Inspection Reports for
Good Samaritan Society – Red Oak
201 Alix Avenue, Red Oak, IA, 515661001
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
264% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
37 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
A revisit of the survey ending August 12, 2025 was conducted on September 22, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective August 26, 2025.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Date: Aug 12, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide timely assessments and interventions following a change in condition for Resident #3, who had a history of right great toe amputation and exhibited increased pain and functional decline.
Complaint Details
The investigation was triggered by a complaint regarding Resident #3's increased pain and impaired circulation. The complaint was substantiated with findings of Immediate Jeopardy due to failure to timely assess, intervene, and transfer the resident to the hospital despite worsening condition and physician orders.
Findings
The facility failed to provide timely assessments and interventions for Resident #3 after a significant change in condition, resulting in Immediate Jeopardy to resident health and safety. The resident experienced critical limb ischemia leading to hospital transfer and thrombectomy. Documentation and communication deficiencies were noted, including lack of timely pain assessments and failure to send the resident to the hospital promptly despite orders.
Deficiencies (4)
Failure to provide timely assessments and interventions for a resident with a change in condition related to impaired circulation and pain.
Lack of comprehensive care planning for impaired circulation prior to 8/6/25.
Inadequate documentation of pain assessments and follow-up after administration of pain medication.
Failure to send resident to hospital promptly despite physician orders for uncontrolled pain and numbness.
Report Facts
Residents present: 37
Pain complaints: 5
PRN medication administration: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Provided report of resident's pain and crying behavior, contacted on-call physician, administered medication, but left shift early |
| Staff B | Certified Nurse Assistant (CNA) | Observed resident crying with pain and reported to Staff A |
| Staff C | Certified Nurse Assistant (CNA) | Noted increased assistance needed for resident and resident crying with pain |
| Staff D | Certified Medication Aide (CMA) | Administered pain medication and communicated with nursing staff about resident's pain |
| Staff E | Registered Nurse (RN) | Received report from Staff A, worked on 8/3/25, but had no contact with Resident #3 |
| Staff F | Wound Care Nurse / Licensed Practical Nurse (LPN) | Provided wound care and Tylenol to resident, did not consistently assess pedal pulse |
| Staff G | Registered Nurse (RN) | Administered PRN medications, prepared resident for hospital transfer |
| Staff H | Licensed Practical Nurse (LPN) | Overnight shift nurse on 8/3-8/4, unaware of hospital transfer order |
| Staff I | Certified Nurse Assistant (CNA) | Provided care on night shift 8/3-8/4, noted resident's abnormal behavior and pain complaints |
| On-call Physician | Provided verbal orders for pain medication and hospital transfer if pain/numbness persisted | |
| Physician Assistant (PA) | Vascular Surgeon Physician Assistant | Reported resident had through-knee amputation on 8/7/25 and stated earlier hospital transfer would have reduced suffering |
| MDS Coordinator | Conducted assessment on 8/4/25, acknowledged lack of documentation of assessments | |
| Social Services Supervisor | Registered Nurse (RN) | Confirmed Director of Nursing was on vacation and noted documentation deficiencies |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Aug 12, 2025
Visit Reason
The inspection was conducted as a result of complaints #1681260-C, #2570970-C, #2571882-C, and #2580351-C between August 6, 2025 and August 12, 2025, with complaint #2580351-C resulting in a deficiency.
Complaint Details
The investigation was triggered by complaints #1681260-C, #2570970-C, #2571882-C, and #2580351-C. Complaint #2580351-C was substantiated and resulted in a deficiency related to quality of care and failure to provide timely assessments and interventions for Resident #3.
Findings
The facility failed to provide timely assessments and interventions for a resident with impaired circulation and pain related to a recent amputation, resulting in immediate jeopardy to the resident's health, safety, and security. The facility implemented corrective actions including staff education, daily oversight, and audits to address these deficiencies.
Deficiencies (1)
Failure to provide assessments and interventions timely for a resident with impaired circulation and pain following amputation, resulting in immediate jeopardy.
Report Facts
Resident census: 37
Dates of complaint investigation: August 6, 2025 to August 12, 2025
Date of survey completion: August 12, 2025
Number of complaints investigated: 4
Pain level entries: 5
Audit frequency: 5
Audit frequency: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 28, 2025
Visit Reason
A revisit of the survey ending April 17, 2025 was conducted on May 27, 2025 to May 28, 2025 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance.
Inspection Report
Routine
Census: 43
Deficiencies: 3
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including oral care, pressure ulcer care, and fall prevention.
Findings
The facility failed to provide adequate oral care for one resident, failed to provide appropriate pressure ulcer care for two residents, and failed to implement effective fall prevention interventions for two residents, resulting in actual harm.
Deficiencies (3)
Failed to provide oral care for 1 of 3 residents reviewed (Resident #28).
Failed to provide appropriate pressure ulcer care and prevent new ulcers for 2 of 3 residents reviewed (Resident #28 and #39).
Failed to establish and implement interventions to prevent falls and injuries for 2 of 3 residents reviewed (Resident #20 and #6).
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 2
Census: 43
Pressure ulcer measurements: 2
Pressure ulcer measurements: 3
Pressure ulcer measurements: 2
Pressure ulcer measurements: 2.3
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 0.5
Pressure ulcer undermining/tunneling depth: 0.8
Fall count: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Certified Nurse Aide (CNA) | Mentioned in oral care deficiency related to Resident #28 |
| Staff M | Certified Nurse Aide (CNA) | Mentioned in oral care deficiency related to Resident #28 |
| Director of Nursing | Director of Nursing (DON) | Provided expectations and comments on oral care and wound care |
| Staff E | Certified Nurse Aide (CNA) | Observed wound care and skin issues for Resident #28 |
| Staff F | Certified Nurse Aide (CNA) | Observed wound care and skin issues for Resident #28 |
| Staff C | Certified Nurse Aide (CNA) | Involved in care and observation of Resident #39's wounds |
| Staff D | Certified Nurse Aide (CNA) | Involved in care and observation of Resident #39's wounds |
| Staff G | Treatment Nurse | Provided wound treatment for Resident #39 |
| Staff K | Certified Nurse Aide (CNA) | Witnessed fall of Resident #20 and provided statements |
| Staff H | Certified Nurse Aide (CNA) | Witnessed fall of Resident #20 and provided statements |
| Staff B | Licensed Practical Nurse (LPN) | Witnessed fall of Resident #20 and provided statements |
Inspection Report
Routine
Census: 43
Deficiencies: 8
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication administration, wound care, fall prevention, feeding tube management, nutrition, food handling, and infection control at Good Samaritan Society - Red Oak.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents with suicidal ideation and smoking risks, improper medication administration practices, inadequate pressure ulcer care, insufficient fall prevention interventions, improper feeding tube medication administration, failure to measure pureed food portions, unsafe food handling practices, and lapses in infection control procedures.
Deficiencies (8)
Failed to develop and implement a complete care plan for a resident with suicidal ideations and failed to implement interventions for a smoking resident as listed on the care plan.
Failed to provide needed services in accordance with professional standards by leaving medications in the resident's room for self-administration without nurse visualization for 1 of 8 residents.
Failed to provide adequate pressure ulcer care for 2 of 3 residents reviewed, including failure to complete ordered treatments and document skin breakdowns.
Failed to establish and implement interventions to prevent falls and injuries for 2 of 3 residents reviewed, including failure to remove wheelchair pedals and evaluate risks after falls.
Failed to implement policies and procedures regarding technical aspects of feeding tubes by pushing enteral medication with a piston syringe into enteral tube for 1 of 1 resident.
Failed to provide a well balanced diet that meets nutritional and special dietary needs by using incorrect serving size portions for meals.
Failed to prepare, serve and distribute food in accordance with safe food handling practices, including improper handling of scoop and lids during meal service.
Failed to use infection control practices for 3 of 13 residents reviewed, including exposure of an open pressure ulcer to a soiled mechanical lift sling, inadequate hand hygiene during enteral tube care, and catheter bag resting on the floor.
Report Facts
Residents affected: 43
Falls: 11
Pressure ulcer measurements: 2
Medication doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff N | Registered Nurse | Named in medication administration and enteral tube care findings |
| Staff B | Licensed Practical Nurse | Interviewed regarding smoking resident care plan compliance |
| Staff C | Certified Nurse Aide | Involved in wound care and mechanical lift use for Resident #39 |
| Staff D | Certified Nurse Aide | Involved in wound care and mechanical lift use for Resident #39 |
| Staff G | Treatment Nurse | Provided wound treatment for Resident #39 |
| Staff A | Food Service Staff | Observed preparing pureed food and handling food service items |
| Staff K | Certified Nurse Assistant | Witnessed fall incident and resident agitation |
| Staff H | Certified Nurse Assistant | Witnessed fall incident |
| Staff O | Certified Nursing Assistant | Involved in catheter care for Resident #33 |
| Staff P | Certified Nursing Assistant | Involved in catheter care for Resident #33 |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care plan, fall prevention, medication administration, and infection control |
| Physician | Physician | Provided input on wound care and infection control concerns |
| Food and Nutrition Supervisor | Food and Nutrition Supervisor | Interviewed regarding food portioning and preparation |
| Administrator | Administrator | Interviewed regarding food service and infection control expectations |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 9
Date: Apr 17, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and included investigation of complaint #127042-C and facility reported incident #127810-I.
Complaint Details
Complaint #127042-C was substantiated. Facility reported incident #127810-I was substantiated.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents with suicidal ideations and smoking interventions, failure to meet professional standards in medication administration, inadequate oral care provision, insufficient pressure ulcer care, failure to prevent falls and injuries, improper tube feeding medication administration, incorrect meal portioning for textured diets, unsafe food handling practices, and lapses in infection prevention and control practices.
Deficiencies (9)
Failed to develop a comprehensive care plan including problems, goals, or interventions for a resident with suicidal ideations and failed to implement interventions for a smoking resident.
Failed to provide needed services in accordance with professional standards by leaving medications in the resident's room for self-administration without nurse visualization.
Failed to provide oral care for a dependent resident.
Failed to provide adequate pressure ulcer care for residents with stage II and stage IV pressure ulcers, including failure to complete treatments as ordered and document skin breakdowns.
Failed to establish and implement interventions to prevent falls and injuries for residents with a history of multiple falls, including failure to remove wheelchair pedals that caused tripping.
Failed to implement policies and procedures regarding feeding tubes by pushing enteral medication with a piston syringe into enteral tube without proper care plan documentation.
Failed to provide a well balanced diet that meets nutritional and special dietary needs by using incorrect serving size portions for meals.
Failed to prepare, serve and distribute food in accordance with safe food handling practices, including improper handling of serving utensils and lack of hand hygiene.
Failed to maintain an infection prevention and control program, including failure to use adequate hand hygiene, improper handling of open wounds and dressings, and improper catheter care.
Report Facts
Deficiencies cited: 9
Resident census: 43
Fall incidents: 11
BIMS score: 15
BIMS score: 12
BIMS score: 7
BIMS score: 13
BIMS score: 3
BIMS score: 14
Pressure ulcer measurements: 2
Pressure ulcer measurements: 2
Pressure ulcer measurements: 2
Medication order frequency: 2
Medication volume: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Interviewed regarding smoking item storage and medication administration. |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding care plan expectations, medication administration, wound care, fall prevention, and infection control. |
| Staff N | Registered Nurse (RN) | Observed administering medication via enteral tube and interviewed about medication administration practices. |
| Staff C | Certified Nurse Aide (CNA) | Observed and interviewed regarding wound care and skin issues. |
| Staff D | Certified Nurse Aide (CNA) | Observed and interviewed regarding wound care and skin issues. |
| Staff A | Cook | Observed preparing pureed food without measuring portions. |
| Staff O | Certified Nursing Assistant (CNA) | Observed providing catheter care without proper hand hygiene. |
| Staff P | Certified Nursing Assistant (CNA) | Observed providing catheter care without proper hand hygiene. |
| Staff K | Certified Nursing Assistant (CNA) | Interviewed regarding fall incidents and resident agitation. |
| Staff H | Certified Nursing Assistant (CNA) | Interviewed regarding fall incidents. |
| Staff L | Certified Nurse Aide (CNA) | Interviewed regarding oral care supplies for Resident #28. |
| Staff M | Certified Nurse Aide (CNA) | Interviewed regarding oral care supplies for Resident #28. |
| Staff E | Certified Nurse Aide (CNA) | Observed and interviewed regarding wound care. |
| Staff F | Certified Nurse Aide (CNA) | Observed and interviewed regarding wound care. |
| Staff G | Treatment Nurse | Observed providing wound treatment and interviewed regarding wound care. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
A complaint investigation for facility reported incident #123962-I was conducted on January 8, 2025 to January 9, 2025.
Complaint Details
Complaint investigation for incident #123962-I; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 17, 2024
Visit Reason
The visit was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and to review the provider's plan of correction.
Findings
The Good Samaritan Society-Red Oak Nursing Home was found to be in substantial compliance as of July 17, 2024, based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Routine
Census: 40
Deficiencies: 4
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to assess compliance with nursing staffing data posting, food safety and temperature standards, food preparation and storage practices, and infection prevention and control protocols.
Findings
The facility failed to post daily nursing staffing data, served food at unsafe temperatures, improperly stored and prepared food, and did not consistently follow infection control practices, including hand hygiene and catheter care, posing potential minimal harm to residents.
Deficiencies (4)
Failed to complete and post daily nursing staffing data.
Failed to provide food at an appetizing temperature to residents.
Failed to prepare, serve, distribute, and store food in accordance with professional standards.
Failed to implement infection prevention and control practices to prevent cross contamination of invasive medical devices.
Report Facts
Residents census: 40
Residents census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse (LPN) / Wound Nurse | Responsible for changing the nursing staffing sheet |
| Staff A | Dietary Aide | Delivered room trays and involved in food temperature observations |
| Staff B | Cook | Conducted food temperature checks and food preparation |
| Dietary Manager | Dietary Manager (DM) | Provided statements on food temperature and refrigerator cleaning |
| Staff D | Certified Nursing Aide (CNA) | Performed catheter care with noted infection control deficiencies |
| Staff E | Certified Nursing Aide (CNA) | Assisted in catheter care with noted infection control deficiencies |
| Staff F | Certified Nursing Assistant (CNA) | Performed catheter care and hand hygiene observations |
| Staff G | Certified Nursing Assistant (CNA) | Performed catheter care and hand hygiene observations |
| DON | Director of Nursing | Provided statements on staffing sheet expectations and hand hygiene |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 4
Date: Jul 3, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 30, 2024 to July 3, 2024.
Findings
The facility was found deficient in several areas including failure to post nurse staffing data daily, serving food at improper temperatures, unsanitary food storage and preparation practices, and inadequate infection prevention and control practices related to catheter care and hand hygiene.
Deficiencies (4)
Failure to complete and post daily nurse staffing data as required.
Failure to provide food at an appetizing temperature to 3 of 15 residents reviewed.
Failure to prepare, serve, distribute, and store food in accordance with professional standards, including unsanitary refrigerator conditions and improper glove use.
Failure to implement infection control practices to prevent cross contamination of invasive medical devices, including improper catheter care and hand hygiene.
Report Facts
Residents reviewed for food temperature: 15
Facility census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse / Wound Nurse | Responsible for changing the nurse staffing sheet |
| Staff A | Dietary Aide | Observed delivering room trays with improper food temperatures |
| Staff B | Cook | Observed handling food improperly and glove misuse |
| Staff D | Certified Nursing Aide | Observed performing catheter care with improper hand hygiene |
| Staff E | Certified Nursing Aide | Observed assisting with catheter care and improper hand hygiene |
| Staff F | Certified Nursing Assistant | Observed performing catheter care with improper hand hygiene |
| Staff G | Certified Nursing Assistant | Observed performing catheter care with improper hand hygiene |
| Michael A. Early | Administrator | Signed the inspection report |
| DON | Director of Nursing | Provided statements regarding nurse staffing and infection control expectations |
| DM | Dietary Manager | Provided statements regarding food temperature and kitchen sanitation |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 7, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective May 7, 2024.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 5
Date: Apr 18, 2024
Visit Reason
Investigation of complaints #117087-C, #119750-C, and #120047-C conducted April 11 through April 18, 2024, with complaints #117087-C and #120047-C substantiated.
Complaint Details
Complaints #117087-C and #120047-C were substantiated. The investigation focused on failure to notify family and management of bruising, failure to supervise medication administration, failure to assess bruising, and failure to notify hospice.
Findings
The facility failed to notify family of a bruise on Resident #1, failed to timely report the bruise to management, failed to supervise medication administration for Resident #3 by leaving medication unattended, failed to assess and intervene timely for Resident #1's bruise, and failed to notify hospice of Resident #1's bruise.
Deficiencies (5)
Failed to notify family of Resident #1's bruise on right thigh.
Failed to timely notify facility management of Resident #1's bruise found on 11/5/23.
Failed to supervise medication administration by leaving Resident #3's medication on bedside table.
Failed to assess and intervene timely for Resident #1's bruise.
Failed to notify hospice provider of Resident #1's bruise on right hip and thigh.
Report Facts
Resident census: 44
Deficiency count: 5
BIMS score: 15
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Documented bruise on Resident #1's right thigh and acknowledged bruise likely from mechanical lift sling |
| Staff C | Licensed Practical Nurse (LPN) | Called hospice for Resident #1 due to condition change and documented bruise; uncertain if notified management timely |
| Director of Nursing | Director of Nursing (DON) | Acknowledged family should be notified of new bruises; stated notification to hospice not required if no change in condition |
| Staff D | Certified Nursing Assistant (CNA) | Reported Resident #1 had bruise for about a month before passing and told nurses multiple times |
| Staff E | Certified Nursing Assistant (CNA) | Noted redness and bruising on Resident #1 during baths and reported to nurse |
| Administrator | Administrator | Stated all incidents must be reported promptly and incident reports completed within 24 hours |
| Resident #3's son | Reported finding medication on Resident #3's bedside table and notified DON | |
| Hospice Nurse | Licensed Practical Nurse (LPN) | Cared for Resident #1, aware of bruising on right lower leg but not on right hip/thigh |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 5
Date: Apr 18, 2024
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to notify family and hospice about a resident's bruise, failure to timely report suspected abuse, failure to supervise medication administration, failure to provide appropriate treatment and care, and failure to arrange hospice services properly.
Complaint Details
The visit was complaint-related due to allegations that the facility failed to notify family and hospice about a bruise on Resident #1, failed to timely report suspected abuse, and failed to supervise medication administration properly. The complaint was substantiated with findings of minimal harm affecting a few residents.
Findings
The facility failed to notify family and hospice timely about a significant bruise on Resident #1, failed to notify management timely about suspected abuse, left medications unattended for Resident #3, and failed to assess and intervene timely for the bruise. The facility also lacked a clear policy on family notification and did not document hospice notification of the bruise. Staff interviews revealed inconsistent reporting and documentation practices.
Deficiencies (5)
Failed to notify 1 of 3 resident's family when a bruise developed.
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Failed to supervise medication administration by leaving medication on resident's bedside table.
Failed to assess and intervene timely for a bruise for 1 of 3 residents.
Failed to notify hospice provider when a bruise was found on resident's right hip and thigh.
Report Facts
Residents Affected: 3
Census: 44
Deficiency Count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse (RN) | Documented bruise on Resident #1's right thigh and acknowledged bruise likely caused by mechanical lift sling |
| Staff C | Licensed Practical Nurse (LPN) | Called hospice due to Resident #1's condition change and documented bruise; uncertain about reporting to management |
| Director of Nursing (DON) | Director of Nursing | Acknowledged family notification policy absence, stated management was notified late, and commented on medication supervision |
| Staff D | Certified Nursing Assistant (CNA) | Reported Resident #1 had a large bruise that bothered her during care |
| Staff E | Certified Nursing Assistant (CNA) | Noted bruising on Resident #1 and reported calling nurse for assessment |
| Administrator | Administrator | Stated incident reports must be completed within 24 hours and assumed nursing would have done skin assessments |
| Hospice LPN | Licensed Practical Nurse | Cared for Resident #1 and was unaware of bruise on right hip/thigh until provided photos |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of credible allegation of compliance.
Findings
The facility was certified in compliance effective June 15, 2023, based on acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Census: 46
Deficiencies: 3
Date: May 25, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care plan participation, respiratory care equipment maintenance, pharmaceutical services, and medication management at Good Samaritan Society - Red Oak.
Findings
The facility failed to ensure one resident was invited to participate in their care plan conference, nebulizer equipment was not dated or initialed when replaced for one resident, and expired medications were found in the medication room refrigerator. The facility reported a census of 46 residents during the inspection.
Deficiencies (3)
Failed to ensure 1 of 2 sampled residents reviewed for care plan participation had been invited to participate in their care plan conferences (Resident #22).
Failed to ensure nebulizer equipment was dated and initialed when replaced for 1 of 1 resident reviewed for respiratory services (Resident #35).
Failed to ensure expired medications had been removed from the refrigerator in 1 medication room inspected.
Report Facts
Residents Affected: 1
Residents Affected: 1
Expired medications found: 6
Census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #8 | Registered Nurse | Interviewed regarding nebulizer equipment labeling and expired medication checks |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Changed Resident #35's nebulizer equipment and oxygen tubing |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan participation and nebulizer equipment labeling |
| Administrator | Administrator | Interviewed regarding expectations for resident care plan participation and medication management |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 3
Date: May 25, 2023
Visit Reason
The inspection was conducted as the facility's annual recertification survey combined with an investigation of complaint #IA00112471-C from 05/22/2023 to 05/25/2023.
Complaint Details
Complaint #IA00112471-C was investigated and found not substantiated.
Findings
The facility was found to have deficiencies related to residents' right to participate in care planning, respiratory and tracheostomy care, and pharmacy services including expired medications. The complaint was not substantiated. Corrective actions and monitoring plans were put in place for each deficiency.
Deficiencies (3)
Failure to ensure 1 of 2 sampled residents was invited to participate in their care plan conferences.
Failure to ensure nebulizer equipment was dated and initialed when replaced for 1 resident.
Failure to ensure expired medications were removed from the medication room refrigerator.
Report Facts
Census: 46
Deficiencies cited: 3
Expiration dates: 4
Expiration dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael A. Garry | Administrator | Signed the statement of deficiencies and plan of correction. |
| Registered Nurse #8 | Interviewed regarding unlabeled nebulizer equipment and medication room procedures. | |
| Licensed Practical Nurse #7 | Interviewed about changing nebulizer equipment and oxygen tubing. | |
| Director of Nursing | Interviewed regarding care plan participation and medication expiration checks. | |
| Administrator | Interviewed about expectations for care plan conferences and medication removal. |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 9
Date: May 4, 2022
Visit Reason
The inspection was a Recertification survey and investigation of substantiated Complaints #103925 and #101574 conducted April 18-28, 2022.
Complaint Details
Complaints #103925 and #101574 were substantiated. The complaint investigation revealed failures in assessment accuracy, care planning, infection control, and medication management.
Findings
The facility was found deficient in multiple areas including accuracy of assessments, development and revision of comprehensive care plans, provision of bathing services, restorative care exercises, psychotropic medication management, food safety and sanitation, infection prevention and control including COVID-19 outbreak management, and proper hand hygiene during clinical tasks.
Deficiencies (9)
Failed to ensure assessments accurately reflected residents' status, including pressure ulcers and care needs for 2 of 13 residents reviewed.
Failed to develop and implement timely, comprehensive, person-centered care plans for 4 of 13 residents reviewed, including failure to update care plans with new orders and conditions.
Failed to provide bathing services as scheduled for 5 of 13 residents reviewed, with multiple baths documented as 'did not occur'.
Failed to provide restorative care exercises as ordered for 1 of 1 resident reviewed.
Failed to ensure residents were free from unnecessary psychotropic medications, including failure to discontinue PRN alprazolam as ordered for 1 resident.
Failed to store food under sanitary conditions, maintain proper dishwasher temperatures, and prepare and serve food in accordance with professional standards, risking foodborne illness.
Failed to implement infection control practices to prevent and mitigate COVID-19 spread, including allowing a symptomatic staff member to work and inadequate staff screening.
Failed to perform proper hand hygiene and glove use during clinical tasks including glucometer testing and catheter care.
Failed to change oxygen tubing as ordered and document changes for 1 resident.
Report Facts
Residents tested positive for COVID-19: 11
Staff tested positive for COVID-19: 8
Residents reviewed for care plans: 13
Residents reviewed for bathing: 13
Residents reviewed for restorative care: 1
Residents reviewed for psychotropic medication: 1
Residents reviewed for oxygen tubing documentation: 1
Residents reviewed for hand hygiene during clinical tasks: 3
Dishwasher temperature failures: 60
Residents census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide | Worked while symptomatic with COVID-19, contributing to outbreak |
| Staff E | Registered Nurse | Screened staff and failed to send symptomatic staff home |
| Staff A | Licensed Practical Nurse | Performed staff screening but did not ask COVID-19 symptom questions |
| Staff B | Registered Nurse | Performed glucometer testing and medication administration with improper hand hygiene |
| Staff C | Certified Nurse Aide | Assisted residents with meals without proper hand hygiene |
| Staff G | Certified Nurse Aide | Performed catheter care with improper glove use |
| Staff K | Dietary Cook | Handled food with improper glove use and cross-contamination |
| Staff N | Dietary Supervisor | Reported ice build-up in freezer and lack of cleaning schedules |
| Staff O | Maintenance | Notified outside company for freezer maintenance; placed caution tape around ice |
| Staff P | Housekeeping Supervisor | Unaware dishwasher failed to reach proper temperatures |
| Staff Q | Certified Nurse Aide | Reported no COVID-19 screening questions asked before work |
| Staff F | Housekeeper | Tested positive for COVID-19; reported limited screening questions |
Inspection Report
Renewal
Census: 40
Deficiencies: 12
Date: May 4, 2022
Visit Reason
The inspection was a recertification survey and investigation of substantiated complaints #103925 and #101574 conducted from April 18 to May 4, 2022.
Complaint Details
Complaints #103925-C and #101574-C were substantiated. The investigation revealed multiple deficiencies related to resident care, medication administration, and infection control.
Findings
The facility failed to ensure accurate assessments and comprehensive care plans for residents, including issues with pressure ulcer documentation, medication administration, and infection control. The facility also experienced a COVID-19 outbreak affecting residents and staff, and failed to maintain proper hygiene and monitoring practices.
Deficiencies (12)
Accuracy of Assessments - The facility failed to ensure assessments accurately reflected residents' status.
Develop/Implement Comprehensive Care Plan - The facility failed to develop timely, person-centered care plans for residents.
Care Plan Timing and Revision - The facility failed to revise care plans for 4 of 13 residents reviewed.
ADL Care Provided for Dependent Residents - The facility failed to provide bathing services for 5 of 13 residents reviewed.
Increase/Prevent Decrease in ROM/Mobility - The facility failed to provide restorative care for 1 resident.
Free from Unnecessary Psychotropic Meds/PRN Use - The facility failed to ensure residents were free from unnecessary psychotropic medications.
Food Procurement, Store, Prepare, Serve - The facility failed to maintain sanitary conditions in food preparation and storage.
Infection Prevention & Control - The facility failed to implement infection control practices to prevent and mitigate COVID-19 spread.
Food and Nutrition Services - The facility failed to maintain proper cleaning schedules and food safety practices.
Linens - The facility failed to handle, store, and transport linens to prevent infection spread.
Infection Control - The facility failed to establish and maintain an infection prevention and control program.
Deficit related to dementia and able to eat by self - The facility failed to provide adequate assistance to residents with dementia during meals.
Report Facts
Census: 40
Deficiencies cited: 14
COVID-19 outbreak: 11
COVID-19 outbreak: 8
Bathing services missed: 5
Care plans not revised: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Registered Nurse | Provided wound care and medication administration observations |
| Staff D | Certified Nurse Aide (CNA) | Screened for COVID-19 symptoms and reported on testing and illness |
| Staff E | Registered Nurse (RN) | Acknowledged screening logs and medication administration issues |
| Staff F | Housekeeper | Acknowledged COVID-19 screening questions and testing |
| Director of Nursing | Provided multiple interviews regarding care plan updates, infection control, and COVID-19 outbreak management | |
| Staff K | Dietary Cook | Observed during meal service and food handling |
| Staff N | Dietary Supervisor | Reported on dishwasher maintenance and cleaning schedules |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 13
Date: Apr 18, 2022
Visit Reason
The inspection was conducted as a Recertification survey and investigation of Complaints #103925 and #101574 from April 18-28, 2022. Complaints #103925-C and #101574-C were substantiated.
Complaint Details
Complaints #103925-C and #101574-C were substantiated based on the investigation conducted April 18-28, 2022.
Findings
The facility failed to ensure accurate assessments, develop and implement comprehensive care plans, provide timely care plan revisions, administer medications as ordered, provide adequate bathing services, maintain infection control, and properly manage pressure ulcers and skin integrity. The facility also experienced a COVID-19 outbreak affecting residents and staff.
Deficiencies (13)
Failure to ensure accuracy of assessments for residents #21 and #191.
Failure to develop and implement comprehensive care plans for residents #15, #21, and #191.
Failure to revise care plans timely for residents #5, #18, #21, and #40.
Failure to provide adequate bathing services for residents #18, #20, #21, #38, and #191.
Failure to administer medications as ordered for resident #38.
Failure to prevent and treat pressure ulcers for residents #21 and #191.
Failure to provide restorative care services for resident #22.
Failure to implement infection prevention and control program.
Failure to ensure food safety and sanitary conditions in food service.
Failure to maintain proper hand hygiene and glove use among staff.
Failure to maintain proper cleaning schedules and equipment maintenance.
Failure to ensure proper blood glucose monitoring procedures.
Failure to ensure proper oxygen administration and documentation for resident #15.
Report Facts
Census: 40
Residents reviewed: 13
Residents sampled for care changes: 13
Residents reviewed for bathing: 5
Residents sampled for medication administration: 5
Residents reviewed for pressure ulcers: 2
Residents reviewed for restorative care: 1
Residents reviewed for infection control: 40
Residents reviewed for food service observation: 40
Residents reviewed for blood glucose monitoring: 1
COVID-19 positive residents: 11
COVID-19 positive staff: 8
COVID-19 positive residents and staff total: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nurse Aide (CNA) | Reported COVID-19 symptoms and testing positive; involved in screening and interviews. |
| Staff B | Registered Nurse (RN) | Provided wound care, medication administration, and interviews. |
| Staff F | Housekeeper | Acknowledged COVID-19 testing and screening procedures. |
| Staff K | Dietary Cook | Observed during food service and interviewed about food handling. |
| Staff N | Dietary Supervisor | Interviewed regarding dishwasher maintenance and food safety. |
| Staff G | Certified Nurse Aide (CNA) | Performed catheter care and assisted with resident care. |
| Staff R | Health Information Technician | Interviewed about COVID-19 screening and infection control. |
| Staff Q | Certified Nurse Aide | Interviewed about care plan expectations. |
| Staff C | Certified Nurse Aide | Interviewed about care plan expectations and assisted residents. |
| Staff A | Licensed Practical Nurse (LPN) | Interviewed about care plan expectations. |
| Staff P | Housekeeping Supervisor | Interviewed about dishwasher maintenance. |
| Director of Nursing | Involved in care plan updates, infection control, and COVID-19 outbreak management. |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 4
Date: Oct 26, 2021
Visit Reason
The inspection was conducted due to complaints 97657-I and 100347-I. Complaint 97657-I was not substantiated, while complaint 100347-I was substantiated.
Complaint Details
Complaint 97657-I was not substantiated. Complaint 100347-I was substantiated. The investigation found that Staff D CNA physically and verbally abused Resident #1 by grabbing him by the chin and restricting his movement. The facility failed to report these allegations to the State Agency Office and failed to investigate them properly. Staff D was suspended and later terminated. The facility educated all staff on abuse policies and reporting procedures.
Findings
The facility failed to ensure a resident was free from abuse and neglect, including verbal, mental, sexual, and physical abuse by staff. The facility also failed to report allegations of abuse to the State Agency Office within required timeframes and failed to investigate allegations of abuse thoroughly. Additionally, the facility did not have sufficient nursing staff to meet residents' needs in a timely manner.
Deficiencies (4)
Failure to ensure freedom from abuse, neglect, and exploitation of residents, including verbal and physical abuse by staff.
Failure to report alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Agency Office within required timeframes.
Failure to investigate allegations of abuse, neglect, exploitation, or mistreatment thoroughly and timely.
Failure to have sufficient nursing staff with appropriate competencies and skills to meet residents' needs and respond to call lights in a timely manner.
Report Facts
Census: 46
Deficiencies cited: 4
Resident count reviewed for call light response: 3
Resident count reviewed for abuse: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Certified Nursing Assistant (CNA) | Named in findings related to abuse of Resident #1 and subsequent suspension and termination. |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed abuse by Staff D and reported concerns. |
| Staff A | Reported observations of Staff D's behavior and interactions with Resident #1. | |
| Director of Nursing | Director of Nursing (DON) | Involved in reviewing allegations, video footage, and educating staff on abuse policies. |
| Administrator | Facility Administrator | Provided education to staff and involved in follow-up interviews and investigations. |
| Staff C | Licensed Practical Nurse (LPN) | Reported concerns about Staff D's treatment of residents. |
| Staff H | Certified Nursing Assistant (CNA) | Reported on Resident #7's care and call light response. |
| Staff G | Certified Nursing Assistant (CNA) | Reported on Resident #7's care and call light response. |
| Staff J | Registered Nurse (RN) | Observed Resident #7 during video footage review. |
Inspection Report
Abbreviated Survey
Census: 41
Deficiencies: 0
Date: Dec 16, 2020
Visit Reason
A focused COVID-19 infection survey was conducted to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Total residents: 41
Inspection Report
Abbreviated Survey
Census: 44
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/17/20 to assess 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
Complaint Investigation
Census: 53
Deficiencies: 9
Date: Feb 27, 2020
Visit Reason
The inspection visit was conducted to investigate complaint #85981-C regarding care plan timing and revision, medication administration, and other resident care concerns.
Complaint Details
Complaint #85981-C was investigated and found not substantiated.
Findings
The facility failed to revise comprehensive care plans timely for residents using medications, failed to update care plans after falls, administered incorrect medication doses, failed to limit psychotropic PRN orders to 14 days, crushed medications without physician orders, served food at unsafe temperatures, and had infection control and hand hygiene deficiencies. The complaint was not substantiated.
Deficiencies (9)
Failure to revise comprehensive care plans timely for residents using pain and antianxiety medications.
Failure to update care plans and implement interventions after resident falls.
Administered incorrect dose of Coumadin due to pharmacy error and failure to verify medication cassette dosage.
Psychotropic PRN medication orders were not limited to 14 days and not reviewed timely.
Crushing medications without physician orders and combining multiple medications in applesauce without orders.
Food served at unsafe temperatures and failure to ensure timely delivery of room trays.
Failure to follow infection prevention and control policies including hand hygiene and glove use during feeding and food service.
Failure to maintain sanitary dining environment due to use of blue painter's tape on tables that prevented proper cleaning.
Failure to implement and monitor an effective Quality Assurance Performance Improvement (QAPI) program.
Report Facts
Resident census: 53
Falls: 9
Medication doses: 48
Medication error rate: 5
Temperature: 129.9
Temperature: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse | Named in medication error finding for not administering correct Coumadin dose. |
| Director of Nursing | Director of Nursing | Named in multiple findings including care plan revisions, medication errors, infection control, and QAPI program. |
| Staff C | Certified Medication Aide | Named in medication crushing and food delivery findings. |
| Staff E | Certified Nursing Assistant | Named in infection control and hand hygiene deficiencies during feeding. |
| Staff B | Cook | Named in food handling and glove use deficiencies. |
| Dietary Manager | Dietary Manager | Named in food handling and temperature monitoring deficiencies. |
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