After death and injuries, two Iowa nursing homes added to federal watchlist

Oct 15, 2026 | 6:05 pm ET

By Clark Kauffman

After death and injuries, two Iowa nursing homes added to federal watchlist

The Northbrook Healthcare and Rehabilitation Center, formerly known as Northbrook Manor, in Cedar Rapids, Iowa. (Photo via Google Earth)

The federal government has added two Iowa nursing homes to its list of the worst care facilities in the nation.

Adel Acres and Northbrook Healthcare and Rehabilitation Center in Cedar Rapids have been added to the Center for Medicare and Medicaid Services’ nationwide list of care facilities that are eligible for special-focus status, indicating a history of serious, recurring resident-care issues.

At any given time, two to five nursing homes per state appear on the list of federally designated “special-focus facilities,” while 10 others in each state are typically designated as eligible for such a designation due to recurring resident-care issues.

The 100 facilities that are designated special-focus facilities are subject to a comprehensive, on-site inspection at least once every six months, with the expectation that they will eventually take substantive action to address any ongoing issues.

The two Iowa nursing homes that are currently enrolled in the special-focus program are Garden View Care Center in Shenandoah, and Pine Acres Rehabilitation and Care Center in West Des Moines. Garden View has been in the program for 14 months and Pine Acre for 16 months.

Adel Acres cited for resident death

Adel Acres’ addition to the list of eligible facilities appears to be tied to the 24 state and federal violations cited at the facility during the past 12 months.

In October 2025, the state proposed, but held in suspension, $14,500 in fines against Adel Acres. Inspectors alleged a resident of the home fell and subsequently died of blunt force head trauma after the staff failed to promptly intervene and assess the resident’s condition. In a separate incident, the home allegedly failed to follow a physician’s order to administer antibiotics for a resident with an infection. The resident was re-hospitalized for sepsis, a potentially life-threatening condition that stems from an infection.

In response to that situation, the federal government imposed a $16,544 fine against Adel Acres.

In March 2026, the state proposed, but held in suspension a $15,000 for medication errors at Adel Acres. A resident who was mistakenly given an overdose of Oxycodone later “appeared pale, with garbled speech and not making sense,” inspectors reported. Two employees had each mistakenly given the resident three times the prescribed amount of the drug, inspectors concluded.

In response to the March 2026 findings, the federal government imposed a $41,470 fine against Adel Acres.

In June 2026, the state proposed, but held in suspension, a fine of $5,250 against Adel Acres, alleging the staff failed to provide adequate nursing supervision for a female resident who fell from the bed to the floor, causing “significant pain and injuries.”

A worker at the home had allegedly attempted to change the sheets on the resident’s bed, with the resident still in the bed. According to inspectors, the worker stated he stood on one side of the bed and pulled the sheet toward him, causing the resident to slip off the opposite side of the bed and onto the floor. One employee told inspectors the woman was “in true pain and was screaming out in pain — a blood-curdling scream.”

CMS has yet to publicly report any federal fines associated with the June 2026 findings at Adel Acres.

The Iowa Capital Dispatch was not able to reach the home’s administrator for comment.

Northbrook fined by federal agency

The addition of Northbrook Healthcare and Rehabilitation Center to the list of eligible facilities appears be tied to the July 2026 findings of state inspectors who proposed, but held in suspension, a $10,000 fine against the home. Inspectors alleged the staff failed to monitor the urinary output of four residents with catheters, three of whom were then diagnosed with a urinary tract infection.

One of the residents allegedly showed “no urinary output for 32 hours” and on Jan. 12, 2026, was taken to a hospital where his catheter was removed, resulting in “a large gush of blood from the patient’s urethra.” According to inspectors, the man was then transferred to an intensive care unit for treatment of acute kidney injury and a life-threatening case of sepsis. The resident was then placed in hospice care and died on Feb. 5, 2026, according to inspectors.

In response to the July 2026 findings, the federal government imposed a $16,435 fine against Northbrook Healthcare and Rehabilitation Center.

Earlier this year, the home’s administrator declined to comment on the situation but said the home had procedures in place to ensure residents were properly cared for.