Good Samaritan - Davenport

In the surveyor’s words

From the most serious findings on record at Good Samaritan - Davenport, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 12, 2022

  Based on observation, record review, and staff interviews, the facility failed to implement appropriate Pressure Sore prevention interventions, complete regular skin assessments and document the assessments, which resulted in an unstageable Pressure Sore and subsequent Pressure Sore developments for 1 of 3 residents reviewed identified with Pressure Sores (Resident #1). The facility reported a census of 98 residents. Findings Include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF758Oct 19, 2021

  Based on observation, record review, staff, physician, Pharmacist and family member interviews, the facility failed to provide a medication regimen free from unnecessary [CONDITION(S)] medications, administered [CONDITION(S)] medications without assessment and documentation of the need for the medication, which resulted in the resident's confusion, physical decline, repeated falls, and inability to participate in physician ordered skilled Physical and Occupational Therapy services for strengthening and return to independence for 1 of 9 resident records reviewed (Resident #3). […]

• No harm, potential for more than minimal, patternF804Jan 29, 2026

  Based on observations, resident and staff interviews and facility policy review the facility failed to serve a palatable meal for 2 out of 2 meals observed and four out of four residents reviewed (Resident#14, 3, 43 and 6). The facility reported a census of 98 residents.Findings include: 1. The Minimum Data Set (MDS) assessment for Resident#14, dated 10/18/25, list of diagnoses included heart failure and malnutrition (insufficient intake of calories and/or protein). The Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicated the resident with intact cognition. The Care Plan for Resident#14 dated 10/28/25, directed educate resident not to skip meals. […]

• No harm, potential for more than minimal, patternF880Jan 29, 2026

  Based on observations, staff and resident interview and facility policy review the facility failed to use Enhanced Barrier Precautions (EBP) and failed to completed hand hygiene for 2 out of 4 residents reviewed (Resident#2 and #92) and failed to transport clean laundry covered for 2 out of 2 days. The facility reported a census of 98 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #92, dated 11/28/25, list of diagnoses included anemia (lack of red blood cells), Parkinson's disease, and diabetes mellitus (DM). The MDS identified Resident#92 Brief Interview for Mental Status (BIMS) as 12 out of 15, which indicated moderately impaired cognition. […]

• No harm, potential for more than minimal, patternF644Jan 15, 2025

  Based on clinical record review, policy review and staff interviews the facility failed to accurate mental health diagnoses are indicated on the Preadmission Screening and Resident Review (PASARR) for 2 of 2 residents reviewed (Resident #80 and Resident #84). The facility reported a census of 86 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE], documented Resident #80 diagnoses included: bipolar disorder, stroke, hemiplegia (paralysis or weakness on one side) affecting right side, and aphasia (difficulty speaking). The Brief Interview for Mental Status (BIMS) assessment not completed. The electronic health record titled Medical Diagnosis, dated 1/15/25 included the diagnosis of manic episode, unspecified with a diagnosis date of 8/2/24. […]