Inspection Reports for
Good Samaritan Society – Indianola

The complaint investigation was substantiated, with findings confirming insufficient staffing levels causing delayed call light responses and unmet resident needs. The facility had repeated staffing deficiencies documented in prior surveys and ongoing issues reported by residents and staff.

The facility failed to maintain adequate staffing levels, resulting in delayed call light responses often exceeding 45 minutes to over an hour. Multiple resident and staff interviews, call light logs, and resident council minutes confirmed ongoing staffing shortages and repeated violations over several years.

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.

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.

The facility was found to have multiple deficiencies including failure to maintain resident dignity, delayed feeding assistance, inadequate response to call lights, missing documentation of 15-minute resident checks, unsecured medications, and failure to disinfect reusable equipment between residents.

Complaints #126388-C, #126899-C, #127107-C, #127521-C, and #127817-C were substantiated. Facility reported incidents #126900-I and #128094-I were substantiated.

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.

The complaint investigation substantiated multiple deficiencies including failure to protect residents from sexual abuse, failure to update care plans after incidents, failure to provide adequate incontinence care, failure to respond timely to call lights, and failure to implement proper infection control practices.

The facility failed to ensure accurate advance directive documentation, maintain clean floors, protect residents from abuse including sexual abuse, update care plans after incidents, provide adequate assistance with activities of daily living including incontinence care, respond timely to call lights, and implement proper infection control practices including enhanced barrier precautions for residents with catheters.

The facility failed to provide adequate nursing supervision and fall prevention interventions for a high fall risk resident, had insufficient nursing staff including the Director of Nursing working the floor, and served food at unsafe temperatures during meal service.

Complaints #124345-C, 124674-C, 124778-C, 125184-C, 125357-C, and 125982-C were substantiated. Facility Reported Incident #125593-I was substantiated.

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.

Complaints #120150-C, #120678-C, and #120707-C were substantiated. Facility reported incidents #119043-I, #119631-I, and 120544-I were substantiated.

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.

The complaint investigation focused on missing cigarettes reported by multiple residents, medication errors including a resident receiving another resident's medications leading to hospitalization, insufficient staffing impacting resident care and supervision, failure to provide ordered treatments, and incomplete medical records. The facility was found to have substantiated deficiencies in these areas.

The facility failed to investigate and follow up on residents' concerns about missing cigarettes, did not provide ordered treatments leading to hospitalization, failed to document wound care and medication administration properly, had insufficient staffing to meet resident needs, administered unnecessary medications without documented non-pharmacological interventions, and committed significant medication errors including administering medications to the wrong resident and incorrect doses. Additionally, the facility failed to maintain complete and accessible medical records.

The facility had multiple deficiencies including failure to investigate resident grievances about missing cigarettes, failure to notify the Ombudsman of resident hospital transfers, inaccurate Minimum Data Set (MDS) assessments, inadequate bathing and skin care, insufficient staffing, improper use of psychotropic medications, significant medication errors including a resident receiving another resident's medications, incomplete medical records, and lapses in infection control practices.

The complaint investigation was substantiated. The facility failed to timely assess and intervene for a resident with stroke symptoms, failed to provide adequate pressure ulcer care resulting in deterioration and hospitalization, and failed to maintain accurate controlled substance medication records, leading to unaccounted narcotic doses.

The facility failed to ensure timely assessment and intervention for a resident exhibiting stroke symptoms, resulting in delayed hospital transfer. The facility also failed to provide adequate skin assessments, interventions, and treatments for residents with pressure ulcers, leading to deterioration and hospitalization. Additionally, the facility failed to maintain accurate controlled substance medication records, resulting in unaccounted doses of Oxycodone.

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.

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.

The facility failed to maintain a clean environment in all seven hallways accessing resident rooms, with multiple areas of gray and black discoloration observed. Staff interviews and record reviews confirmed ongoing issues with carpet stains and the need for replacement or professional cleaning.

Complaint #114416-C was substantiated.

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.

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.

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.

Complaint #100462 was substantiated. Facility reported incident #100250 was substantiated.

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.

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.

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.

The visit was triggered by a complaint related to incident #95059-I, which was investigated and found not substantiated.

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.

The facility reported incident was substantiated. Both complaints were substantiated.

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.

Complaints #89495-C and #89821-C were investigated and found not substantiated.

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.