Inspection Reports for Good Samaritan Society – Indianola
708 South Jefferson, Indianola, IA, 501250319
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 16, 2025 found the facility to be in substantial compliance with no deficiencies noted. Prior inspections showed a pattern of deficiencies related mainly to staffing shortages, delayed or inadequate resident care including assistance with activities of daily living, medication management issues, and infection control lapses. Several complaint investigations substantiated issues such as failure to maintain resident dignity, insufficient nursing response times, and improper medication storage, but enforcement actions like fines or license suspensions were not listed in the available reports. Most complaints were substantiated, though some investigations found no deficiencies or were corrected upon revisit. The facility’s record shows some improvement with the latest survey indicating compliance following previous citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
88 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 16, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey, indicating acceptance of a credible allegation of substantial compliance and certification of the facility in compliance effective August 16, 2025.
Findings
The facility was found to be in substantial compliance based on the credible allegation and plan of correction, resulting in certification of compliance effective August 16, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 4
Date: Jul 29, 2025
Visit Reason
A complaint investigation was conducted from July 24, 2025 through July 29, 2025, regarding multiple complaints and a facility reported incident.
Complaint Details
The investigation was conducted for Complaints 1697208, 1697210, 1697213, 1692719, 1697226, 2561277 and Facility Reported Incident 1692717. Investigation of complaints #1697210, 1697213, 1697219, 1697226, 2561277 resulted in deficiencies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, delayed feeding assistance, insufficient nursing staff response to call lights, improper medication storage, and failure to disinfect mechanical lifts between resident use.
Deficiencies (4)
Failure to speak to resident in a dignified manner, failure to change a resident's stained shirt after putting the resident in bed, and delayed feeding of a dependent resident.
Failure to provide sufficient nursing staff to respond to resident call lights within 15 minutes and failure to document 15-minute resident checks.
Failure to secure prescribed medications from unauthorized access; medication left unattended on medication cart.
Failure to disinfect mechanical lift between use on different residents.
Report Facts
Census: 88
Call light response time: 45
Missing 15-minute checks: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide (CNA) | Named in dignity and resident rights deficiency for failing to change stained shirt and speaking in undignified manner |
| Staff D | Certified Medication Aide (CMA) | Named in medication storage deficiency for leaving medication unattended on medication cart |
| Staff C | Certified Nurse Aide (CNA) | Named in infection control deficiency for failure to disinfect mechanical lift between resident use |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding staff expectations and deficiencies |
| Administrator | Administrator | Provided statements and education related to deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 15, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance with health requirements effective May 15, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 7
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of multiple complaints and facility reported incidents.
Complaint Details
Complaints #126388-C, #126899-C, #127107-C, #127521-C, and #127817-C were substantiated. Facility reported incidents #126900-I and #128094-I were substantiated.
Findings
The facility was found deficient in multiple areas including failure to maintain accurate advance directives, failure to maintain a safe and clean environment, failure to protect residents from abuse, failure to update care plans after resident-to-resident incidents, failure to provide adequate assistance with activities of daily living, insufficient nursing staff to timely respond to call lights, and failure to implement proper infection prevention and control practices.
Deficiencies (7)
Failure to ensure staff had access to an accurate code status for 1 of 24 residents reviewed for advance directives (Resident #16).
Failure to ensure floors were clean and non-sticky for 1 of 24 resident rooms reviewed (Resident #16).
Failure to protect residents from abuse for 1 of 2 residents reviewed for abuse (Resident #69).
Failure to update and revise the Care Plan to reflect a resident-to-resident incident and interventions for Resident #69.
Failure to ensure a resident received assistance with incontinence care and nail care for 1 of 4 residents reviewed (Resident #16).
Failure to answer resident call lights in a timely manner within 15 minutes for one of two nursing units and failure to address incontinence care needs for Resident #16.
Failure to carry out adequate infection control practices to prevent the spread of infection for 1 of 4 residents reviewed for incontinence cares (Resident #16) and failure to carry out enhanced barrier precautions for 1 of 4 residents who required EPB (Resident #9).
Report Facts
Residents reviewed for advance directives: 24
Facility census: 81
Residents reviewed for abuse: 2
Residents reviewed for ADL care: 4
Residents reviewed for infection control: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Interviewed regarding advance directives and incontinence care. |
| Staff F | Certified Nursing Assistant | Witnessed resident-to-resident abuse incident and reported findings. |
| Staff G | Registered Nurse/Clinical Care Coordinator | Interviewed regarding resident-to-resident abuse incident and resident behaviors. |
| Staff M | Certified Nursing Assistant | Observed assisting resident with incontinence care. |
| Staff D | Certified Medication Aide | Interviewed regarding resident-to-resident abuse incident and infection control practices. |
| Staff E | Certified Nursing Assistant | Interviewed regarding resident-to-resident abuse incident. |
| Staff K | Certified Nursing Assistant | Interviewed regarding medication administration and infection control. |
| Director of Nursing | Director of Nursing | Interviewed regarding care plans, infection control, and call light response. |
| Administrator | Administrator | Interviewed regarding abuse incident and call light system. |
| Social Services Coordinator | Social Services Coordinator | Interviewed regarding resident-to-resident abuse incident and follow-up. |
| Staff J | Licensed Practical Nurse | Interviewed regarding resident monitoring and behaviors. |
| Staff N | Certified Nursing Assistant | Interviewed regarding incontinence care routine. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on February 19, 2025.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective February 19, 2025.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Date: Jan 27, 2025
Visit Reason
The inspection was conducted as a result of investigations into multiple complaints (#124345-C, 124674-C, 124778-C, 125184-C, 125357-C, 125982-C) and facility reported incidents (#125593-I, #125424-I) between January 27, 2025 and January 30, 2025.
Complaint Details
Complaints #124345-C, 124674-C, 124778-C, 125184-C, 125357-C, and 125982-C were substantiated. Facility Reported Incident #125593-I was substantiated.
Findings
The facility was found to have failed in providing adequate nursing supervision to prevent falls for residents at high risk, failed to ensure fall interventions were added to care plans, and failed to provide sufficient nursing staff to meet resident needs. Additionally, the facility failed to maintain appropriate food temperatures during meal service.
Deficiencies (3)
Facility failed to provide adequate nursing supervision for residents at high risk for falls and failed to ensure fall interventions were added to care plans.
Facility failed to provide sufficient nursing staff to meet resident care needs.
Facility failed to serve food within appropriate temperature ranges during meal service.
Report Facts
Complaints investigated: 6
Facility Reported Incidents investigated: 2
Resident census: 78
Dates of investigation: 2025-01-27 to 2025-01-30
Compliance Date: Feb 19, 2025
Staffing review date: Feb 11, 2025
Resident falls documented: 3
Fall risk assessments: Quarterly and after each fall
Audit frequency: Daily x 10 working days, then weekly x 2 months
Food temperature observations: 1
Steam table temperature: 173
Mixed vegetables temperature: 199
Potato salad temperature: 38
Plate warmer temperature: 38
New plate warmer installation date: Feb 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse involved in fall incidents and education | |
| Director of Nursing (DON) | Director of Nursing | Instructed staff education and involved in staffing issues |
| Staff C | Registered Nurse (RN) | Reported staffing concerns and resident falls |
| Staff D | Registered Nurse (RN) | Documented incident reports and assessments for falls |
| Staff F | Certified Nursing Assistant (CNA) | Reported resident fall and head injury |
| Staff G | Registered Nurse (RN) | Reported staffing inadequacies and increased falls and UTIs |
| Staff I | Certified Nurses Aide (CNA) | Reported staffing concerns and burnout |
| Staff J | Certified Nurses Aide (CNA) | Reported staffing struggles and breaks issues |
| Staff K | Certified Nurses Aide (CNA) | Reported need for more CNAs and nurses |
| Advanced Registered Nurse Practitioner | ARNP | Reported staffing concerns and performance improvement plan |
| Director of Clinical Services | DCS | Reported performance improvement plan and staffing issues |
| Administrator | Administrator | Oversaw staffing reviews and education |
| Certified Dietary Manager | CDM | Educated dietary staff on food temperature and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
A complaint investigation was conducted for multiple complaints and facility reported incidents from October 14, 2024 to October 17, 2024.
Complaint Details
Investigation covered complaints #122404-C, #122558-C, #122734-C, #122816-C, #123480-C, #124048-C, and facility reported incidents 122848-I, #123498-I, and #124049-I. Complaint #123480-C was substantiated without a deficiency.
Findings
Complaint #123480-C was substantiated without a deficiency, and the facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
A revisit of the survey ending June 18, 2024 was conducted on July 25, 2024 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective July 18, 2024.
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 10
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of substantiated complaints and facility reported incidents from June 10, 2024 to June 18, 2024.
Complaint Details
Complaints #120150-C, #120678-C, and #120707-C were substantiated. Facility reported incidents #119043-I, #119631-I, and 120544-I were substantiated.
Findings
The facility was found deficient in multiple areas including grievance investigation and follow-up, failure to notify the Ombudsman of resident transfers, incomplete and inaccurate PASRR documentation and care planning, failure to provide scheduled ADL care and treatments, medication errors including incorrect administration and documentation, insufficient staffing leading to resident safety concerns, incomplete and inaccessible resident records, and infection control breaches such as improper glove use during wound care.
Deficiencies (10)
Failure to investigate and follow up on residents' concerns regarding missing cigarettes for multiple residents.
Failure to notify the Ombudsman of resident transfers to the hospital for 5 residents.
Failure to accurately complete MDS assessment and incorporate PASRR recommendations into care planning for one resident.
Failure to maintain a valid PASRR and develop a comprehensive care plan for one resident.
Failure to ensure residents received scheduled baths and grooming, with inconsistent documentation of bathing.
Failure to provide treatments as ordered for one resident, including lymphedema pump treatments, resulting in untreated conditions.
Failure to attempt and document non-pharmacological interventions prior to administration of antipsychotic medications for one resident.
Medication errors including administration of medications to the wrong resident, incorrect dosing of pain medication, and leaving medications unattended.
Failure to maintain complete, accurate, and readily accessible resident medical records, including lack of timely access to electronic records and missing PASRR documentation.
Failure to follow infection control procedures including changing gloves and hand hygiene during wound care treatments.
Report Facts
Residents on census: 86
Resident unobserved time: 56
Medication administration errors: 7
Medication administration errors: 7
Bathing documentation missing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Involved in medication error where Resident #87 took another resident's medications |
| Staff B | Registered Nurse | Reported medication error and notified emergency department |
| Staff C | Registered Nurse | Observed medication administration and reported missing lymphedema pump treatment |
| Staff D | Social Worker | Reported grievance process and PASRR issues |
| Staff E | Licensed Practical Nurse | Observed performing wound care without proper glove changes |
| Staff G | Certified Nursing Assistant/Bath Aide | Reported bathing duties and documentation practices |
| Staff K | Certified Medication Aide | Reported insufficient staffing and performing CNA duties during medication pass |
| Staff L | Licensed Practical Nurse | Reported insufficient staffing and fear of retribution |
| Staff M | Certified Nursing Assistant | Reported insufficient staffing and care delays |
| Staff N | Certified Nursing Assistant | Reported staffing challenges on evening shifts |
| Staff O | Certified Medication Aide | Reported being pulled from medication duties to assist with CNA duties |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 15, 2024
Visit Reason
An on-site revisit of the complaint survey ending January 10, 2024, along with a new complaint investigation for complaints #118179-C and #118384-C was conducted from February 13, 2024 to February 15, 2024.
Complaint Details
Complaint investigations for complaints #118179-C and #118384-C were conducted, and all deficiencies were corrected.
Findings
All deficiencies identified during the complaint investigations were corrected, and the facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 3
Date: Dec 11, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations and facility reported incidents between December 27, 2023 and January 10, 2024, focusing on quality of care and treatment issues for residents.
Complaint Details
Complaints #115858-C, #116322-C, #116724-C, #116817-C, #117390-C, #117685-C, and #117732-C were substantiated. Facility reported incidents #115955-I, #116382-M, and #117446-I were substantiated.
Findings
The investigation substantiated multiple complaints and facility incidents involving inadequate assessment and intervention for residents experiencing changes in condition, including a resident who suffered a brain stem stroke. Deficiencies were found in quality of care, pressure ulcer prevention and treatment, medication administration, and documentation. Staff education and corrective actions were initiated.
Deficiencies (3)
Failure to ensure staff appropriately completed resident assessments and timely interventions when a resident exhibited signs and symptoms of a stroke.
Failure to provide skin assessments, implement interventions, and provide treatments per physician orders resulting in deterioration of pressure ulcers for 2 of 4 residents.
Failure to maintain accurate records and accountability for controlled substances, including missing medications and medication administration errors.
Report Facts
Census: 73
Deficiencies cited: 3
Pressure ulcer residents: 2
Medication doses missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Registered Nurse (RN) | Named in findings related to resident stroke incident and medication administration issues |
| Staff A | Licensed Practical Nurse (LPN) | Involved in medication administration and narcotic count discrepancies |
| Staff C | Registered Nurse (RN) | Involved in medication administration and narcotic count discrepancies |
| Staff B | Certified Medication Aide (CMA) | Involved in medication administration and narcotic count discrepancies |
| Director of Nursing | Director of Nursing Services (DON) | Involved in investigation and oversight of findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 27, 2023
Visit Reason
The document is a plan of correction submitted by the facility following a survey, indicating acceptance of the credible allegation of compliance and certification in compliance effective August 27, 2023.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction; no specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and included an investigation of Complaint #114416-C, which was substantiated.
Complaint Details
Complaint #114416-C was substantiated.
Findings
The facility failed to maintain a safe, clean, comfortable, and homelike environment due to unclean carpeted hallways with stains and discoloration. Multiple staff interviews and record reviews confirmed the issue and the administration acknowledged the problem and plans for carpet replacement.
Deficiencies (1)
Facility failed to maintain a clean environment throughout resident room accessed hallways, with multiple areas showing gray and black discoloration on carpeted hallways.
Report Facts
Census: 66
Date of Compliance: Aug 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed about housekeeping problem and carpet condition | |
| Environment Services Supervisor | Interviewed about carpet condition and stains | |
| Ancillary Services Manager | Interviewed about carpet condition and replacement plans | |
| Administrator | Interviewed about carpet cleaning expectations and replacement goals | |
| Maintenance Director | Involved in education and monitoring carpet cleaning and replacement |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
A revisit of the survey ending May 4, 2023 and investigation of complaints #113193-C, #113476-C, and #113693-C was conducted from July 10, 2023 to July 13, 2023.
Complaint Details
Complaints #113193-C, #113476-C, and #113693-C were investigated and found not substantiated.
Findings
All deficiencies were corrected and the facility was found in substantial compliance effective June 14, 2023. Complaints #113193-C, #113476-C, and #113693-C were not substantiated.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: May 4, 2023
Visit Reason
The inspection resulted from an investigation of complaints #104779-C, #105215-C, #112138-C, and #112597-C, as well as facility reported incidents #110927-I and #111011-I, conducted from April 26, 2023 to May 4, 2023.
Complaint Details
Complaint #105215-C and facility reported incident #110927-I were unsubstantiated. Complaints #104779-C, #112138-C, and #112597-C were substantiated. Facility reported incident #111011-I was also substantiated.
Findings
The facility failed to ensure adequate frequency of baths/showers for residents and failed to ensure staff used gait belts to safely transfer residents, resulting in significant pain, swelling, and injuries. Several residents had documented deficits in ADL care and bathing, and the facility was short-staffed, contributing to these deficiencies.
Deficiencies (3)
The facility failed to ensure residents received adequate frequency of baths/showers for 3 of 3 residents reviewed.
The facility failed to ensure staff used a gait belt to safely transfer a resident for 1 of 4 residents reviewed who fell resulting in significant pain and swelling.
The facility failed to ensure a resident's bed was placed in a low position for safety and failed to utilize a fall mat and body pillow as care planned for 1 of 7 residents reviewed who fell resulting in an eye laceration and bruising.
Report Facts
Residents reviewed for bathing: 3
Residents reviewed for transfers: 4
Residents reviewed for falls: 7
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) and Director of Nursing (DON) | Reported on documentation practices and bath audits; worked at facility until 3/9/23 |
| Staff D | Certified Nursing Assistant (CNA) | Reported on bath/shower documentation and resident care |
| Staff E | Licensed Practical Nurse (LPN) | Reported on staffing and bath aide availability |
| Staff F | Registered Nurse (RN) and Interim DON | Reported on bath audit forms and staff interviews |
| Staff B | Certified Nursing Assistant (CNA) | Reported on staffing shortages and resident care issues |
| Staff J | Certified Nursing Assistant (CNA) | Reported on scheduling and gait belt use |
| Staff A | Registered Nurse (RN) | Reported on resident fall and injury assessment |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 3
Date: Feb 24, 2022
Visit Reason
The inspection was conducted as an annual health survey in conjunction with an investigation of complaint #100462 and a facility reported incident #100250. Both the complaint and the incident were substantiated.
Complaint Details
Complaint #100462 was substantiated. Facility reported incident #100250 was substantiated.
Findings
The facility was found deficient in providing adequate nursing supervision and assistance devices to prevent accidents during resident transfers, medication administration errors related to insulin pens, and infection control practices including hand hygiene and cleaning protocols. Multiple residents were affected by these deficiencies.
Deficiencies (3)
Facility failed to provide adequate nursing supervision and assistance devices to prevent accidents during transfers for Resident #75.
Facility staff failed to ensure insulin pens were primed before administration, resulting in medication errors for Resident #58.
Facility failed to establish and maintain an infection prevention and control program, including hand hygiene and cleaning protocols, affecting multiple residents.
Report Facts
Resident census: 79
Medication administration errors: 2
Residents reviewed for infection control: 24
Residents with infection control deficiencies: 3
Resident MDS assessment dates: Various dates from 2021 and 2022 for resident assessments
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Licensed Practical Nurse (LPN) | Observed transferring Resident #75 with mechanical sit to stand lift |
| Staff D | Certified Nursing Assistant (CNA) | Assisted Staff C in transferring Resident #75 and interviewed regarding care plans |
| Staff B | Licensed Practical Nurse (LPN) | Administered insulin to Resident #58 and involved in medication error |
| Staff F | Speech Therapist | Reported on therapy discharge and transfer recommendations for Resident #75 |
| Staff G | Physical Therapist | Reported Resident #75 discharged from therapy and transfer recommendations |
| Staff H | Certified Nursing Assistant (CNA) | Reported use of mechanical sit to stand lift for Resident #75 transfers |
| Staff I | Unit Manager / Registered Nurse | Reported expectations for staff to follow Care Plans and insulin administration education |
| Director of Nursing (DON) | Director of Nursing | Observed infection control practices and provided education on transfer plans |
| Staff E | Registered Nurse (RN) | Observed wound care and infection control practices for Resident #74 |
| Staff A | Licensed Practical Nurse (LPN) | Observed performing blood glucose monitoring and infection control procedures |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 23, 2021
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint #99799-C.
Complaint Details
Complaint #99799-C was not substantiated.
Findings
The complaint was investigated and found to be not substantiated.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 4
Date: Aug 25, 2021
Visit Reason
The inspection was conducted as an investigation of complaints numbered 95213-C, 96378-C, 98264-C, 98699-C, and 98832-C, which were substantiated following a Department of Inspections and Appeals review from 07/22/21 to 08/25/21.
Complaint Details
Complaints 95213-C, 96378-C, 98264-C, 98699-C, and 98832-C were substantiated. The investigation revealed failures in timely family notification of COVID-19 positive results, adherence to physician orders, and infection control practices.
Findings
The facility failed to notify Resident #7's family of a positive COVID-19 test result in a timely manner, failed to follow physician orders for lab tests and timely ER transfers for residents, and did not complete required weekly skin assessments for some residents. Additionally, the facility failed to implement proper infection control measures including mask usage by staff and timely notification of family members about COVID-19 positive results.
Deficiencies (4)
Failure to notify Resident #7's family of positive COVID-19 test result in a timely manner.
Failure to follow physician orders for obtaining laboratory tests and timely ER transfers for residents #1 and #6.
Failure to complete weekly skin assessments for residents including Resident #6 and Resident #14.
Failure to implement and maintain an infection prevention and control program including staff mask usage and infection control policies.
Report Facts
Census: 84
Number of complaints substantiated: 5
Correction plan completion date: Correction date listed as 09/20/2021
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jan 6, 2021
Visit Reason
A focused COVID-19 infection control survey was conducted in conjunction with the investigation of facility reported incident #95059-I. The facility was assessed for compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
The visit was triggered by a complaint related to incident #95059-I, which was investigated and found not substantiated.
Findings
The facility was found not in compliance with infection prevention and control requirements, specifically failing to properly screen 17 staff members on multiple days, and issues were identified with staff self-screening and screening log completion. The incident #95059-I was not substantiated.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program including proper screening of staff for COVID-19 symptoms and exposures.
Report Facts
Total residents: 81
Staff screening failures: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Resident Assistant (RA) | Completed screening tool and temperature checks during observation |
| Staff C | Nursing Assistant (NA) | Donning mask and assisting with screening during observation |
| Staff D | Food Service Assistant (FSA) | Temperature checked and reported no symptoms during observation |
| Staff H | Infection Preventionist (IP) | Interviewed and could not answer multiple questions regarding IP duties |
| Staff A | Senior Sales Representative | Interviewed regarding IP duties and screening log reviews |
| Director of Nursing (DON) | Director of Nursing | Interviewed about staff screening procedures and facility policies |
| Staff E | Certified Nursing Assistant (CNA) | Interviewed about screening practices and habits |
| Staff F | Certified Nursing Assistant (CNA) | Interviewed about screening practices and habits |
| Staff G | Licensed Practical Nurse (LPN) | Interviewed about screening practices and self-reporting system |
| Staff I | Social Worker (SW) | Interviewed about reviewing Employee Screening Log |
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Date: Oct 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigations of facility reported incident 93420-I and complaints 88586-C and 92826-C between September 23 and October 13, 2020.
Complaint Details
The facility reported incident was substantiated. Both complaints were substantiated.
Findings
The facility was found to be in noncompliance with CMS and CDC recommended practices for COVID-19. Deficiencies included failure to provide adequate bathing services, inadequate supervision and use of assistance devices to prevent accidents, failure to ensure timely physician visits, and insufficient in-service training for nurse aides. The facility reported a census of 86 residents and the incident and complaints were substantiated.
Deficiencies (4)
Failure to provide bathing services in accordance with professional standards for 4 residents unable to carry out the activity independently.
Failure to provide adequate supervision and proper use of assistance devices to mitigate resident risk for elopement, including failure to ensure kitchen doors remained securely locked and proper door alarm procedures.
Failure to ensure residents are seen by a physician at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter for 2 of 4 residents reviewed.
Failure to provide sufficient in-service training to ensure competency of nurse aides, including dementia management and resident abuse prevention training.
Report Facts
Total residents: 86
Residents reviewed for bathing deficiency: 4
Certified Nursing Assistants (CNA) training records reviewed: 10
CNA aides not meeting minimum training hours: 5
Residents reviewed for physician visits: 4
Inspection Report
Abbreviated Survey
Census: 87
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 10
Date: Mar 12, 2020
Visit Reason
The inspection was conducted as the facility's annual health survey from 03/09/2020 to 03/12/2020, including review of complaints #89495-C and #89821-C which were not substantiated.
Complaint Details
Complaints #89495-C and #89821-C were investigated and found not substantiated.
Findings
The facility was found deficient in multiple areas including failure to provide mandatory Medicaid denial notices, inaccurate resident assessments, incomplete comprehensive care plans, failure to meet professional standards during medication administration, inadequate smoking assessments, improper catheter care, insufficient nursing staff, and infection control deficiencies. The facility reported a census of 90 residents during the survey.
Deficiencies (10)
Failure to provide Mandatory Denial Notice form 10055 to Medicaid-eligible residents.
Inaccurate Minimum Data Set (MDS) assessments for residents.
Failure to develop and implement comprehensive care plans for residents.
Failure to meet professional standards during medication administration.
Failure to assess and update smoking status and provide related care.
Failure to provide appropriate catheter care and handling.
Failure to ensure bed rails are used and maintained properly with consent and assessment.
Insufficient nursing staff to meet resident needs and respond to call lights timely.
Failure to maintain infection prevention and control program including hand hygiene and wound care.
Failure to conduct regular inspection and maintenance of beds, mattresses, and bed rails.
Report Facts
Census: 90
Residents reviewed: 18
Residents reviewed for call light response: 18
Residents reviewed for medication administration: 5
Residents reviewed for catheter care: 3
Residents reviewed for bed rails: 18
Residents reviewed for infection control: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Services Assistant | Verified date resident signed form 10055 for Medicare claim appeal rights. |
| Staff E | MDS Nurse | Reported observations related to hospice services and MDS completion. |
| Staff G | Registered Nurse | Observed administering medications and medication administration practices. |
| Staff F | Certified Nurse's Aide | Observed assisting with catheter drainage bag and resident transfers. |
| Staff J | Registered Nurse | Observed catheter irrigation and hand hygiene practices. |
| Director of Nursing | Interviewed multiple times regarding care plans, assessments, and facility policies. | |
| Administrator | Interviewed regarding assessments and consents for hand assist bars. |
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