Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Ottumwa during CMS and state inspections, most recent first.
Breakfast menus were not followed when mixed fruit cups were not served during 2 observed breakfast meals. During one meal, staff noted the fruit was usually placed into dishes but it was not done, and during another meal no fruit cups were seen in the dining room or on resident trays. The Dietary Mgr and Dietary Aide gave conflicting accounts about whether fruit was available or offered, and the Administrator stated the facility should follow the menu or offer a substitution.
Failure to provide fresh water consistently affected two residents reviewed for hydration. One resident had severely impaired cognition, dementia, renal insufficiency, and diabetes, while another had intact cognition with urinary incontinence, arthritis, and diabetes. Observations showed fluids were not readily available or offered for extended periods, and staff and resident council notes confirmed that water pass was often not completed and fresh water was not consistently available, including at night.
A RN handled pills with bare hands during med pass for multiple residents, failed to perform hand hygiene after glove removal, and moved between medication prep, blood glucose checks, and insulin administration without consistent hand hygiene. Staff also used the same hairbrush on multiple residents and stored resident toothbrushes, toothpaste, and denture supplies in a common bathroom without covering or labeling them. The DON stated residents should have their own hairbrushes and that shared bathroom storage required items to be covered, labeled, secured, and protected from splashes.
A resident with moderately impaired cognition, depression, heart failure, repeated falls, and polyarthritis was placed on a mattress on the floor in the common area when he became behaviorally upset and yelled out. EHR notes documented staff using a Hoyer lift with two staff to transfer him to the floor, where he remained asleep or under direct supervision, while interviews showed the family and multiple staff members felt the practice was not appropriate or dignified.
Failure to notify the physician of a significant weight loss for a resident with dementia and severe cognitive impairment. The resident had a care plan for malnutrition and monitoring for weight loss, but the record showed a 9.2 lb loss in 7 days with no documentation that the MD was informed. An LPN said she did not report it because she did not believe it was a true loss, and the MD stated he wanted staff to notify him of significant losses.
Failure to maintain a homelike environment: a sunroom ceiling had hanging drywall tape and visible water damage, and two residents had unresolved room damage including scuffed drywall, drywall powder on the floor, and a baseboard heater coming off the wall with a large crack. The residents had intact cognition and reported the issues had been present for weeks to months, while the MDS and maintenance interviews confirmed the repairs had been delayed.
A facility failed to check and change two residents with incontinence every 2 hours and failed to provide morning oral care for one resident. One resident with severe cognitive impairment and total toileting dependence remained in a recliner for over 2 hours before being found with a saturated brief, and another resident with urinary incontinence was left for over 4 hours with a heavily soaked brief and deep red indentations on both buttocks and the backs of both thighs. Staff also did not brush the second resident’s teeth during morning care, and a CNA said she was unsure whether the resident had natural teeth or dentures.
Two residents at risk for pressure ulcers were involved in deficiencies related to skin monitoring and wound care. One resident with impaired cognition and multiple diagnoses had a buttock wound order in the chart, but weekly skin observations did not address that wound and staff reported the assessments were not being completed as assigned. Another resident with severe dementia and chronic conditions received a dressing change to the right lower arm even though no physician order for wound care was found in the EHR, and the RN confirmed the order was missing.
A resident with moderately impaired cognition, repeated falls, and extensive assistance needs was left unattended in the shower room despite a care plan directing staff not to leave him alone. He was later found on the floor in front of the toilet after trying to stand, and staff interviews confirmed he should have remained in view and under supervision.
Medication Orders Not Available or Administered as Prescribed: Two residents did not receive ordered meds as prescribed. One resident with pain, cancer, and constipation had a buprenorphine patch order entered incorrectly after hospitalization, and the MARs lacked documentation that the patch was given. Another resident with COPD had a Trelegy Ellipta inhaler unavailable for several days, with pharmacy and staff interviews showing delays in reordering and receipt. Facility policy required timely pharmacy contact, documentation, and order updates after hospitalization.
A resident room tray was served with hot foods below the facility’s stated hot-holding standard. Dietary staff recorded acceptable tray-line temps, but the mechanical-texture room tray later showed cream of wheat, french toast, and sausage link at low temps, and the SA noted the french toast tasted lukewarm. A resident and a resident representative also reported that food was often cold or inconsistently cooked.
Call Light Out of Reach for Dependent Resident: A dependent resident with multiple diagnoses, including dementia, COPD, and respiratory failure, was observed sitting in a recliner and calling for help, but the call light was tied to the bed and out of reach. Staff and the DON acknowledged that call lights must be within reach at all times, and the facility policy directed staff to place the call light in easy reach when leaving the room.
Delayed Response to Significant Weight Loss: A resident with dementia and impaired cognition had a significant wt loss that was identified by nursing staff, but the RN did not promptly notify the MD. The loss was not addressed for several days, ARC discussion was inconsistent, and the RD’s supplement and fortified food recommendations were delayed while staff relied on the consultant RD rather than immediately escalating the change.
Failure to use gloves during medication administration was identified when an LPN gave a resident's insulin injection and eye drops without donning gloves. The resident had type 2 DM and severely impaired cognition, and the MAR directed insulin twice daily and ophthalmic drops four times daily. The LPN acknowledged the omission, and the DON stated gloves should be worn for infection control purposes.
A resident with heart failure and intact cognition did not consistently receive ace wrap application to the lower extremities as ordered by a physician. Documentation in the Medication Administration Records was lacking, and staff interviews revealed confusion about the order's implementation and documentation, resulting in the resident not having the ace wrap applied as prescribed.
Two residents with orders for supplemental oxygen did not receive timely administration as required by their care plans and physician orders. One resident was observed with an empty oxygen tank on multiple occasions, while another was found without her nasal cannula and with an empty tank before it was replaced. Staff interviews revealed unclear responsibility for monitoring and changing oxygen tanks, leading to lapses in care.
A staff member failed to use both gown and gloves as required by Enhanced Barrier Precautions while providing peri care to a resident with an indwelling catheter. The staff member initially wore only gloves and not a gown during high-contact care activities, and had to interrupt care to obtain additional supplies and proper PPE before completing catheter care.
A resident with intellectual disabilities and impaired cognition fell from a wheelchair, sustaining major injuries, due to inadequate supervision and delayed assistance. Despite previous incidents of leaning forward, the care plan lacked timely interventions. Another resident with Parkinson's disease was observed being pushed in a wheelchair with a foot dragging on the floor, contrary to facility policy.
A facility failed to ensure consistent documentation of a resident's code status, resulting in a discrepancy between the IPOST form, which indicated CPR, and the electronic profile, which directed DNR. The resident, with a terminal prognosis and intact cognition, had their advance care planning choices misrepresented due to an RN's error in completing the IPOST form.
An LPN at a facility failed to follow proper infection control practices during medication administration for two residents. The LPN did not perform hand hygiene between medication passes and touched pills with bare fingers, contrary to the facility's policy. Interviews revealed a lack of clarity and adherence to the policy, which mandates hand hygiene before and after each medication pass and prohibits touching pills with bare hands.
A resident with severe cognitive impairment and requiring assistance with eating was observed in the dining room with a soiled shirt and food on their beard, compromising their dignity. Staff interviews revealed that clothing protectors were not available in the dining room, and the facility had a policy of not providing them unless requested by the family.
A resident with Parkinson's disease and respiratory issues experienced significant weight loss due to inadequate eating assistance. Despite a care plan requiring guidance and cueing, staff provided minimal help during meals, leading to the resident struggling to eat independently. The facility's policy on nutritional care was not followed, resulting in insufficient support for the resident's needs.
A resident with Alzheimer's and dementia, requiring substantial assistance, was not repositioned or toileted as per their care plan, leading to skin damage. Observations showed the resident left in a recliner for over two hours without assistance, resulting in reddened and excoriated skin. Staff acknowledged the lapse in care, and the DON confirmed the expectation for adherence to care plan interventions.
A resident with Alzheimer's and other health issues was not provided adequate hydration, as observed during multiple periods where no fluids were offered or accessible. Despite a care plan encouraging fluid intake, a family member reported concerns about the resident not receiving enough water. The DON and Administrator acknowledged the issue, which violated the facility's policy on hydration.
The facility failed to provide adequate personal hygiene services, specifically at least two bathing opportunities per week, for two residents with significant medical conditions. One resident missed five scheduled bathing opportunities, while another missed three in April and May 2024.
The facility failed to provide sufficient staff to meet resident needs, resulting in missed bathing opportunities for a resident who required maximal assistance. Staff interviews and Daily Assignment Records confirmed that the facility often operated with fewer aides than necessary, particularly on the 300 and 400/500 halls.
Breakfast Menu Not Followed for Fruit Service
Penalty
Summary
The facility failed to follow the breakfast menu when fruit was not served for 2 of 2 breakfast meals observed. The breakfast menu for 5/28/26 listed french toast, sausage patty, mixed fruit cup, choice of hot or cold cereal, assorted juice, and milk/beverage, but during the 6:57 AM breakfast observation no fruit cup was observed. Staff H, Dietary, stated at 9:10 AM that the fruit was put into dishes and she did not know it was not done, adding that the fruit usually came out of the can and was placed into dishes. A second breakfast observation on 6/1/26 at 9:00 AM showed residents eating in the dining room with no fruit cups observed in front of residents. The menu for that meal listed pancakes, bacon, mixed fruit cup, choice of hot/cold cereal, assorted juice, and milk/beverage. During interviews, the Dietary Manager stated fruit cups were usually offered and stored in the back, while Staff I, Dietary Aide, stated she did not know they had fruit and no one asked for it. The Dietary Manager later stated she had been working in the kitchen that week and knew what was being dished up, and the Administrator stated the facility should follow the menu or offer a substitution. Facility policy stated menus were prepared to meet the balanced nutritional needs of residents in accordance with established national standards.
Failure to Provide Fresh Water Consistently
Penalty
Summary
The facility failed to routinely offer fresh water to residents for extended periods of time for 2 of 4 residents reviewed for hydration, including a resident with severe cognitive impairment and another resident with intact cognition. Resident #15 had a BIMS score of 3 out of 15, indicating severely impaired cognition, and diagnoses that included Alzheimer's dementia, renal insufficiency, and diabetes mellitus; the resident also required set up/clean up assistance with eating and took a diuretic, antidepressant, and antipsychotic. The task intake record for fluids outside of meals showed no data found for the last 30 days, and during observation the resident was seated in a recliner in the common area without fluids readily available and without a table placed near him, although fluids were later given during medication administration and breakfast. Resident #11 had diagnoses including urinary incontinence, arthritis, and diabetes, was occasionally incontinent of urine, required assistance of one staff for toileting hygiene, and had a BIMS score of 14 out of 15. During observation, the resident sat in a wheelchair in the dining room, then was moved to the common area, chapel, and back to the common area and dining room, and staff did not offer fluids from 9:09 AM until 11:18 AM. Resident council notes also documented concerns that there was no fresh ice water and that fresh water at night was an issue, and staff interviews confirmed that water pass was supposed to occur each shift but was often not completed because staff were too busy or could not get to it. The DON stated that once a shift water should be passed and that residents in the 200 hall should have a pitcher beside them in the common area.
Infection Control Lapses During Medication Administration and Resident Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices during medication administration and resident care activities. During observations, a RN handled pills with bare hands while preparing medications for Resident #10, Resident #15, and Resident #2. The RN poured pills into bottle lids, used ungloved fingers to pick up pills that fell into the lids, returned pills to the bottles, and used ungloved fingers to guide pills from bubble packs into medication cups. For Resident #15, the RN also prepared and administered medications, performed blood glucose monitoring, and gave an insulin injection while moving between tasks without completing hand hygiene after glove removal. The report also documented shared use of hairbrushes among residents. A CNA was observed using the same hairbrush on multiple residents in the 200 Hall common area, and later two hairbrushes were observed sitting in the common area. Staff interviews confirmed that the hairbrushes were being used communally, although staff acknowledged they should not be used for multiple residents. The DON stated each resident should have their own hairbrush. In addition, the facility stored multiple resident denture cups and gray basins containing toothbrushes and toothpaste in a common bathroom without covering or labeling the items to identify which belonged to which resident. Staff stated resident oral care supplies were kept in the common bathroom and sometimes taken to resident rooms, while the DON stated the items could be stored there only if covered, labeled, secured from others, and protected from splashes. The facility policy titled Hand Hygiene Policy dated 11/13/25 directed staff to complete hand hygiene after glove removal.
Resident Placed on Mattress in Common Area During Behaviors
Penalty
Summary
The facility failed to treat a resident in a dignified manner when staff placed him on a mattress on the floor in the common area during episodes of behavioral distress. The resident had moderately impaired cognition, depression, heart failure, repeated falls, and polyarthritis, and his care plan addressed behaviors such as yelling out, using profanity, calling the nurses station and front desk repeatedly, and threatening to put himself on the floor. The care plan included interventions allowing him to lie on a mattress or sit on the floor when he became belligerent or tried to hit, and it was revised on 5/10/26. EHR documentation showed that when the resident began yelling out and acting out, staff used a Hoyer lift with two staff to transfer him to the floor with a mattress in the common area. Notes documented him sleeping on the floor or on the mattress in the common area, being monitored closely, and remaining there while staff provided care. One note stated staff were worried to put him in bed due to behaviors and safety concerns, and that he was under one-on-one direct supervision. Another note documented that he remained laying on the mattress in the common area while asleep and that staff were turning and repositioning him. During interviews, the resident's family member stated the facility put him on a mattress on the floor in the common area when he had behaviors and said it was not right because he still had some pride left. Several staff members stated they did not think placing him on a mattress in the common area was appropriate or dignified, and one CNA said she would have taken him to his room instead. One LPN stated she had placed him on a mattress in the common area three times until he calmed down, and another LPN said she did so because she thought it was more dignified than laying on the floor. The DON stated staff appeared desperate and worried about safety, and the facility policy required residents to be treated in a manner and environment that maintains or enhances dignity and respect.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss for Resident #4, who had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and muscle weakness, and had a BIMS score of 5 out of 15 indicating severe cognitive impairment. The care plan stated the resident met criteria for malnutrition and directed staff to monitor for weight loss. The facility policy stated the resident's nutritional status would be routinely assessed and nutritional risk monitored, and that the physician would be notified as appropriate in evaluating and managing causes of nutritional risks. Resident #4's weight record showed a weight of 128.0 lbs on 5/15/26 and 118.8 lbs on 5/22/26, a loss of 9.2 lbs in 7 days, or 7.9%. The facility had no documentation that the physician was notified between 5/22/26 and 6/2/26. During interview, an LPN stated she did not report the loss because she did not believe it was a true weight loss. The physician stated staff should reweigh the resident if there was a large weight loss and wanted to be informed of significant losses. The RN case manager stated staff should contact the physician for a 10 lb weight loss in one week, and the DON stated the resident's wheelchair was reweighed later because of the weight discrepancy.
Failure to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment when drywall tape was observed hanging from the ceiling in the sunroom, with a wet spot and bubbling drywall from water damage. This condition was first observed on 5/26/26 and remained unchanged on multiple later observations through 6/1/26. The Maintenance Supervisor stated the roof had been replaced about a month earlier, that the ceiling had needed repair for 8 months, and that the work had been delayed until the roof was fixed. The facility also failed to maintain the condition of two residents’ rooms. Resident #8, who had a BIMS score of 15 indicating intact cognition, had scuffed drywall by a recliner with multiple scratches and drywall powder on the floor near the wall; the resident stated the damage had been present for months and bothered her when she had visitors. Resident #13, who also had a BIMS score of 15, had an electric baseboard heater coming off the wall with a large crack and scuffed paint above it; the resident said he had reported it about a month earlier and it had not yet been fixed. The Maintenance Supervisor stated the wall repair for Resident #8 was still pending and the heater register for Resident #13 needed to be specially ordered and had been known about for about 6 months.
Failure to Provide Timely Incontinence Care and Morning Oral Hygiene
Penalty
Summary
The facility failed to check incontinent residents and change them as needed every 2 hours for Resident #15 and Resident #11, and failed to perform morning oral hygiene for Resident #11. Resident #15 had a BIMS score of 3 out of 15, indicating severe cognitive impairment, and was dependent for toileting hygiene, required substantial to maximal assistance with toilet transfer, and was always incontinent of urine and frequently incontinent of bowel. His care plan directed staff to assist with transfers and toilet use with a stand aid and one staff member. During continuous observation, Resident #15 remained in a recliner for 2 hours and 26 minutes before staff assisted him to the shower room and onto the toilet, where his incontinent brief was found saturated. Staff interviews confirmed incontinence care was expected every 2 hours, and the DON stated the resident had not been asked or checked and changed for over 4 hours. Resident #11 had diagnoses including urinary incontinence, arthritis, and diabetes, with a BIMS score of 14 out of 15. She was dependent for toilet hygiene, required substantial to maximal assistance with oral hygiene, and was documented as occasionally incontinent. Her care plan directed staff to check and change her brief before and after meals, at bedtime, and as needed, and to assist with oral hygiene because she had her own teeth. During observation, she remained in her wheelchair through breakfast, time in the common area, chapel, and lunch, and when staff finally transferred her to bed after more than 4 hours, her brief was heavily soaked with urine and both buttocks and the backs of both thighs had deep red indentations. Staff then completed incontinence care and applied a new brief. On another morning, staff assisted Resident #11 with dressing and transfer to a wheelchair but did not complete oral care before taking her out of the room. She later remained in the dining room and therapy area without oral hygiene being provided. The resident stated staff did not brush her teeth. A CNA said she did not brush the resident's teeth because she was unsure whether the resident had real teeth or dentures. The RN case manager stated staff should check and change the resident and complete oral care in the morning, and the DON stated staff should check and change residents every 2 hours and complete oral care when they get up and before bed.
Failure to complete weekly skin observations and obtain wound care orders
Penalty
Summary
The facility failed to perform weekly skin observations for residents at risk for pressure ulcers and failed to ensure a physician order was in place before a wound dressing change was completed for two residents. Resident #2 had moderately impaired cognition, diagnoses including depression, heart failure, repeated falls, and polyarthritis, and was identified on the MDS as at risk for pressure ulcer development. The care plan addressed potential pressure development related to obesity, impaired mobility, and bladder incontinence, and directed staff to notify the nurse immediately of any new skin breakdown noted during baths and daily care. During observation, Resident #2 was seated in a wheelchair near the nurse’s station with multiple bruises on the left arm and bandages on both knees and the left elbow. The EHR contained a physician order for an open area to the left buttock, but the weekly skin observation notes reviewed for May documented puncture and skin tear areas on the right outer wrist and left hand and did not address the buttock wound. An RN stated she thought the wound was healed and had not looked at it that day, and the ADON stated she did not complete the weekly skin assessments and that floor nurses were supposed to do them. Resident #15 had severe cognitive impairment, diagnoses including Alzheimer’s dementia, renal insufficiency, and diabetes mellitus, and was also identified as at risk for pressure ulcer development. During observation, an RN completed a dressing change on the resident’s lower right arm while the resident sat in the common area. Review of the EHR found skin observation entries on several January and February dates, but no physician order for wound care or dressing changes for the right lower arm. The RN later confirmed there was no order in the chart and stated the resident had a skin tear, while the DON stated skin assessments were done weekly and that staff used a skin protocol and entered the order in the chart.
Failure to Supervise a Resident With Repeated Falls in the Shower Room
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of repeated falls and moderately impaired cognition. The resident’s MDS showed a BIMS score of 9 out of 15, use of a manual wheelchair, and need for substantial to maximal assistance with rolling, bed mobility, and transfers. The care plan identified the resident as at risk for falls due to poor safety awareness, noncompliance with asking for assistance, impaired balance, and behaviors such as putting himself on the floor, and it specifically directed staff not to leave him unattended in the shower house. The care plan also stated he required a reclining shower chair with 1-person assist for bathing and 1-person assist for toilet use. Despite these documented needs, the resident had multiple falls during the year, including a fall in the public bathroom/shower room when staff left him alone. The event record stated a medication aide found the resident lying on the floor in front of the toilet after hearing yelling from the shower room, with the resident yelling to be helped off the floor and no injury noted. The resident representative stated the resident was left alone in the shower room, tried to stand, and fell. Staff interviews confirmed the resident should not have been left unattended, with one CNA stating staff left to get a brief and the resident pushed the stand aid out of the way and fell. Other staff and the DON acknowledged the resident should not be left alone in the bathroom/shower room.
Medication Orders Not Available or Administered as Prescribed
Penalty
Summary
The facility failed to ensure that ordered medications were available and administered for two residents reviewed for medication provision. Resident #1 had diagnoses including pain, cancer, and constipation, and was cognitively intact with a BIMS score of 13 out of 15. A hospital medication list showed an active order for buprenorphine 7.5 mcg/hour, one patch every 7 days. The eAdmin record documented that the patch did not arrive from the pharmacy, and the February 2026 MAR showed the order entered as a 7-day medication rather than every 7 days, with the 2/13/26 entry marked unavailable. The MARs for February and March lacked documentation that the resident received the medication. The DON stated the buprenorphine was entered incorrectly for only 7 days instead of every 7 days, and an RN case manager stated she erred when entering the order into the computer. Resident #8 had COPD with acute exacerbation and a BIMS score of 15 out of 15, indicating intact cognition. The care plan addressed shortness of breath related to COPD, and the physician ordered Trelegy Ellipta inhalation powder. The April 2026 MAR showed the inhaler was not available for 4 days, from April 4 through April 7. E-admin notes showed the medication was ordered from the pharmacy on April 4 and again on April 5. A pharmacy technician stated the first fax requesting a refill was not received until April 7, and two faxes were received that day. An LPN stated inhalers are usually monitored by meter and refilled through fax requests, and the DON stated the inhaler may have been delayed because of cost and would need to be looked into. Facility policy required staff to call the pharmacy if a medication was not delivered by med pass time, document the details in the EMR, notify the ordering physician if the medication was unavailable, and follow routine reordering procedures. The physician/practitioner orders policy also required medication orders to be updated after hospitalization and a drug regimen review following return from the hospital. The records and interviews showed that the ordered medications were not available as prescribed and that the ordering and reordering process did not result in timely receipt and administration for the two residents reviewed.
Food Temperatures on Room Tray Were Too Low
Penalty
Summary
The facility failed to maintain appropriate food temperatures for a breakfast room tray. Resident #8 had an MDS assessment showing a BIMS score of 15 out of 15, indicating cognition intact. During an interview, Resident #8 stated she did not like the food and reported that sometimes the food was hot, but the meat could be cold on the outside and warm on the inside, and could be partially cooked or partially frozen. A resident representative also stated the food was terrible and was usually cold if residents stayed in their room. On the breakfast menu, the meal included french toast, sausage patty, mixed fruit cup, choice of hot or cold cereal, assorted juice, and milk/beverage. During observation, dietary staff completed pre-service temperatures for tray-line items, including french toast at 164.1 F, sausage at 196.1 F, and cream of wheat at 180.1 F. Later, a mechanical-texture room tray was prepared and sent to the unit, and temperatures taken on the test tray showed cream of wheat at 130.2 F, french toast at 113.1 F, and sausage link at 131.2 F. The State Agency taste-tested the items and found the cream of wheat and sausage warm, while the french toast tasted lukewarm. The Dietary Manager stated the temperatures were low and that the french toast sticks cool so fast, and the Administrator stated the temperatures were too low.
Call Light Out of Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure a call light was within reach of one dependent resident. Resident #95 had diagnoses including atrial fibrillation or other dysrhythmias, diabetes mellitus, non-Alzheimer's dementia, anxiety disorder, depression, and respiratory failure. The MDS identified the resident as dependent on staff for transfers and unable to walk. The care plan addressed an ADL self-care performance deficit related to COPD and included transfer assistance with two staff and a total lift when needed. During an observation, Resident #95 was sitting in a recliner in the room and called for help, stating that no one answered and that help was needed. The resident's call light was observed tied to the bed with multiple knots and positioned out of the resident's reach, while the bed was across the room from the recliner. Staff interviews confirmed that call lights are required to be within reach of residents at all times, including when residents are in their rooms. The DON also acknowledged that call lights should be within reach at all times. The facility policy stated that when leaving the room, the call light should be placed in easy reach of the resident.
Delayed Response to Significant Weight Loss
Penalty
Summary
The facility failed to respond in a timely manner to a significant weight loss for one resident with hyperlipidemia, anxiety, depression, dementia, pain, hypokalemia, and severely impaired cognition. The resident required set-up assistance with eating and had a care plan addressing potential nutrition issues related to dementia, prior surgical wound history, anxiety disorder, muscle wasting, and risk for malnutrition. The resident’s weight decreased from 153.8 pounds to 133.0 pounds, and then to 132.8 pounds, reflecting a significant loss over a short period. Staff L, an RNA, stated she identified the weight loss when she weighed the resident before breakfast and re-weighed her to confirm it, then informed Staff G, the RN. Staff G stated the weight loss of 20 pounds was not addressed until nine days later, and she acknowledged that this was a little lengthy to address a significant weight change. The facility’s ARC meeting minutes showed the resident’s significant weight loss was not noted at the earlier meeting, and no dietary staff attended that meeting. The consultant RD documented the resident’s significant weight loss and recommended house supplements and fortified foods, but the physician did not approve the recommendation until later. The DON stated nursing staff failed to notify the physician when the significant weight loss was identified and that RN case managers relied on the consultant RD to complete the assessment and provide recommendations to the physician. The facility policy required the licensed nurse to notify the DFN within 24 hours of a significant weight change and to immediately notify the medical provider, but this did not occur in a timely manner.
Failure to Use Gloves During Medication Administration
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when Staff A, an LPN, administered an insulin injection and eye drops to Resident #3 without wearing gloves. Resident #3 had a diagnosis of type 2 diabetes mellitus, a Brief Interview for Mental Status score of 07 out of 15 indicating severely impaired cognition, and received insulin injections 7 of the past 7 days during the review period. The Medication Administration Record directed Humulin KwikPen insulin 10 units in the AM and PM, and Polyvinyl Ophthalmic Solution 1 drop in both eyes four times daily for dry eyes. During a medication pass observation, Staff A administered both the insulin and the eye drops without donning gloves. Staff A later acknowledged that gloves should have been worn before giving the eye drops and the insulin. The Administrator also acknowledged that not wearing gloves during the administration of an insulin injection and eye drops was a concern. Review of the facility's medication administration policies showed they did not specifically include wearing gloves for insulin pen injections or eye drop administration, and the DON stated she was surprised that glove use was not mentioned in the policies and stated that gloves should be worn for infection control purposes.
Failure to Follow Physician Orders for Ace Wrap Application
Penalty
Summary
The facility failed to implement and follow physician orders for the application of an ace wrap to a resident's lower extremities. The resident, who had a diagnosis of heart failure and demonstrated intact cognition, had a physician order for an ace wrap to be applied in the morning and removed in the evening. Review of the Medication Administration Records for three months showed no documentation that the ace wrap or compression stockings were applied as ordered. During observation, the resident was seen without the ace wrap or compression stockings, only wearing socks and shoes. When questioned, the resident reported that the ace wrap was applied once but caused significant discomfort, leading to its removal. Staff interviews revealed confusion regarding the documentation and implementation of the order. A registered nurse was unable to locate the task in the computer system, and the DON was uncertain where completion of the task would be documented, despite confirming the order existed. The ADON was eventually able to show where aides documented the application and removal of the ace wrap, indicating a lack of consistent process and oversight in ensuring physician orders were followed and properly documented.
Failure to Ensure Timely Administration of Supplemental Oxygen
Penalty
Summary
Facility staff failed to ensure that supplemental oxygen was administered in accordance with physician orders and individual care plans for two residents. For one resident with diagnoses including Parkinson's disease, coronary artery disease, and a right femur neck fracture, physician orders required oxygen at 2-3 liters per minute as needed to maintain oxygen saturation above 90%. Observations revealed that this resident was seated in a wheelchair with a nasal cannula attached to an oxygen tank that was empty or nearly empty, as indicated by the tank gauge in the red range, during both morning and afternoon checks. Staff interviews indicated that responsibility for changing oxygen tanks was shared among nurses and aides, but there was reliance on aides to notify nurses when tanks were low or empty. Another resident, with diagnoses including rheumatoid arthritis and requiring oxygen therapy for hypoxia, was observed in the dining room with an empty oxygen tank and not wearing her nasal cannula. Later, her tank was exchanged and she was observed wearing the nasal cannula with a half-full tank. The care plan for this resident included monitoring for respiratory distress and ensuring proper oxygen therapy. These observations demonstrate that staff did not promptly intervene to ensure oxygen was administered as ordered, resulting in residents not receiving prescribed oxygen therapy.
Failure to Use Enhanced Barrier Precautions During Peri Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) during peri care for a resident with an indwelling catheter. The resident, who had a history of Parkinson's disease, coronary artery disease, malnutrition, and a right femur neck fracture, required moderate to dependent assistance with activities of daily living and was care planned for EBP due to the presence of a catheter. The care plan specified that staff should use both gown and gloves during high-contact care activities, including dressing, hygiene, and device care. During an observation, a certified nurse aide was seen providing care to the resident while only wearing gloves and not a gown, as required by EBP protocols. The aide was preparing to complete peri care with the resident's brief open and a new brief nearby. After being interrupted and leaving to get a supervisor, the aide returned and donned both gloves and a gown to empty the catheter bag, but had to request additional supplies such as a graduate and alcohol wipes. The aide then completed catheter care, removed the protective equipment, and continued with dressing and transferring the resident without following the full EBP protocol throughout the care process.
Inadequate Supervision and Unsafe Wheelchair Transport
Penalty
Summary
The facility failed to provide adequate supervision and timely care to prevent a fall with major injury for a resident with intellectual disabilities, seizure disorder, and pain. The resident, who was dependent on staff for transfers and had moderately impaired cognition, was found on the floor after falling from her wheelchair. Despite previous incidents of the resident leaning forward and nearly falling, the care plan lacked documentation to address these concerns until after the fall occurred. The resident sustained significant injuries, including fractures to the right fibula and tibia, after falling forward out of her wheelchair. The facility also failed to ensure safe wheelchair transport for another resident with Parkinson's disease and respiratory disease. During an observation, a CNA was seen pushing the resident down the hall with one foot off the foot pedal, dragging on the floor. This action was contrary to the facility's policy, which directed staff not to push residents in wheelchairs without pedals, as it could result in serious injury. Interviews with staff revealed that the resident who fell had expressed a desire to go to bed multiple times before the incident, but staff were unable to assist her promptly due to other responsibilities. The facility's fall prevention and management policy required identifying causes of falls and implementing appropriate interventions, which were not adequately followed in these cases.
Inconsistent Documentation of Resident's Code Status
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident, leading to a discrepancy in the resident's advance directives. The resident, who had medical diagnoses including Parkinson's disease and respiratory disease, was cognitively intact as indicated by a score of 13 out of 15 on the Brief Interview for Mental Status exam. The resident's care plan noted a terminal prognosis related to cancer and directed staff to review and respect the resident's advance care planning choices. However, there was conflicting information between the Iowa Physician Orders for Scope of Treatment (IPOST) form, which indicated to perform CPR, and the electronic clinical resident profile, which directed Do Not Resuscitate (DNR). The discrepancy was acknowledged by the Director of Nurses during an interview, who stated that there should not be conflicting information to ensure appropriate resident end-of-life choices. A Registered Nurse admitted to completing the IPOST form incorrectly, marking CPR instead of DNR as per the resident's choice, and had the resident sign it. This inconsistency in documentation could potentially lead to actions that do not align with the resident's wishes in an emergency situation.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during medication administration, as observed in two instances involving Resident #13 and Resident #269. On October 8, 2024, at 7:23 AM, Staff A, an LPN, did not perform hand hygiene after administering medication to one resident before preparing medications for Resident #13. During the preparation, Staff A used her fingers to push acetaminophen pills into a medication cup and touched furosemide and gabapentin pills with her fingers before placing them in the cup. After administering the medications, Staff A continued to handle various items, including a water pitcher and a wheelchair, without washing her hands before starting a new medication pass. Similarly, at 7:29 AM, Staff A prepared medication for Resident #269 and used her finger to push a Senna tablet into a medication cup. Interviews with Staff A, the DON, and the Administrator revealed a lack of clarity and adherence to the facility's policy, which requires hand hygiene before and after each medication pass and prohibits touching pills with bare hands. The facility's policy, dated March 29, 2023, specifies that hands should be washed with soap and water if visibly soiled, or an alcohol-based hand rub should be used if not visibly soiled.
Failure to Maintain Resident Dignity in Dining Room
Penalty
Summary
The facility failed to ensure the dignity of a resident in the main dining room, as observed during a survey. A resident with severe cognitive impairment, as indicated by a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, was seen with a soiled shirt from spilled liquid and pureed food. The resident, diagnosed with non-traumatic brain dysfunction, Alzheimer's disease, dysphagia, and pain, required supervision or assistance with eating and a mechanically altered diet. Despite these needs, the resident was eating independently and subsequently moved through the dining area in a wheelchair with food on their clothing and beard, which compromised their dignity. Interviews with staff revealed that the facility had discontinued the use of clothing protectors unless requested and provided by the family. A Certified Nursing Assistant (CNA) mentioned that clothing protectors were not readily available in the dining room and had to be brought from another hall, which was not done in this instance. The Director of Nurses (DON) confirmed the policy change regarding clothing protectors and indicated that they would contact the family about the issue. The facility's policy on resident dignity emphasized maintaining or enhancing each resident's dignity and respect, which was not upheld in this situation.
Failure to Provide Adequate Eating Assistance
Penalty
Summary
The facility failed to provide adequate eating assistance to a resident with Parkinson's disease and respiratory disease, who was unable to eat independently due to hand tremors and difficulty holding silverware. The resident, who had an intact cognition as indicated by a BIMS score of 13 out of 15, experienced a significant weight loss of 8.75% over a month. The care plan for the resident included interventions such as hand-over-hand guidance, reminding, prompting, and cueing, but these were not consistently implemented during meal times. Observations revealed that during breakfast, lunch, and dinner, the resident struggled to eat independently, often dropping food and spilling drinks due to tremors. Staff provided minimal assistance, feeding only a few bites during breakfast and offering no assistance during lunch and dinner. The facility's policy on nutrition and hydration emphasized the need to assess and monitor residents' nutritional status and provide care consistent with their needs, but this was not adhered to in the case of the resident, leading to inadequate nutritional support.
Failure to Reposition and Toilet Resident at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary care for a resident with impaired skin and a high risk of pressure ulcers. Resident #81, who has Alzheimer's disease, dementia, and other medical conditions, required substantial assistance with transfers and had moisture-associated skin damage. The care plan for this resident included interventions such as repositioning every two hours and toileting assistance due to bladder incontinence. However, during observations on two separate days, the resident was left in a recliner for over two hours without being repositioned or toileted, contrary to the care plan requirements. Further observations revealed that the resident's buttocks were reddened, excoriated, and peeling, with drainage present, indicating a lack of timely care. Staff B, a CNA, acknowledged that the resident had not been toileted for hours. The Director of Nursing confirmed that the expectation was for staff to follow the care plan interventions for residents at risk of pressure ulcers, which included repositioning and toileting. The facility's policy also stated that residents unable to reposition themselves should be repositioned as directed by the care plan.
Failure to Ensure Adequate Hydration for a Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident diagnosed with Alzheimer's disease, dementia, urinary tract infection, pain, and cellulitis of the buttocks, who required substantial assistance with transfers and had severely impaired cognition. The resident's care plan included interventions for bladder incontinence and encouraged fluid intake during the morning and afternoon while limiting it in the evening. However, observations revealed that the resident was not offered fluids and had no fluids accessible within reach during multiple periods of observation. A family member expressed concerns about the resident not receiving enough water, noting that an empty cup was often left in the same spot without being refilled. The Director of Nursing acknowledged awareness of the issue, and the Administrator confirmed the lack of fluid accessibility during an observation. The facility's policy on nutrition and hydration required offering sufficient fluid intake and ensuring fresh water was available at the bedside unless contraindicated, which was not adhered to in this case.
Failure to Provide Adequate Bathing Opportunities
Penalty
Summary
The facility failed to ensure residents were provided adequate personal hygiene services, specifically at least two bathing opportunities per week, for two residents. Resident #3, with a mildly impaired cognitive status and requiring maximal to dependent assistance for various activities, missed scheduled bathing opportunities on five occasions in April and May 2024. Resident #9, with a severely impaired cognitive status and requiring moderate to maximal assistance, missed scheduled bathing opportunities on three occasions in the same period. Both residents had significant medical conditions, including peripheral vascular disease, diabetes mellitus, malnutrition, non-Alzheimer's dementia, coronary artery disease, and gastroesophageal reflux disease.
Staffing Deficiency Leading to Missed Bathing Opportunities
Penalty
Summary
The facility failed to provide sufficient staff to ensure resident needs were met and bathing opportunities were provided as scheduled. Interviews with staff members revealed that the facility often operated with fewer aides than necessary, particularly on the 300 and 400/500 halls. Staff members reported that at times, only one aide was available to cover shifts that required at least two aides to meet resident needs. This staffing shortage was confirmed by Daily Assignment Records, which showed instances where only one aide was scheduled for shifts that required more personnel. Resident #3, who had a mildly impaired cognitive status and required maximal to dependent assistance with mobility, transfers, dressing, toilet use, and personal hygiene, was directly affected by the staffing deficiencies. The resident was scheduled to receive showers on Wednesdays and Saturdays but missed multiple scheduled bathing opportunities due to insufficient staffing. Specifically, Resident #3 did not receive showers on 4/17, 5/4, 5/11, 5/15, and 5/18, as documented in the bathing records and corroborated by the Daily Assignment Records showing inadequate staffing on those dates.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ottumwa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgewood Specialty Care | 0.3 mi | ★★★★★ | 5 | 0 |
| Accura Healthcare Of Ottumwa | 2.3 mi | ★★★★★ | 0 | 0 |
| Bloomfield Care Center | 17.1 mi | ★★★★★ | 6 | 0 |
| Oakwood Specialty Care | 18.1 mi | ★★★★★ | 0 | 0 |
| Davis Center | 20.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.