Inspection Reports for Good Samaritan Society – Forest City
606 South Seventh Street, Forest City, IA, 504362032
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 21, 2025 found the facility in substantial compliance with no deficiencies. Earlier inspections showed a mixed record, with some deficiencies related to resident care, including abuse and neglect findings in August 2025 and issues with catheter care. Prior reports also noted deficiencies in care planning, nursing assessments, accident prevention, and food safety, as well as some substantiated complaints involving failure to identify and intervene for resident condition changes. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows periods of improvement following corrective actions, but some recurring challenges in care quality and staff conduct have appeared over time.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
34 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
A complaint investigation for facility reported incident #2644782-I was conducted on October 20, 2025 to October 21, 2025.
Complaint Details
Investigation was related to incident #2644782-I; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 25, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of compliance and plan of correction for certification.
Findings
The facility was found to be in compliance based on the accepted plan of correction, with no specific deficiencies detailed in this document.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
A recertification survey and investigation of complaint #2562150-A and self-reported incident #2562198-M were conducted from 8/4/25 to 8/7/25, resulting in findings related to abuse and neglect and catheter care.
Complaint Details
Complaint #2562150-A and self-reported incident #2562198-M were investigated. The citation for abuse and neglect was considered past non-compliance. The investigation included interviews, review of phone messages, police reports, and staff statements. Staff A was arrested for dependent adult abuse.
Findings
The facility was found not free from abuse and neglect related to a resident's interaction with staff, including inappropriate conduct and dependent adult abuse. Additionally, the facility failed to provide appropriate catheter care for a resident, with catheter bags observed touching the floor contrary to policy and CDC guidelines.
Deficiencies (2)
Facility failed to ensure a resident was free from abuse, neglect, misappropriation of resident property, and exploitation, including inappropriate conduct and dependent adult abuse by staff.
Facility failed to provide appropriate catheter care for a resident, including ensuring catheter bags did not touch the floor.
Report Facts
Census: 34
Deficiencies cited: 2
Education date: Aug 21, 2025
Audit frequency: 2
Audit frequency: 1
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in dependent adult abuse finding and arrest | |
| Director of Nursing | Director of Nursing | Provided education to nursing staff on catheter bag care and stated expectations for catheter bag placement |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
The inspection was conducted as a facility complaint investigation #126070-C.
Complaint Details
The complaint investigation #126070-C was conducted and no deficiencies were found.
Findings
No deficiencies resulted from the facility complaint investigation conducted on February 26, 2025.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective September 19, 2024.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification of compliance effective September 19, 2024.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 4
Date: Sep 5, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of a substantiated facility reported incident #120372-I from September 3 to September 5, 2024.
Complaint Details
Facility reported incident #120372-I was substantiated.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, quality of care related to nursing assessments and interventions, free of accident hazards and supervision, and food safety requirements. Specific failures included incomplete care plans addressing high-risk medications, inadequate nursing assessments for fluid retention, and failure to document proper use of assistive devices and wound care. The facility reported a census of 35 residents during the survey.
Deficiencies (4)
Failed to develop and implement comprehensive care plans addressing risk factors and interventions for 3 of 13 residents reviewed.
Failed to provide assessment and interventions necessary to maintain residents' highest practical physical well-being for 1 of 13 residents reviewed.
Failed to provide adequate nursing supervision to prevent accidents and injuries for 1 of 3 residents reviewed.
Failed to obtain food temperatures and maintain kitchen cleanliness to meet food safety standards.
Report Facts
Residents reviewed for comprehensive care plans: 13
Residents reviewed for quality of care: 13
Residents reviewed for accident supervision: 3
Resident census: 35
Deficiency counts: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in relation to failure to provide appropriate level of assistance during resident transfer resulting in injury |
| Staff B | Registered Nurse (RN) | Named in relation to resident assessment after fall and care plan follow-up |
| Administrator | Administrator | Reported disciplinary action and education related to deficiencies |
| DON | Director of Nursing | Acknowledged and verified care plan and assessment issues, reported on medication and resident assessments |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
A revisit of the survey ending October 19, 2023, and investigation of complaint #116593-C was conducted on November 14-15, 2023.
Complaint Details
Complaint #116593-C was investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective November 8, 2023. Complaint #116593-C was not substantiated.
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 3
Date: Oct 16, 2023
Visit Reason
The inspection was the facility's annual recertification survey conducted from October 16, 2023 to October 19, 2023.
Findings
The facility failed to notify the family and/or physician of incidents involving residents #17 and #27, including a cold sore and a coughing/choking episode. The facility also failed to assess and provide interventions for these residents in a timely manner. Additionally, the facility failed to provide the correct texture of diets to at least six residents for an extended period.
Deficiencies (3)
Facility failed to notify family or physician of incidents involving residents #17 and #27.
Facility failed to assess and provide interventions for residents #17 and #27 after condition changes.
Facility failed to provide correct texture of diets to at least six residents for an extended time.
Report Facts
Census: 38
Residents with diet texture issues: 6
Residents reviewed for notification failures: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Registered Nurse (RN), Wound Nurse | Acknowledged lack of documentation and notification regarding Resident #17's cold sore |
| Staff G | Licensed Practical Nurse (LPN) | Initially assessed Resident #27 after coughing/choking episode and reported to Staff I |
| Staff I | Registered Nurse (RN) | Received report from Staff G about Resident #27's coughing/choking episode |
| Staff F | Speech Therapist | Evaluated residents for International Dysphagia Diet Standardization Initiative (IDDSI) diets |
| Staff A | Speech Therapist | Evaluated residents for IDDSI diets and provided training |
| Staff C | Cook | Prepared pureed food and managed diet menus |
| Staff D | Certified Nurse Assistant (CNA) | Assisted Resident #24 with meals |
| Staff B | Cook | Prepared meals and trained on IDDSI diet |
| Staff H | Certified Nurse Assistant (CNA) | Called for nurse during Resident #27's coughing episode |
| Director of Nursing (DON) | Director of Nursing | Acknowledged lack of notification and assessment for residents #17 and #27 |
| Administrator | Administrator | Educated staff on notification policies and diet procedures |
| Certified Dietitian Manager (CDM) | Certified Dietitian Manager | Managed dietary assessments, training, and diet menu compliance |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
An investigation of complaint #112536-C and revisit of the survey ending April 25, 2023 was completed from May 30, 2023 to June 1, 2023.
Complaint Details
Complaint #112536 was not substantiated.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective May 9, 2023. Complaint #112536 was not substantiated.
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 3
Date: Apr 25, 2023
Visit Reason
The inspection was conducted as a result of investigation of complaints #103966-C, #107763-C, and facility reported incident #109249-I from April 17 to April 25, 2023. Additionally, a COVID-19 Focused Infection Control Survey was conducted during this period.
Complaint Details
Complaints #103966-C and #107763-C were substantiated. Facility reported incident #109249-I was substantiated.
Findings
The facility was found to be in compliance with CDC recommended practices for COVID-19. However, deficiencies were identified related to failure to obtain urine analysis as ordered, failure to apply TED hose as ordered, and failure to promptly identify and intervene for a resident's condition change resulting in a fracture. These deficiencies were substantiated and affected multiple residents.
Deficiencies (3)
Failure to obtain urine analysis as ordered for residents reviewed.
Failure to apply TED hose per physician orders for Resident #5.
Failure to promptly identify and intervene for a resident's condition change related to pain, swelling, and bruising resulting in a right humerus fracture for Resident #7.
Report Facts
Total Residents: 35
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Services | Director of Nursing Services | Named in relation to education of nursing staff on TED hose application and urine analysis procedures. |
| Staff A | Licensed Practical Nurse | Interviewed regarding Resident #7's condition and bruising. |
| Staff B | Licensed Practical Nurse | Interviewed regarding Resident #7's condition and bruising. |
| Staff C | Registered Nurse | Interviewed regarding Resident #7's condition and bruising. |
| Staff D | Licensed Practical Nurse | Interviewed regarding Resident #7's condition and bruising. |
| Staff E | Registered Nurse | Interviewed regarding Resident #7's condition and bruising. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
The document is a plan of correction acceptance following a prior inspection, indicating the facility's compliance and certification effective March 9, 2022.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance as of March 9, 2022.
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 3
Date: Feb 10, 2022
Visit Reason
The inspection was conducted as part of an annual health recertification survey and investigation of complaint #98624-C and facility reported incident #99157.
Complaint Details
Complaint #98624 was not substantiated. Incident #99157 was not substantiated.
Findings
The facility was found not to have notified the Long Term Care Ombudsman for 1 of 4 residents transferred to the hospital, and failed to document menu changes and notify residents and dietician accordingly. Additionally, the facility lacked a current contract with one hospice provider.
Deficiencies (3)
Facility failed to notify the Long Term Care Ombudsman for 1 of 4 residents transferred to the hospital.
Facility failed to document menu changes, notify residents and dietician of menu changes as required.
Facility failed to have a current contract with one hospice provider.
Report Facts
Total residents: 35
Residents transferred to hospital: 1
Hospice contracts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Holly Smith | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Dietary Manager | Interviewed regarding menu substitutions and dietician approval | |
| Dietician | Interviewed regarding menu changes and approval process | |
| Director of Nursing | Interviewed regarding documentation of menu changes |
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 0
Date: Sep 10, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from August 20 to September 10, 2020. The Department also investigated multiple complaints and an incident during this period.
Complaint Details
Complaints #92076-C, #92793-C, #93005-C and incident #92836-I were investigated and found not substantiated.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices during the COVID-19 outbreak. The complaints and incident investigated were not substantiated.
Report Facts
Total residents: 35
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 4
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from 6/15/20 to 6/17/20 to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found non-compliant with CMS and CDC COVID-19 infection control practices. Deficiencies included failure to develop and implement comprehensive care plans, inadequate infection prevention and control practices, and failure to follow the Antibiotic Stewardship Program requirements.
Deficiencies (4)
Failure to develop and implement a comprehensive person-centered care plan for each resident, including discharge planning and wound care.
Failure to establish and maintain an infection prevention and control program that includes surveillance, policies, hand hygiene, and staff education.
Failure to follow appropriate infection control practices during wound care, including hand hygiene and glove use.
Failure to follow the Antibiotic Stewardship Program, including monitoring and follow-up of antibiotic treatment for MRSA infection.
Report Facts
Total residents: 32
Survey dates: 6/15/20 to 6/17/20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Nance | Administrator | Signed the report and plan of correction |
| Gina Anderson | Infection Preventionist | Named in wound care and infection control education and monitoring |
| Director of Nursing | Interviewed regarding care plan and infection control deficiencies | |
| Staff A | Licensed Practical Nurse (LPN) | Observed performing wound care with infection control deficiencies |
| Staff C | Activity Director | Interviewed about social services and discharge planning |
| Staff D | Social Service Worker (SSW) | Interviewed about discharge planning |
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