Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
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.
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 | ★★★★★ | 2 | 0 |
| Bloomfield Care Center | 17.1 mi | ★★★★★ | 5 | 0 |
| Oakwood Specialty Care | 18.1 mi | ★★★★★ | 2 | 0 |
| Davis Center | 20.6 mi | — | 0 | 0 |
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