Garden View Care Center

F-F865 QAPI Program deficient practice cited during the Complaint Survey ending on 9/11/24 and the Complaint Survey ending on 2/27/25

During an interview on 4/10/25 at 11:30 AM, the Administrator said that the QA (Quality Assurance) team has been meeting monthly since they started the transition of companies. He stated that they have made progress but there have been so many areas in need of change it's been a slow process.

The QAPI Facility Plan dated 1/2/25, the facility specific goals included to implement the QAPI process successfully as evidenced by the formulation of effective Performance Improvement Plans. Systematic action would be analyzed by the PIP committee not only for desired outcome but also for any unintended outcomes.

The Root Cause Analysis (RCA) would be completed when a significant event or practice that may negatively impact a resident safety or reception of quality care was identified through QAPI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 165531 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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** 47673 potential for actual harm Based on observation, clinical record review, policy review, and staff interview the facility failed to use Residents Affected - Some Enhanced Barrier Precautions (EBP) when providing ileostomy care for 1 of 3 residents (Resident #26), and complete an annual review of the facility Infection Prevention and Control Program (IPCP). The facility reported a census of 41 residents.

Findings include:

1. The Minimum Data Set (MDS), dated [DATE REDACTED] for Resident #26 documented a Brief Interview for Mental Status (BIMS) of 11 indicating moderate cognitive impairment. MDS also indicated Resident #26 utilized an ileostomy (an opening in the abdominal will from the small intestine to the outside the body to allow waste to exit the body).

During an interview on 4/7/25 at 1:35 PM, Resident #26 stated he had an ileostomy that was about a month old. Resident #26 stated the staff do not ever wear gowns when emptying his colostomy bag.

Review the Care Plan, Date Initiated: 3/24/25 revealed a Focus area to address Requires enhanced barrier precautions related to the presence of ileostomy. The Focus area included the Intervention: PPE (Personal Protective Equipment) and waste disposal regularly monitored for compliance. Date Initiated: 3/24/25.

During a continuous observation on 4/8/25 starting at 12:48 PM, Staff M, Certified Nursing Assistant (CNA) and Staff G, CNA emptied Resident #26 ' s ileostomy collection bag. Both staff completed hand hygiene, and donned gloves. Neither staff donned a gown. Staff M obtained a graduated container (a container that has markings to measure contents collected) and garbage bag, which she placed inside of the graduate. Staff M proceeded to unfold the ileostomy bag, and emptied the contents into the bagged graduate container. Staff M handed the garbage bag to Staff G. Staff M cleansed the open end of the ileostomy bag and resealed. Gloves were removed by both staff and placed in the garbage bag with the waste. Both staff completed hand hygiene. Staff G then carried the garbage bag down the hall to the garbage area in the hallway.

During an interview on 4/9/25 at 11:01 AM, the Director of Nursing (DON) stated if a resident was on EBP then a gown should have been worn in the room when the ileostomy was emptied. The DON acknowledged Resident #26 was on EBP.

Review of policy dated 3/25/24 titled, Enhanced Barrier Precautions revealed a Policy Statement which declared Enhanced Barrier Precautions are utilize to prevent the spread of multi-drug resistant organisms (MDROs) to residents. The Policy Interpretation and Implementation section directed, in part:

1. Enhanced Barrier Precautions (EBPs) are used as in infection prevention and control intervention to reduce the spread to multi-drug resistant organisms (MDROs).

2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 165531 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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. Examples of high-contact resident care activities requiring the use of gown and gloves include .g. Indwelling device care of use (Central lines, Urinary catheters, feeding tubs, tracheotomy/ventilator etc). Level of Harm - Minimal harm or potential for actual harm 4. EBPs are indicated (when contact precautions do not otherwise apply) for residents with chronic wounds and/or indwelling medical devices regardless of MDRO colonization. Residents Affected - Some 41785

2. A review of the Infection Control (IC) program for the facility revealed that the Infection Prevention and Control Program policy was last updated on 10/1/22.

During an interview on 4/09/25 11:47 AM, the DON stated that she thought the IC policy would have been reviewed in the Quality Assurance (QA) meetings but she did not have documentation.

Review of the policy, updated 10.01.22, titled Infection Prevention and Control Program revealed a Policy Statement which declared An infection prevention and control program is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transition of communicable diseases and infections. The Policy Interpretation and Implementation section directed, in part:

a. The infection prevention and control program is developed to address the facility-specific infection control needs and requirements identified in the facility assessment and the infection control risk assessment. The program is reviewed annually and updated as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 165531 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41785

Residents Affected - Some Based on clinical record review, facility policy review, and staff interview the facility failed to offer residents a COVID-19 immunization in 2024 for 4 of 5 residents reviewed (Residents #30, #32, #22 and #38.) The facility reported a census of 41 residents.

Findings include:

1. Review of the Minimum Data Set (MDS) dated [DATE REDACTED], revealed Resident #30 admitted to the facility on [DATE REDACTED]. She had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) Her diagnoses included; diabetes mellitus, respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) and morbid obesity. The clinical page in the electronic chart titled: Immunizations, indicated that on 10/2/24

the resident had an influenza immunization. The chart lacked documentation that the COVID-19 immunization had been offered.

2. Review of the MDS dated [DATE REDACTED], revealed that Resident #32 admitted to the facility on [DATE REDACTED]. His diagnoses include; spinal cord injury, muscle wasting atrophy, quadriplegia. The Immunizations tab in the electronic chart documented that the resident had refused a influenza immunization in 2024 and he had a COVID-19 booster in 9/30/22. The chart lacked evidence that the COVID -19 immunization had been offered

in 2024.

3. Review of the MDS dated [DATE REDACTED], revealed Resident #22 admitted to the facility on [DATE REDACTED]. The resident had diagnoses that included; idiopathic peripheral autonomic neuropathy, chronic kidney disease, stage 3, type 2 diabetes mellitus, and benign prostatic hyperplasia. The Immunization page in the electronic chart revealed Resident #22 had the influenza vaccine on 10/2/24 and the COVID-19 vaccine on 11/16/23. The chart lacked information that the COVID-19 vaccine had been offered in 2024.

4. Review of the MDS MDS dated [DATE REDACTED], Resident #38 admitted on [DATE REDACTED]. His diagnoses included; flaccid hemiplegia affecting the right side, peripheral vascular disease, transient cerebral ischemic attack, and osteomyelitis. The immunization page for Resident #38 had completed the influenza vaccine on 10/2/24, but

the chart lacked information that the COVID -19 immunization had been offered in 2024.

During an interview on 4/09/25 at 10:18 AM, the Director of Nursing (DON) said she was not at the facility in October of last year [2024] and was not sure if the COVID -19 vaccine was offered to the residents in 2024.

She said they had a list of 30 residents that would like a COVID vaccine and it's been ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 165531 Department of Health & Human Services Printed: 08/29/2025 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 04/10/2025

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 0887 Review of the facility policy, COVID-19 Policy Guidelines, last updated on 9/1/24, revealed the COVID vaccine would be offered and provided directly or by arrangement with pharmacy partner. The facility would Level of Harm - Minimal harm or educate residents and or resident representatives and staff on COVID -19 vaccinations prior to each dose potential for actual harm administered. The facility would provide COVID-19 vaccinations per CDC (Center for Disease Control) guidance and schedules, resident physician orders and resident/staff consent and administer in accordance Residents Affected - Some with CDC, ACIP (Advisory Committee on Immunization Practices), FDA (Food and Drug Administration) and manufacturer guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 165531

F-F880 Infection Control deficient practice cited during Recertification Survey ending on 7/25/24, Complaint Survey ending on 9/11/24, and Complaint Survey ending on 2/27/25.

b.