Inspection Reports for
Good Samaritan Society – Forest City

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.

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.

The complaint investigation was substantiated. The incident involved a staff member who had a consensual relationship with Resident #2, including inappropriate messages and a kiss. The staff member was arrested for dependent adult abuse.

The facility failed to ensure a resident was free from abuse involving inappropriate communications and a physical relationship between a staff member and a resident. The staff member was arrested for dependent adult abuse following the investigation.

The complaint involved allegations of abuse by Staff A toward Resident #2. The investigation substantiated the complaint, resulting in Staff A's arrest for dependent adult abuse. The relationship was consensual but violated facility policies and legal standards.

The facility failed to protect Resident #2 from abuse by a staff member who engaged in a consensual but inappropriate relationship, resulting in dependent adult abuse charges. The facility also failed to provide appropriate catheter care for Resident #17, with catheter urine bags repeatedly observed touching the floor contrary to policy and CDC guidelines.

Facility reported incident #120372-I was substantiated.

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.

The facility failed to provide adequate nursing assessments and interventions related to fluid retention and diuretic use for Resident #21, and failed to provide appropriate supervision during transfers for Resident #87, resulting in injury. Documentation and communication deficiencies were noted.

The facility failed to develop comprehensive care plans addressing high-risk medications for multiple residents, did not provide adequate nursing assessments and interventions for fluid retention and edema, failed to ensure proper nursing supervision during transfers resulting in a resident fall and fracture, and did not consistently obtain food temperatures or maintain kitchen equipment cleanliness.

The complaint investigation was triggered by concerns that the facility failed to notify family and physician of incidents involving residents #17 and #27, and failed to provide appropriate assessments and interventions. The investigation confirmed these failures and also identified diet texture noncompliance affecting multiple residents.

The facility failed to notify family and physician timely about incidents involving residents #17 and #27. The facility also failed to provide appropriate assessments and interventions for these residents. Additionally, the facility failed to provide correct diet textures to at least six residents, resulting in an Immediate Jeopardy situation that was later abated.

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.

The complaint investigation found substantiated failures in obtaining urine analyses as ordered and applying TED hose, as well as failure to promptly identify and respond to a resident's acute condition change leading to a fracture diagnosis.

The facility failed to obtain urine analyses for two residents as ordered and failed to apply TED hose for one resident. Additionally, the facility failed to promptly identify and intervene for an acute change in condition related to pain, swelling, and bruising in a resident's right upper arm, which resulted in a diagnosis of a right humerus fracture.

Complaints #103966-C and #107763-C were substantiated. Facility reported incident #109249-I was substantiated.

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.

Complaint #98624 was not substantiated. Incident #99157 was not substantiated.

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.

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.