Garden View Care Center

F-F732 Posted Nurse Staffing Information,

The facility's complaint survey ending on 4/5/2024:

a)

F-F842 Resident Records-Identifiable Information

The facility's annual recertification survey ending on 7/25/2024:

a)

F-F865 QAPI Program/Plan Good Faith Attempt

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 e)

F-F880 Infection Control

Level of Harm - Minimal harm or On 2/27/2025 at 8:41 AM the Administrator stated after a survey, the results are shared with the potential for actual harm management team members and start their plan of correction of moving forward, work on meeting the standards to get back in compliance. When asked what is done to ensure items identified are not repeated in Residents Affected - Some future surveys, he stated depends on the items identified. They may need to demote or remove staff, do more audits, provided education and see what training needs to be redone. They will do daily or weekly reports to see what has been done and what issues have come up that have not been addressed yet.

The facility provided a document titled Quality Assurance Performance Improvement (QAPI), Quality Assessment Assurance (QAA) Plan with a revision date of 1/2/2025. The purpose of QAPI in our organization is to develop a culture of proactive leadership that solicits the input from employees in various departments, including contracted professionals, if indicated, as well as those we serve residents, resident representatives, and family members. Further, our purpose includes ongoing development of plans for improvement leading to systematic changes that support exceptional health care to seniors and operating excellence in every aspect of our business.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37074 potential for actual harm Based on observations, record review, staff and resident interviews, and facility policy reviews the facility Residents Affected - Some failed to ensure all staff wore masks, and provided masks upon entry in to the facility while in outbreak status. Staff also failed to follow proper practices when obtaining a resident's blood sugar and prior to administering resident's insulin. The facility reported a census of 37 residents.

Findings include:

1. On 2/13/2025 at 11:45 AM on the front entrance door was a sign that notified visitors the facility was in outbreak status, masks are required. Once inside the main entrance double doors, no masks were available to put on. There were no masks and no one at the nurse's station at the start of center hall. One had to walk down center hall to the nurse's station where the three halls meet to ask for a mask.

On 2/13/2025 at 12:20 PM the Administrator walked in the surveyor's room with no mask on, there was no mask present around his neck or in his hands. At 2:25 PM the Administrator was at the back nurse's station with no mask on, no mask around his neck or chin. Once he saw the surveyor, he put on a mask. At 4:13 PM observed the Director of Nursing (DON) walking around behind the nurse's station with no mask on, she had been witnessed to be coughing throughout the day.

On 2/14/2025 at 8:30 AM the sign remained on the front door indicating masks required for staff and visitors. Once inside the facility through the front doors, no masks available at the main entrance. At 8:45 AM observed the DON and Administrator at the back nurse's station with no masks on. At 10:35 AM the DON walked from her office to the Administrators office without a mask on, she was observed coughing without covering her mouth.

On 2/18/2025 at 10:00 AM Staff I Dietary Aide (DA) walked from the kitchen to the front of the building. At 10:01 AM Staff I walked from the front of the building to the kitchen with a mask on. At 3:30 PM the Activity Director (AD) assisted 11 residents with an activity. The AD had his mask on his chin, not covering his nose and mouth. At 3:45 PM the AD remained in the dining room with residents assisting with an activity, 11 residents remain for the activity. Once he saw the surveyor he covered his mouth and nose with his mask. At 3:52 PM 11 residents remained in the dining room for the activity and the AD mask was off again.

On 2/19/2025 at 9:56 AM the Administrator placed masks on the table directly in front of the front entrance.

On 2/20/2025 at 11:07 AM the AD assisted 8 residents with an activity in the dining room with his mask down, not covering his face or nose. The Transportation staff member walked down [NAME] hall with her mask below her chin, not covering her mouth and nose. Staff A Licensed Practical Nurse (LPN) observed at

the nurse's station with her mask on her chin, below her mouth and nose.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/25/2025 at 8:45 AM the DON reported they had 6 new cases of COVID-19 since the 21st. She reported none of the residents were showing signs and symptoms. At 10:41 AM the Social Worker walked down Level of Harm - Minimal harm or [NAME] hall from the dining room with her mask under her chin. Once she saw the surveyor she pulled the potential for actual harm mask over her mouth and nose. At 1:19 PM the Social Worker walked down center hall, passing 3 residents and 2 staff members with her mask below her chin. Once she saw the surveyor she pulled her mask over her Residents Affected - Some mouth and nose.

On 2/26/2025 at 10:30 AM Staff J Certified Medication Aide (CMA) was at the medication cart at the beginning of East hall with her mask under her chin. Staff C LPN sat at the nurse's station with her mask below her chin. At 10:37 AM the AD walked out of resident room [ROOM NUMBER] with his mask under his chin, once he saw the surveyor he pulled his mask up to cover his nose and mouth. At 10:38 AM the Social Worker walked from her office on center hall, down east hall to the room where the vending machines were with her mask under her chin, not covering her mouth or nose. At 11:08 AM the AD was at the front of the facility with 6 residents assisting with an activity. His mask was under his chin, once he saw the surveyor he pulled the mask up to cover his nose and mouth.

The facility provided a document titled Long Term Care (LTC) Respiratory Surveillance Line List dated 2/24/2025. The list documented the Transportation staff member tested positive for COVID-19 on 2/21/2025 with the following symptoms documented: fever, cough, body aches, headaches, and chills.

On 2/23/2025 at 10:00 AM located behind the nurse's station, a print out was posted on the bulletin board.

The ADON stated the Corporate Infection Control Nurse sent this via email at the start of their outbreak. The print out contained the following information: COVID-19 1 positive, 2 staff:

1. Resident isolation x 10 days with today being day 0, to come off isolation on 2/21/2025. They may only exit room for medical necessary reasons with source control in place. Full set of vitals and respiratory assessment completed every shift for monitoring for 10 days.

2. Roommate of positive resident (if they have one) should be tested every 48 hours for 3 days and monitored for symptoms every shift with full set of vitals for 10 days. If the roommate is able to wear source control they may come out of their room, but only if they are willing to be tested per the above schedule and war a mask when outside of their room. If they are unable and or unwilling to comply with that rule, they must be placed on contact/droplet isolation for 7 days until the final test confirms they are negative.

An outbreak sign must be posted for both outbreaks at the front door. As well ensure there is a passive screen sign for COVID-19 posted at the front door at all times. It must remain in place always.

Outbreak: now that you are in outbreak as far as COVID-19 goes, all staff are required to wear surgical masks at all times. You will be in outbreak status a minimum of 2 weeks. You must complete routine testing of all staff and residents a minimum of every 7 days. This will continue until you have no new positives for 14 days.

On 2/19/2025 at 7:05 AM Staff W Certified Nursing Assistant (CNA) stated since they have been in outbreak status, staff are not wearing masks in the halls or in resident's rooms. She started to wear one once everyone started to get sick.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/19/2025 at 1:26 PM Staff C Licensed Practical Nurse (LPN) stated the facility used to have sheets that were filled out that included the time tested and whether the test was positive or negative. She indicated Level of Harm - Minimal harm or masks are worn when remembered to do so. They started in outbreak status once they had staff and potential for actual harm residents test positive for COVID-19 plus an Influenza positive resident.

Residents Affected - Some On 2/21/2025 at 10:13 AM Staff D CNA stated the facility is not doing COVID-19 since they have been in outbreak status. She stated even for staff, they are doing them so she is doing them on her own at home. It's been a concern that they are not doing testing, people have been asking for guidance but they get told there is no protocol to follow. When the previous Administrator was in house, they were testing every 48 hours. Staff D stated they have not been testing residents either. When asked what their current protocol is she indicated she is unsure of it. They thought they should be following CDC guidelines but was told the facility makes up their own guidance.

On 2/25/2025 at 2:15 PM Staff S Agency CNA stated masks are not getting worn. A lot of times they are on their neck or under staff's nose. They are not keeping track of COVID-19 testing; they test two days ago but

before that they were tested the week prior. They used to have to fill out sheets when they would get tested to help keep track of things but they don't have that anymore.

The facility provided a document titled COVID-19 Policy Guidelines with a revision date of 9/1/2024. The policy indicated the facility has established protocol for the prevention and spread of COVID-19 in accordance with the CDC, CMS, and State/Local Agencies. For residents and visitors, the safest practice is to wear masks. All employees, consultants, contractors should be educated related to virus, infection control, prevention, early detection, and monitoring.

Resident close contact exposure: if a the resident or family report possible close contact to an individual with COVID-19 the facility testing should be as follows, test 24 hours after known exposure and if negative, again 48 hours after the first negative test and, if negative, 48 hours after the second negative test. The resident should be monitored for signs and symptoms and wear source control for 10 days.

All residents experiencing a new onset of symptoms as outlined by the CDC consistent with that of COVID-19 should be placed on airborne transmission-based precautions and testing should be performed.

1) All symptomatic resident with a positive antigen test should be considered positive for COVID-19.

2) A symptomatic resident with a negative antigen test should have a confirmatory NAAT/PCR test completed, or a second antigen test performed 48 hours after the first negative test.

Empiric Use of Transmission Based Precautions (quarantine): Residents who have experienced close contact and remain asymptomatic do not require empiric use of transmission-based precautions.

1) The resident should wear source control for 10 days following the exposure

2) The resident should be tested immediately but not sooner than 24 hours after known exposure and if negative, again 48 hours after the first negative test and, if negative, 48 hours after the second negative test.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 3) The resident should be monitored for signs and symptoms and wear source control.

Level of Harm - Minimal harm or High risk exposure requiring testing with no work restriction: potential for actual harm 1) The healthcare provider should wear source control for 10 days following the exposure, and Residents Affected - Some 2) Perform COVID-19 testing immediately (but not earlier than 24 hours after the exposure) and, if negative, again in 48 hours after the first negative test, if negative, again 48 hours after the second negative test and

3) Follow all recommended infection prevention control practices including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19 and not reporting to work when ill or if testing positive for COVID-19 infection.

2. According to the quarterly Minimum Data Set (MDS) assessment tool with a reference date of 12/4/2024 documented Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15. A BIMS score of 15 suggested no cognitive impairment. Resident did not refuse cares during the review period and received insulin. The following diagnoses were listed for Resident #2: type 2 diabetes mellitus, renal failure.

The Care Plan focus area with a revision date of 6/16/2024 documented Resident #2 had diabetes mellitus type 2. Staff were directed to administer diabetes medications as ordered by her doctor and to monitor/document for side effects and effectiveness.

Resident #2 had the following orders:

a) Blood sugars four times a day (QID), with an order start date of 10/2/2023,

b) Humalog (treatment of diabetes) injection solution 100 unit/milliliters (u/mL), inject per sliding scale.

On 2/18/2025 at 10:35 AM Resident #2 stated Staff A has a habit of doing accuchecks and giving insulin without using alcohol wipes. Resident #2 would tell her she needed to use the wipes and Staff A would tell her she forgot the wipes. Resident#2 would tell Staff A she is not forgetting to use the alcohol wipes with her. Resident #2 stated it's just crazy to her that she would not use alcohol wipes before getting her blood sugar and before administering her insulin.

3. According to the annual MDS assessment tool with a reference date of 1/30/2025, Resident #6 had a BIMS score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS documented she received insulin 7 days of the 7-day review period. The MDS listed the following diagnoses: stage 5 kidney disease, hypertension, renal failure, diabetes mellitus, thyroid disease, Parkinson's disease, anxiety, and depression.

The Care Plan focus area with a revision date of 11/19/2019 documented Resident #6 was insulin dependent due to her diagnosis of diabetes mellitus. She received Humalog sliding scale daily before meals. Staff were directed to administer insulin as ordered by doctor and to monitor/document for side effects and effectiveness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Resident #6 had the following orders:

Level of Harm - Minimal harm or a) Lantus (treatment of diabetes) 100 u/mL, give 30 U two times a day (BID), with an order date of 2/3/2025 potential for actual harm b) Lyumjev 100 u/mL, inject as per sliding scale, with an order date of 2/3/2025. Residents Affected - Some

On 2/25/2025 at 1:14 PM Resident #6 indicated she had a device placed on her upper arm that monitors her blood sugars. When staff replaces the device, they cleanse the area prior to placing a new device. When

they administer her insulin in her abdomen or the back of her upper arms, not all staff cleanse the area prior to administering her insulin.

4. According to the Annual MDS assessment tool with a reference date of 2/13/2025 Resident #8 had a BIMS score of 15. A BIMS score of 15 suggested no cognitive impairment. Resident #8 received insulin 7 days during the 7 day review period. The MDS listed the following diagnoses for Resident #8: diabetes mellitus, depression, long term use of insulin and obesity.

The Care Plan focus area with a revision date of 11/18/2024 documented he had diabetes mellitus and had

an order to self-administer his insulin. The Care Plan directed staff to administer diabetic medications as ordered by the doctor.

Resident #8 had the following orders:

a) Tresiba (treatment of diabetes mellitus) inject 45u every day, with a start date of 11/5/2024,

b) Lyumjev 100u/mL give 15 U before meals, with a start date of 4/20/2024,

c) Lyumjev 100u/mL inject per sliding scale, with a start date of 4/9/2024,

d) Accuchecks four times day, with a start date of 11/9/2022.

On 2/18/2025 at 3:48 PM Resident #8 stated Staff A on the evening shift will check his blood sugars but does not cleanse his finger before checking it. She also does not cleanse the site before she gives him his insulin. She does this a lot and when asked why, Staff A would tell him she forgot the alcohol wipes. Resident #2 will argue with Staff A until she goes to get an alcohol wipe. Resident #8 stated he stopped asking her because it was the same excuse each time and nothing changed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 2/13/2025 at 11:43 AM Staff C Licensed Practical Nurse (LPN) stated residents have told her that Staff A does not cleanse sites before obtaining resident's blood sugars and before administering their insulin's. At Level of Harm - Minimal harm or one time Resident #8 made Staff A go get an alcohol wipe because she told him she forgot. During a follow potential for actual harm up on 2/19/2025 at 1:26 PM Staff C stated prior to obtaining a resident's blood sugar, you must cleanse the site with an alcohol wipe, make sure the area is dry then use the lancet to obtain the sample. The same goes Residents Affected - Some for when administering insulin, you let the resident know what you are doing, ask where they would like the insulin administered then cleanse the site then administer the insulin. During a follow up interview on 2/21/2025 at 9:39 AM Staff C stated two Mondays ago, the ADON printed off COVID-19 testing guidelines informing them they were in outbreak status, staff need to be in masks for two weeks, testing needed to be done every seven days, until there are no new positives for 14 days. Staff C stated there are residents that are currently sick so she is testing residents and as of current she has had four residents test positive.

On 2/19/2025 at 11:03 AM Staff F Registered Nurse (RN) stated when obtaining a resident's blood sugar staff should cleanse the resident's finger with an alcohol wipe first. Same goes prior to administering their insulin; the site should be cleansed with an alcohol wipe first.

On 2/25/2025 at 9:29 AM Staff T CNA stated depending on who is working depends on whether or not masks are being worn. They are not testing staff members, she does her own testing.

On 2/25/2025 at 10:30 AM Staff E Certified Medication Aide (CMA) stated COVID-19 testing is not getting done. She stated when the previous Administrator was there, they were doing testing every 48 hours, but now that's not getting done. Staff used to have sheets to fill out when staff were tested but they don't have that anymore. The last time she had a COVID-19 test was last Wednesday (2/19/2025). Staff E was asked if masks are being worn at the facility, she laughed and said people are not wearing them like they were supposed to.

On 2/26/2025 at 11:45 AM the DON stated while they are in outbreak status the protocol is supposed to be

the residents are tested initially, then 48 hours later all residents are to be bested. The residents that are positive will be tested again at the end of the 10-day isolation period. Staff should be tested before coming in to work and that is offered onsite. When asked she was aware staff are not wearing their masks appropriately or at all, she indicated she knew. They should be worn at all times, unless staff are in their own personal space. The DON was asked to define personal space, she stated: in their office, bathroom. They should be worn when staff are within 6 feet of any human being, it should always be on during resident cares and should be worn appropriately over their mouth and nose. The DON indicated she will educate staff on wearing them appropriately. The DON indicated when obtaining a resident's blood sugar staff should cleanse

the resident's finger with an alcohol wipe prior to getting their blood sugar. When staff administer the resident's insulin, they should cleanse the site prior to administration with an alcohol wipe.

The facility provided a procedure titled Blood Sampling-Capillary (Finger Sticks) with a revision date of September 2014. The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees.

Steps in the procedure:

5. Wipe the area to be lanced with an alcohol wipe

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 61 165531 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 165531 B. Wing 02/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Garden View Care Center 1200 West Nishna Road Shenandoah, IA 51601

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 6. Obtain the blood sample.

Level of Harm - Minimal harm or The facility provided a document titled Insulin Administration with a revision date of September 2014. The potential for actual harm purpose is to provide guidelines for the safe administration of insulin to residents with diabetes.

Residents Affected - Some Steps in the procedure:

16. select an injection site

17. clean the infection site with an alcohol wipe and allow to air dry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 61 165531