The resident, who had moderate cognitive impairment and a month-old ileostomy opening in his abdomen, told inspectors that staff "do not ever wear gowns when emptying his colostomy bag." His care plan specifically required enhanced barrier precautions due to the presence of the ileostomy.
On April 8, inspectors watched as two certified nursing assistants performed the procedure. Both staff members washed their hands and put on gloves, but neither wore a gown. One assistant obtained a graduated container and garbage bag, unfolded the ileostomy collection bag, and emptied the contents. After cleaning the bag and resealing it, both staff removed their gloves, washed their hands again, and one carried the waste bag down the hallway.
The Director of Nursing acknowledged the next day that staff should have worn gowns because the resident was on enhanced barrier precautions. "If a resident was on EBP then a gown should have been worn in the room when the ileostomy was emptied," she told inspectors.
The facility's own policy, dated March 25, 2024, states that enhanced barrier precautions "employ targeted gown and glove use during high-contact resident care activities." The policy specifically lists "indwelling device care" as requiring gowns and gloves, and notes that enhanced precautions apply to "residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization."
The infection control failures extended beyond individual care incidents. Inspectors found the facility had not completed the required annual review of its infection prevention and control program. The program policy was last updated on October 1, 2022, despite requirements for yearly reviews.
When asked about the missing annual review, the Director of Nursing said she thought the infection control policy would have been reviewed during Quality Assurance meetings but could not provide documentation.
The facility also failed to offer COVID-19 vaccinations to residents in 2024. Four of five residents whose records were reviewed had no documentation that they were offered the vaccine during the year, despite receiving flu shots in October.
Resident 30, a woman with diabetes, respiratory failure, chronic obstructive pulmonary disease and morbid obesity, received her influenza vaccine on October 2, 2024. Her medical record showed no evidence that COVID-19 vaccination was offered.
Resident 32, a man with spinal cord injury and quadriplegia, had refused the flu vaccine in 2024 and received his last COVID-19 booster on September 30, 2022. His chart contained no documentation of being offered an updated COVID vaccine in 2024.
Two other residents showed similar patterns. Both received flu vaccines on October 2, 2024, but their records lacked any indication they were offered COVID-19 vaccinations during the year.
The Director of Nursing told inspectors she was not at the facility in October 2024 and was "not sure if the COVID-19 vaccine was offered to the residents in 2024." She said the facility had compiled a list of 30 residents who wanted COVID vaccines and the doses had been ordered.
The facility's COVID-19 policy, updated September 1, 2024, requires staff to offer and provide vaccines "directly or by arrangement with pharmacy partner" and to educate residents before each dose. The policy calls for providing COVID-19 vaccinations according to CDC guidance and schedules.
These infection control violations occurred as Garden View Care Center was undergoing what the Administrator described as a "transition of companies." During an April 10 interview, he said the Quality Assurance team had been meeting monthly since the transition began, noting they had "made progress but there have been so many areas in need of change it's been a slow process."
The facility's Quality Assurance and Performance Improvement plan, dated January 2, 2025, set a goal to "implement the QAPI process successfully as evidenced by the formulation of effective Performance Improvement Plans." The plan called for systematic analysis by a Performance Improvement Plan committee and completion of Root Cause Analysis when significant events that might negatively impact resident safety were identified.
The violations came to light during a complaint survey that concluded April 10. The facility, which reported a census of 41 residents, had previously been cited for QAPI program deficiencies during complaint surveys ending September 11, 2024, and February 27, 2025.
Federal inspectors classified both the infection control failures and COVID vaccination lapses as causing "minimal harm or potential for actual harm" to residents. The Enhanced Barrier Precautions violation affected one resident, while the COVID vaccination failure affected four residents.
Garden View Care Center operates at 1200 West Nishna Road in Shenandoah, a town of about 5,000 people in southwestern Iowa near the Nebraska border. The facility's infection control program policy states its purpose is to "provide a safe, sanitary, and comfortable environment and to help prevent the development and transition of communicable diseases and infections."
The resident with the ileostomy, who had been living with the medical device for about a month when inspectors visited, continues to require daily care from staff who are now supposed to follow proper protective equipment protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Garden View Care Center from 2025-04-10 including all violations, facility responses, and corrective action plans.