Good Samaritan - Ottumwa

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 10, 2024

  Based 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. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/5/24, listed diagnoses for Resident #2 which included intellectual disabilities, seizure disorder, and pain. […]

• Actual harm, isolatedF686Aug 24, 2023

  Based 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. Findings include: Review of Resident #96 Admission Assessment Record, dated 2/17/23, revealed resident was determined at risk for pressure ulcer development related to immobility. According to assessment, wounds present on admission included a right trochanter surgical wound and a pressure wound to coccyx. […]

• Actual harm, isolatedF689Aug 24, 2023

  Based 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. Findings include: 1. The Annual Minimum Data Set (MDS) assessment tool, dated 11/17/22, listed diagnoses for Resident #312 which included arthritis (inflammation of the joints), disorder of bone density, and pain. […]

• Actual harm, isolatedF686Jun 22, 2022

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions in order to prevent a pressure ulcer for 1 of 4 residents reviewed with a pressure ulcer(Resident #77). The facility reported a census of 102 residents. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 2/16/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for eating, and depended completely on 2 staff for bed mobility, dressing, toilet use, personal hygiene, and bathing. The MDS stated the resident did not walk and only transferred from surface to surface once or twice during the review period. […]

• Actual harm, isolatedF689Jun 22, 2022

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to carry out interventions in order to prevent a fall with major injury for 1 of 6 residents reviewed for falls (Resident #68). The facility reported a census of 102 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated 4/25/22, listed diagnoses for Resident #68 which included [CONDITION(S)], intellectual disabilities, and pain. The MDS stated the resident required extensive assistance of 2 staff for bed mobility and dressing, and depended completely on 2 staff for transfers, toilet use, personal hygiene, and bathing. […]