Good Samaritan - Ottumwa

Inspectors wroteBased on observation, menu review, facility policy review, resident representative and staff interviews, the facility failed to follow the breakfast menu when fruit was not served for 2 of 2 breakfast meals. The facility reported a census of 95 residents.

Inspectors wroteBased on observation, resident interview, staff interviews, the resident council notes, and the facility policy, the facility failed to routinely offer fresh water to residents for extended amounts of time for 2 of 4 residents (Resident #15 and Resident #11) reviewed for hydration. The facility reported a census of 95 residents.

Inspectors wroteBased on observation, record review, staff interviews, and the facility policy, the facility failed to maintain appropriate infection control practices during medication administration when staff handled pills with bare hands for 3 of 3 residents (Resident #2, Resident #10 and Resident #15), failed to perform hand hygiene after glove removal, and failed to ensure hairbrushes were used for a single resident, and failed to cover and label toothbrushing supplies stored in a common bathroom. The facility reported a census of 95 residents.

Inspectors wroteBased on record review, resident representative interview, staff interviews, and the facility policy, the facility failed to treat a resident in a dignified manner by placing him on a mattress in the common area when he is acting out for 1 of 3 residents (Resident #2) reviewed for dignity. The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to notify the physician of a weight loss for 1 of 4 residents (Resident #4) reviewed for a change in condition. The facility reported a census of 95 residents.

Inspectors wroteBased on observations, facility policy review, resident and staff interviews, the facility failed to maintain a homelike environment due to dry wall tape falling from the ceiling in the sunroom, drywall scuffed off in 2 residents' rooms and the heat baseboard coming off the wall leaving a large crack for 2 of 3 residents reviewed for homelike environment (Resident #8 and Resident #13). The facility reported a census of 95 residents.

Inspectors wroteBased on observation, clinical record review, resident and staff interviews, the facility failed to check incontinent residents and change as needed every 2 hours for 2 of 4 residents (Resident #11 and Resident #15) reviewed for incontinent care; and failed to perform morning oral hygiene for 1 of 3 residents (Resident #11) for residents reviewed for oral hygiene. The facility reported a census of 95 residents.

Inspectors wroteBased on observation, record review, staff interviews, and the facility policy, the facility failed to perform weekly skin observations for residents at risk of pressure ulcers and ensure a physician order in place prior to completing a wound dressing change for 2 of 5 residents (Resident #2 and Resident #15) reviewed for assessment and intervention. The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, resident representative interview, and staff interviews, the facility failed to provide adequate supervision for 1 of 4 residents (Resident #2) reviewed for safety when staff left a resident with a history of falls unattended in the bathroom/shower room. The facility reported a census of 95 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to ensure residents received ordered medications for 2 of 5 residents reviewed for the provision of medications(Residents #1 and #8). The facility reported a census of 95 residents.

Inspectors wroteBased on observation, resident representative interview, resident interview, staff interviews, and the facility policy, the facility failed to maintain appropriate food temperatures for a breakfast room tray. The facility reported a census of 95 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure a call light within the reach of 1 out of 21 dependent residents (Resident #95) in the sample. The facility reported a census of 101.

Inspectors wroteBased on observation, clinical record review, facility policy review and staff interviews, the facility failed to respond to a weight loss in timely manner for 1 of 2 residents (Resident #104) reviewed for weight change. The facility failed to notify the physician of a weight loss in a timely manner which delayed the implementation of dietician recommended interventions. The facility reported a census of 101 residents.

Inspectors wroteBased on observations, clinical record review, and staff interviews, the facility failed to use proper hand hygiene techniques during the administration of an insulin injection and eye drops for 1 of 3 residents (Resident #3) reviewed during medication administration observation. The facility reported a census of 101 residents.

Inspectors wroteBased on observation, clinical record review, and staff and resident interview, the facility failed to implement and follow physician orders for application of an ace wrap for 1 of 3 residents reviewed (Resident #8). The facility reported a census of 92 residents.

Inspectors wroteBased on observation, clinical record review and staff interviews, facility staff failed to ensure prompt intervention to ensure supplemental oxygen was administered in accordance with physician orders and each resident's individual care plan for 2 of 3 residents reviewed (Resident #6, #7). The facility reported census of 92 residents.

Inspectors wroteBased on observation, clinical record review and staff interview, the facility failed to use enhanced barrier precautions (EBP) during peri care for 1 of 3 residents who required EBP (Resident #6). The facility reported a census of 92 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to provide adequate supervision or provide timely care in order to prevent a fall with major injury. The facility also failed to implement new interventions to reduce falls from the wheelchair for 1 of 3 residents reviewed (Resident #2) for falls. The facility failed to ensure safe wheelchair transport and proper use of foot pedals during a general observation of Resident #67. The facility reported a census of 111.

Inspectors wroteBased on observation, staff interviews, and policy review, the facility failed to ensure dignity to residents in the main dining room. Resident with soiled shirt of spilt drink and processed food propelled self near other residents eating thorough the dining area (Resident #71). The facility reported a census of 111 residents.

Inspectors wroteBased on staff interviews, electronic record review, Iowa Physician Orders for Scope of Treatment (IPOST) form, and facility polic review the facility failed to ensure consistent documentation of code status for 1 of 32 resident reviewed for advanced directives (Resident #67). The facility reported a census of 111 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews and policy review the facility failed to provide eating assist to maintain good nutrition to 1 of 3 residents reviewed (Resident #67). The facility reported a census of 111 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to assist with scheduled repositioning, and toileting for a resident with impaired skin and a pressure ulcer risk for 1 of 3 residents observed for skin concerns (Resident #81). The facility reported a census of 111 residents.

Inspectors wroteBased on observations, clinical record review, family interviews, staff interviews and the facility policy the facility failed to ensure adequate hydration for 1 of 3 residents reviewed. (Resident #81). The facility reported a census of 111 residents.

Inspectors wroteBased on observation, staff interview, and the facility policy, the failed failed to use appropriate hand hygiene between resident's medication administration and failed to use proper technique for preparation of medication administration and touched resident's pills with their bare fingers for 2 of 5 oral medication administrations observed (Resident #13 and Resident #269). The facility reported a census of 111 residents.

Inspectors wroteBased on clinical record review and bathing records, the facility failed to ensure residents were provided adequate personal hygiene services to include at least two bathing opportunities per week for 2 of 4 residents reviewed (Residents #3 & #9). The facility reported census was 110 residents.

Inspectors wroteBased on record review, bathing records, and staff interviews, the facility failed to provide sufficient staff to ensure resident needs were met and bathing opportunities are provided as scheduled for 1 of 3 residents reviewed (Resident #3). The facility reported census was 110 residents.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to implement interventions to prevent the development of multiple pressure injuries. Facility also failed to follow physician treatment, using an incorrect medicated treatment on an open pressure injury and further failed to prevent contamination of pressure injuries while performing wound care for 1 of 3 residents (Resident #96) observed for wound care. Facility reported a census of 113 residents.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to carry out fall interventions in order to prevent a major injury for 1 of 3 residents reviewed for falls (Resident #312) and failed to safely assist a resident with wheelchair locomotion for 1 resident during a general observation (Resident #84). The facility reported a census of 113 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean, free from possible hazards, and homelike environment. The facility reported a census of 113 residents.

Inspectors wroteBased on resident interview, staff interview, clinical record review and the facility policy review, the facility failed to consistently answer call lights within a reasonable amount of time for 7 of 9 residents reviewed for staffing(Residents # 19, #22, #32, #49, #75, #100, and #362) . Residents and staff reported having low staffing caused missed or delayed cares. The facility reported a census of 113 residents.

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure chicken thawed properly to avoid potential hazards of contamination to other foods. The facility failed to ensure hygienic practices with serving and with the kitchen ice machine. The facility reported a census of 113.

Inspectors wroteBased on observations, staff interviews, record review, and policy review the facility failed to cover clean linen carts in the hallways to ensure that clean linen was kept free from contamination. The facility also failed to perform hand hygiene or change gloves while performing wound cares and wound dressing change and further failed to sanitize treatment scissors when soiled for 1 of 3 resident (Resident #96) wound cares observed. The facility reported a census of 113 residents.

Inspectors wroteBased on staff interview, resident interview, and clinical record review, the facility failed to treat residents with dignity and respect throughout cares provided for 2 of 7 residents reviewed. (Resident #76 and Resident #85). The facility reported a census of 113 residents.

Inspectors wroteBased on observation, staff interview and family interview the facility failed to post required notifications of ombudsman, survey agencies, and other support for advocacy. The facility also failed to provide accessibility of the survey results. The facility reported a census of 113. Findings Include: On 8/21/23 at 10:15 AM Family Member visiting requested information on how to contact state agencies. It was relayed the information is usually posted at the entrance or halls for easy access. The surveyor proceeded with family down two hallways to the front door and could not locate any signage other than a sign in a glass cabinet that noted This facility's survey results for the past three (3) years are available. The family member reported he did not know how to contact any state agencies and did not recall getting the information. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to complete Beneficiary Notification forms for 2 of 3 residents reviewed for the implementation of Advanced Beneficiary Notification (ABN).

Inspectors wroteBased on staff interviews, resident interviews, and the facility policy review, the facility failed to maintain personal privacy and resident information confidential for 2 residents (Resident #76 and Resident #85) out of 7 reviewed. The facility reported a census of 113 residents.

Inspectors wroteBased on staff interviews, resident interviews, documentation reviews and the facility policy review, the facility failed to report alleged violations related to mistreatment of 2 residents (Resident #76 and Resident #85) out of 2 reviewed. The facility reported a census of 113 residents.

Inspectors wroteBased on clinical record review, staff interview, resident interview, and facility policy review, the facility failed to investigate an allegation of abuse to the State Survey Agency for 2 of 2 residents reviewed for abuse and neglect (Resident #76 and Resident #85). The facility reported a census of 113 residents.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to develop and implement a comprehensive care plan for 3 of 30 residents reviewed (Resident #4, Resident #103, Resident #104). The facility reported a census of 113 residents.

Inspectors wroteBased on record review, observation, interviews, and policy review, the facility failed to properly update the Comprehensive Care Plan care for 3 of 30 residents (Resident #21, Resident #103, Resident #104) reviewed for care plan intervention effectiveness, review, and revision. The facility reported a census of 113 residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow Physician's orders for ACE wraps daily application causing unrelieved swelling of lower extremities and discomfort for 1 of 30 sampled residents (Resident #19). The facility also failed to prime an insulin pen injection prior to administration and/or further failed to keep insulin pen in place after injection for the appropriate amount of time for 2 of 2 residents observed receiving insulin (Resident #86 and #103). The Facility reported a census of 113 residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review the facility failed to implement interventions for blood glucose reading below 70 mg/dL (milligrams per deciliter) and for blood glucose readings above 400 mg/dL for 2 of 2 residents reviewed for unnecessary medications (Resident #63 and Resident #81). The facility census reported a census of 113.

Inspectors wrote2. The Minimum Data Set (MDS) assessment for Resident #104, dated 7/10/23, documented diagnoses of sepsis, kidney failure, and diabetes with diabetic neuropathy. Section H of the MDS, titled Bladder and Bowel, documented an indwelling catheter. The Comprehensive Care Plan (CCP) dated 5/31/23 documented an indwelling catheter related to kidney failure with a goal to remain free from catheter related trauma through the review date of 9/19/23. Interventions included monitor for signs and symptoms of discomfort on urination and frequency and catheter care by CNA Q (every) shift and PRN. The Medication Administration Record (MAR) for August 2023 revealed the resident took ciprofloxacin HCl 500 mg twice a day for possible UTI/penile infection from 8/13/23 through 8/21/23. [...]

Inspectors wrote2. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident#96 had diagnoses including Diabetes Mellitus (DM) as an active diagnosis. MDS revealed the Brief Interview for Mental Status (BIMS) score to be 11, which indicated moderate cognitive impairment. The MDS revealed Resident #96 had one or more unstageable deep tissue injuries that were not present upon admission. MDS revealed that Resident #96 received pressure ulcer/injury care and the application of non-surgical dressings with or without topical medications. The Braden scale with lock date of 1/16/23, used to assess for the risk of pressure injury development, indicated the resident was at risk for pressure sores. The Care Plan documented the resident had potential for pressure ulcer development related to immobility with the initiated date of 2/17/23. [...]