded jobless benefits, with a judge finding she had faced intolerable working conditions at the home.

Last year, an aide who worked at the Grundy home reportedly told state inspectors, “The facility does not give any training … You just figure it out as you go.”

The home was cited for placing residents in immediate jeopardy by failing to protect them from abuse and for failing to prevent a male resident from making sexual advances on female residents.

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