Good Samaritan Society - Villisca
Non profit - Corporation
46 Beds
GOOD SAMARITAN SOCIETY
Data: November 2025
Trust Grade
70/100
#193 of 392 in IA
Photo by Good Samaritan Society - Villisca
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Good Samaritan Society - Villisca has received a Trust Grade of B, indicating it is a good choice, solidly in the middle range for nursing homes. In Iowa, it ranks #193 out of 392 facilities, placing it in the top half, and #2 out of 4 in Montgomery County, meaning only one other local option is better. The facility shows an improving trend, with issues reducing from six in 2024 to two in 2025. Staffing is a strength, rated 4 out of 5 stars, with a low turnover rate of 12%, significantly better than the state average. Although there are no fines on record, which is a positive sign, there were some concerning incidents, including a failure to ensure that one resident was free from abuse and a lack of proper food storage practices in the kitchen. Additionally, the facility did not provide adequate training hours for nurse aides, falling short of the required 12 hours per year. Overall, while there are notable strengths like good staffing and an improving trend, families should be aware of the specific incidents that raise some concerns about care and training practices.
- Trust Score
- B
- In Iowa
- #193/392
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ✓ Good
- 12% annual turnover. Excellent stability, 36 points below Iowa's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Iowa facilities.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Iowa. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 12 deficiencies on record. Higher than average. Multiple issues found across inspections.
70/100
Top 49%
Needs review
6 → 2 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 6 issues
2025: 2 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (12%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (12%)
36 points below Iowa average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
3-Star Overall Rating
Near Iowa average (3.1)
Meets federal standards, typical of most facilities
Chain: GOOD SAMARITAN SOCIETY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 12 deficiencies on record
1 actual harm
Sept 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on clinical document review, observation, resident interview, staff interview, and policy review the facility failed to provide a professional standard of quality by not following physician orde...
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Based on clinical document review, observation, resident interview, staff interview, and policy review the facility failed to provide a professional standard of quality by not following physician orders for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 37 residents. Findings include:Review of the Minimum Data Set (MDS) for Resident #2 dated 6/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of quadriplegia, seizure disorder, anxiety, and respiratory failure.Review of the Electronic Healthcare Record (EHR) page titled, Physician's Orders revealed an order for the lower extremities to be 1. washed with soap and water, 2. irrigate with normal saline, 3. apply skin prep to periwound, 4. apply nickel thick medicated cream, 5. Saline moistened fluffed gauze, 6. Cover with dry gauze, 7. Secure with rolled gauze and tape every day and evening shift for wound care with a start date of 7/21/25. The page further revealed an order for compression socks on in the morning and off in the evening for edema with a start date of 7/21/25.Review of a facility provided document titled, Provider Orders Form dated 7/21/25 revealed an order for compression hose as ordered by vascular.Review of a facility provided document titled, Clinic Referral dated 7/21/25 revealed an entry from an outside physician stating Resident #2 would need to start wearing compression stockings daily and to follow up as necessary. Review of another facility provided document titled, Certified Wound Care Nurse Assessment and Recommendations with a date of 8/20/25 revealed a note stating that Resident #2 reported not getting his new compression stockings, and that the wound nurse would reach out to the facility. Interview 9/2/25 at 2:35 PM with an outside provider revealed that she has been seeing Resident #2 since May of this year. The outside provider further revealed that Resident #2 was seen by vascular at an outside facility, and that Resident #2 has not had his stockings in the last 3 weeks that she has seen the resident. The provider then revealed that if Resident #2 was wearing his stockings as ordered wounds would be healing better on the lower legs. Observation 9/2/25 at 2:50 PM revealed Resident #2 to not be wearing compression stockings bilaterally to the lower extremities. Interview 9/2/25 at 2:57 PM with Resident #2 revealed that he does not have any stockings. Resident #2 revealed that stockings were ordered, and when they came in on August 29th or so of this year they were the wrong size. Resident #2 then revealed that if offered some stockings he would have put them on with the condition of his legs. Review of the Treatment Administration Record for the months of July, and August of 2025 revealed that between the dates of 7/21/25 through 8/31/25 compression stockings were documented that Resident #2 refused them 25 times, they were put on 6 times, and were unavailable 30 times. Interview 9/2/25 at 3:07 PM with Staff B Licensed Practical Nurse (LPN) stated that staff sometimes get click happy when entering/documenting on the Medication Administration Record (MAR), and may not be completing treatments as ordered. Staff stated she may be guilty as well as entering stockings donned when they were not. Staff B then revealed Resident #2 wanted specific stockings as the physician wanted a specific brand.Interview 9/2/25 at 3:15 PM with Staff C Registered Nurse RN revealed Resident #2 is very particular with his treatments, and that as far as Resident #2's compression stocking's he wanted to order his own. Staff C then revealed that Resident #2 did get some stockings in but they were the wrong size, and sent them back. Staff C further revealed that she would expect someone to follow up with the physician who ordered the stockings to be notified that they were not being worn. Interview 9/2/25 at 3:27 PM with Staff D LPN revealed that Resident #2 supposedly ordered his own compression stockings, and when they came in they did not fit. Staff D then revealed that she would expect that with a physician's order staff would follow up with the provider whether that be the primary care provider or the clinic that prescribed them if the supplies had not come in. Interview 9/2/25 at 4:15 PM with the Director of Nursing (DON) revealed that orders should be followed as written, and if the facility or resident was not wearing or did not have compression stockings that the facility should have followed up with the physician who ordered them.Review of a facility provided policy titled, Physician/Practitioner Orders with a revision date of 4/6/25 revealed:a. Physician/Practitioner orders are a critical component to providing quality care to residents. Accurate processing of physician/practitioner orders is important. The nursing services and health information management departments each have responsibilities for processing physician/practitioner orders in a timely and accurate manner. Teamwork and communication between the two departments is essential.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, staff interviews and policy review the facility failed to protect a resident from a possible accident and injury by not following the prevention of fall i...
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Based on clinical record review, observation, staff interviews and policy review the facility failed to protect a resident from a possible accident and injury by not following the prevention of fall interventions for 1 of 3 residents (#5). The facility failed to protect the resident with the completion of 3 movements using a dependent non-weight bearing mechanical lift with only 1 staff present. The facility reported a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #5 dated 8/19/25 identified a Brief Interview for Mental Status (BIMS) score of 3/15 indicating severe cognitive impairment The document revealed the resident required total staff assistance for toileting hygiene and significant/maximal staff assistance for lower body dressing, sit to stand, chair/bed-to-chair transfer and toilet transfers. The document provided the resident was dependent for manual wheelchair mobility. The document provided the resident's diagnoses included cerebrovascular accident, Non-Alzheimer's Dementia and coronary artery disease. Resident #5's Care Plan printed 9/2/25 contained a focus area related to activities of daily living (ADL) with interventions of toileting with 2 staff assist and transfers with 2 staff assist with total lift using medium (yellow) sling. The document contained an additional focus area of impaired cognitive function/dementia and thought processes. Interventions for this focus area included reduction of distractions by turning off the television, radio, breaking tasks into single components, and providing simple direction sentences. The document contained a focus area of Enhanced Barrier Precautions (EBP) related to a pressure ulcer with interventions of applying/removing gown and gloves while performing high contact areas of transferring, checking and changing.On 9/2/25 at 12:00 PM observed an EBP sign on Resident #5's door, a storage container labeled EBP supplies and a disposal container for used products. On 9/2/25 at 3:15 PM observed Staff A, Certified Nurse Assistant (CNA), complete transfer and toileting tasks with Resident #5. The staff took a dependent mechanical non-weight bearing lift into the resident's room and told the resident she was going to get up, use the bathroom, and get into her wheelchair (w/c). The staff completed hand hygiene, donned gloves and approached the resident who was seated on her recliner. The staff prepared the resident for the transfer and toileting by lowering adaptive pants and placing the sling under the resident. Staff A connected the resident to the dependent lift. The staff then picked up a wash basin that was sitting on an arm chair, took it to the bathroom, and returned with a plastic bag in it. The staff proceeded to lift the resident from the recliner, place the wash basin on the recliner, lowered the resident onto the basin, told the resident she could go potty, and placed her blanket over her lap. While Resident #5 was sitting on the wash basin, the staff obtained peri care supplies and a clean brief. When the resident indicated she was finished, the staff lifted the resident off of the basin, completed peri cares and initiated the clean brief. Staff A proceeded to move the resident using the dependent mechanical non-weight bearing lift to the resident's w/c. The staff lowered the resident onto the w/c and completed the dressing tasks. On 9/2/25 at 12:44 PM Staff E, Clinical Care Coordinator, stated Resident #5 used a sit to stand/weight bearing lift in the bathroom. The staff stated if a dependent mechanical non-weight bearing lift was used with the resident a bedside commode was used. On 9/2/25 at 2:50 PM Staff B, Licensed Practical Nurse (LPN), stated the resident transfers with a dependent non-weight bearing mechanical lift and transfers to a bedside commode for toileting. On 9/2/25 at 3:08 PM Staff A stated the resident used a dependent non-weight bearing mechanical lift for transfers and used a commode pot.On 9/2/25 at 3:30 PM Staff A acknowledged there should have been 2 staff present for the use of the dependent non-weight bearing lift. When asked about EBP, the staff stated she utilized gloves. The staff stated Resident #5 was the only resident who utilized a non-weight bearing lift and completed toileting tasks. The staff stated that's how they had always toileted the resident when using the lift. On 9/3/25 at 8:30 AM Staff F, CNA, stated there should be 2 staff present when operating a dependent non-weight bearing mechanical lift. On 9/3/25 at 9:10 AM Staff G, CNA, stated there should be 2 staff present and engaged to use the dependent non-weight bearing lift. The staff stated the 2 staff work together hooking the sling to the lift, ensuring the loops match on both sides, stop and do a time out to ensure safety, the staff ensure no one turns their back on the resident, and work as a team to move the resident from one location to the next. On 9/2/25 at 3:45 PM the Director of Nursing (DON) stated that staff should utilize PPE as required with EBP for all direct contact cares, including transfers and toileting. The staff expected that 2 staff should be present during the use of non-weight bearing lift and transfers. The staff acknowledged a resident was never left alone when connected to the lift and completing toileting tasks.On 9/2/25 at 4:00 PM the Administrator concurred 2 staff should be used with the use of non-weight bearing mechanical lift. The facility's Safe Resident Handling Program Resource Packet reviewed 7/7/25 included the TIME OUT safety stop while a resident is in a sling and over the surface transferring from to ensure all straps were secure before moving away from the surface. The document further provided that residents who require full weight bearing support the total lift would be used with 2 staff.
Dec 2024
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and family interviews, staff interviews and record review the facility failed to treat each resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and family interviews, staff interviews and record review the facility failed to treat each resident with respect and dignity during care for 1 of 1 resident reviewed. Resident #8 reported that a staff member refused to put him to bed until he went to the bathroom, then she tried to pry his hand off of the mechanical lift. The facility reported a census of 42 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #8 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) Resident #8 did not exhibit verbal or physical behavioral symptoms toward others nor did he reject care from staff. The resident required substantial assistance with toileting, lower body dressing, showers, sit to stand, and toilet transfers. His diagnoses included; lymphedema, muscle weakness, need for assistance with personal care, depression and chronic pain.
The Care Plan for Resident #8, updated on 4/26/24, showed that he had a communication problem related to a hearing deficit, staff were to turn off the television during cares and speak clearly and slowly. Resident #8 had impaired mobility, was unable to ambulate and required extensive assistance for toilet use. Staff transferred him with the use of a mechanical lift; Sit to Stand, at times, he was able to pivot transfer to and from the toilet and wheelchair. The resident had bladder incontinence, chronic pain and he was on diuretic therapy related to edema.
On 12/02/24 at 12:13 PM, observed Resident #8 sitting in a wheel chair in his room watching television. He was wearing shorts, and was found to have swelling in his legs and feet. When asked if the staff were treating him respectfully, Resident #8 said that there was just one staff member that he'd had trouble with. I needed to go to the bathroom. He went on to said that he put his call light one evening around 6:30 and when he didn't get help, he transferred himself from the wheel chair to the toilet. Later that evening, when he was ready to go to bed, he put his call light on again and Staff G brought the mechanical lift, Sit to Stand in the room. She told him she wouldn't transfer him to bed until he first went to the bathroom. She tried to pull my arm off the lift, and argued that she was not going to transfer him to bed until he went to the bathroom. The resident said that he needed to put his feet up because he had a lot of swelling and he just wanted to be put in bed. Resident #8 was holding onto the arms of the Sit to Stand machine and Staff G tried to get his hand off by prying and pulling on his fingers. The resident said that Staff G got on the walkie and asked for help. Soon after, another aide came into the room and put him in bed. He said that the Administrator, and the DON failed to come and talk to him about the allegations.
On 12/02/24 at 12:51 PM, a family member (FM) for Resident #8 said that the resident told her that he thought his rights had been violated. He told her that on the evening of 11/8/24 he put his call light on at around 6:30 PM. Staff G came in and said that it would be a while before she could help him and then left the room. He took himself to the bathroom and then put the light back on when he was ready to go to bed. Staff G came back into the room around 7:45 PM and said that she wanted him to go to the bathroom first, and would not transfer him until he went to bathroom. The FM said that Resident #8 told her, she tried to pull his hands off the lift. The FM wrote up a grievance on 11/9 and called the facility on 11/11 to tell the Social Worker (SW) that she did not want Staff G to take care of the Resident #8 until the incident had been investigated. She found out on 11/13 that Staff G had been in his room on 11/12. The FM said that she did not get a call back from the facility or talk to the DON or Administrator about the incident until about a week later.
On 12/3/24 at 10:10 AM, Staff C Licensed Practical Nurse (LPN) said that she was the nurse working the evening of 11/8/24. She said that she gave Resident #8 his medications earlier that evening and there wasn't anything unusual about him at that time. Around bedtime, Staff D came and told her that Resident #8 and Staff G weren't getting a long, so she put the resident to bed herself. She hadn't learned about the details of the incident until the following day from the FM. A couple of days later, she had gone into the resident's room and talked to Resident #8 and the FM and they described what happened. The FM said that it seemed that the administration wasn't doing anything about it and Staff G hadn't been suspended. Staff C said that she had not been interviewed by Administrator or the DON about the events of that evening.
On 12/03/24 at 12:22 PM, Staff D, CNA was getting ready to leave for supper break on the evening of 11/8/24 when she got a message on the Walkie-Talkie that Staff G needed assistance in the room for Resident #8. Staff D said that she went to the resident's room could tell there was tension. Usually, Resident #8 would be friendly and talkative but he was upset, and his facial expressions showed he was angry. Staff D asked what was going on and Staff G responded that Resident #8 was being difficult and rude. The resident did not say anything. She asked Staff G to leave the room and continued with his care, and asked him if everything was okay. Staff D said that he did not want to talk about it. The Sit to Stand was in front of the resident who was sitting in his wheel chair. His feet were on the lift, and the sling was hooked up to the machine. She said that she asked him if he needed to use the bathroom and he responded that he had gone earlier and just wanted to get into bed. The resident didn't need anything else. he goes to restroom every couple of hours. Staff D said that neither the DON nor the Administrator interviewed her related to this incident.
On 12/03/24 at 2:38 PM, the DON said that she learned about the incident between Resident #8 and Staff G the following day, 11/9/24. The resident didn't have any marks on his hands and arms and Staff G didn't work with him over that weekend so she dealt with it on Monday, 11/11/24. She said that she trusted the nurses on duty and none of them expressed concerns of suspected abuse. The DON maintained that she had interviewed Staff C and Staff D and she did not report the incident to the state authorities or complete an incident report because the resident did not have any marks, and they didn't believe that it rose to the level of abuse.
On 12/3/24 at 5:02 PM, the DON said they did not talk to the resident about the incident, but had relied on the Social Worker to complete an interview and had assumed that she had. She said that she hadn't talked to Resident #8 specifically about the interactions with Staff G, but the resident was not shy about coming to them with concerns.
On 12/04/24 at 8:08 AM, the Social Worker (SW) said that she was responsible for resident grievances. She said that the department heads along with DON and Administrator determined if/when the issues had been resolved. She said that it was over the weekend that the FM for Resident #8 completed a grievance so she dealt with it on the following Monday (11/11/24). The SW acknowledged that she hadn't actually talked to the FM, and didn't talk to Resident #8 about the situation until 11/19/24 at which time he said that it was just a moment of frustration. The SW said that she gave the grievance to the DON, and then Staff G had been interviewed by the DON.
On 12/04/24 at 9:21 AM, Staff A RN, said that the FM for Resident #8 told her about an incident the previous evening and she directed her to fill out the grievance form. Staff A and Staff F were in the Resident's room providing care while the FM discussed the detailed with the resident. Staff A said she didn't see any marks on the resident's hands or arms. The resident said that he just wanted to go to bed and didn't need to use the restroom. The resident told Staff A that she grabbed his arm and forcefully pulled his hand off the lift.
On 12/04/24 at 9:51 AM, Staff F, Registered Nurse (RN), said that she provided care to Resident #8 on the morning of 11/9/24. The FM was in with the resident and she and Staff A, RN came in the middle of the conversation. They talked about an incident that happened the night before and the FM was examining the resident's hands. Staff F also looked over his hands and didn't see any marks or bruises. The resident said that Staff G wanted him to go to the bathroom and he had already gone. Staff G got upset and left. He did mention she had walked by the room a couple of times while his call light was on. Watched her walk by the room. He said she forcefully moved his hand off the sit and stand and he thought there were scratches. Staff F said that the resident was grumpy that morning because he hadn't slept well. The FM said she was going to talk to the DON and SW about the details. Staff F said that she did not get interviewed by the DON or Administrator regarding this situation.
The backside of the grievance form also included a second, hand-written note, dated 11/11/24, signed by the DON. The note indicated that the DON spoke to Staff G, and the CNA admitted that on the evening of 11/8, Resident #8 wanted to go to bed but she tried to get him to go to the bathroom so he wouldn't need to get up shortly thereafter. He told her that he already went to the bathroom and he just wanted to get into bed. They argued a little and he told Staff G to get the nurse. She called for help and tried to remove the lift from the room but the resident held on to the lift. She told him she couldn't leave it in the room for safety reasons and tried to remove his left hand, with no luck, then tried to remove the other. A second CNA came into the room and took over the cares. The DON discussed with Staff G that she should not have tried to pry his hand off of the lift. Staff G agreed that she would refrain from providing cares to resident #8, unless necessary.
According to a Grievance Log summary that included a list of resident grievances, on 11/9/24 the grievance for Resident #8 concerning CNA problems had been resolved.
According to a form titled: Suggestion or Concern, dated 6/19/24. Resident #8 reported to a family member that the evening before, he put on his call light to get assistance to the bathroom and Staff G wanted him to use the urinal. The resident did not like to use the urinal because he was concerned that he would make a mess in the chair. He was able to get assistance from a different staff member.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to provide a resident and family with ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and policy review, the facility failed to provide a resident and family with adequate notification of financial responsibility when Medicare Part A services were scheduled to be discontinued for 1 of 3 residents reviewed (Resident #32). The facility reported a census of 42 residents.
Findings include:
According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 had a Brief Interview for Mental Status (BIMS) score of 1 (severe cognitive deficit.) He had diagnoses that included; cancer, anemia, renal insufficiency and Cerebrovascular Accident (CVA).
The Care Plan updated on 2/8/24, showed that Resident #32 had self-care performance deficits related to acute transverse myelitis in demyelinating disease of the central nervous system. He required one staff assistance with ambulation, toileting and transfers.
According to the census tab in the electronic record, on 9/16/24 Resident #32 qualified for Medicare A services and on 9/24/24, he was self pay. The chart lacked a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055.
On 12/03/24 at 1:17 PM, the Social Worker (SW) said that therapy services had initiated the paperwork to discharge Resident #32 from Medicare Part A. The resident was not cognitive enough to participate or make decisions. The SW was unable to locate a 10055 form and did not see where the information had been offered or signed by the family.
According to the facility policy, dated 2/14/23, titled: Advance Beneficiary Notice of Non-Coverage (ABN). The advance Beneficiary Notice of Noncoverage informs the beneficiary of potential none-coverage and shift of financial liability for those items or services, if Medicare denied the claim. The Medicare Administrative Contractor may hold any provider financially liable who either failed to give notice when required or gave an valid notice. The ABN must be issued prior to delivery of the service in question. The provider must allow enough time for the beneficiary to make an informed decision on whether or not to receive the service in question and accept potential financial liability.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents consented to the use of a restrai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents consented to the use of a restraint and obtained a physician's order for the restraint, for 1 of 1 resident reviewed. Resident #33 had a diagnoses of epilepsy and profound intellectual disabilities with limited mobility. Staff were using bilateral foot straps on her wheel chair for safety; they failed to get consent from the family and physician orders. The facility reported a census of 40 residents.
Findings include:
According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #33 had a Brief Interview for Mental Status (BIMS) score that required staff completion and indicated severe impairment. The resident was totally dependent on staff for transfers, dressing, locomotion, and hygiene. She used a wheelchair for mobility. The MDS indicated that the resident had a trunk restraint used daily on her wheelchair. The MDS did not reference the foot restraints.
The Care Plan updated on 6/3/24 showed that Resident #33 had epilepsy with limited mobility, she was chair fast, did not ambulate, and required the use of a dependent non weight bearing mechanical lift for transfers. The document identified a Focus Area of physical restraints in the wheelchair related to epilepsy exhibited by seizure activity. The Interventions for staff guidance included: discussion and recording with the family the risks and benefits of the restraint, application of a seatbelt every time the resident uses the wheelchair and releasing every 2 hours, and monitor/document to the health care provider any changes regarding the effectiveness of the restraint. The Care Plan did not reference the foot restraints.
The Physician Orders revealed an order dated 1/10/24 for a seatbelt in current tilt in space wheelchair for safety related to epilepsy. The seatbelt will be released when repositioned in bed every 2 hours.
Review of Resident #33's Consent Documents noted a signed consent by the resident's Power of Attorney for the use of a seatbelt on the tilt in space wheelchair. The document did not reflect the use of foot restraints.
Observation on 12/2/24 at 12:41 PM revealed Resident #33 positioned in a tilt in space wheelchair with a seatbelt and bilateral foot restraints.
Observation on 12/2/24 at 6:33 AM revealed Staff H, Certified Nursing Assistant (CNA), and Staff J, CNA, completing a transfer of Resident #33 from her bed to the tilt in space wheelchair using a dependent mechanical non weight bearing lift. Upon positioning in the wheelchair, Staff H fastened the seatbelt and foot straps.
On 12/4/24 at 1:50 PM the Director of Nursing (DON) stated a restraint is considered anything that inhibits any body part from movement. The DON further stated a restraint needs to be released every 2 hours and requires physician orders and consent.
On 12/4/24 at 1:54 PM the MDS Coordinator with the DON stated when Resident #33 transferred to the facility from a State Facility the resident had the foot straps and seatbelt in place on the tilt in space wheelchair. The MDS Coordinator stated consent and orders were not obtained for the foot straps upon entry as it was not thought to be a restraint as the resident could not reach her feet. The MDS Coordinator did acknowledge that anything that restricted a resident's movement would be considered a restraint. The DON and MDS Coordinator revealed the foot straps were released every 2 hours with the seat belt as the resident was repositioned from wheelchair to bed every 2 hours.
The facility provided document, Restraints - R/S, LTC, Therapy and Rehab Policy, reviewed/revised 10/29/24 revealed a physical restraint is any manual method, physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily that restricts freedom of movement. Examples of restraints contained in the document included leg or ankle restraints,and waist belt or safety belt if the resident was unable to remove them. The document further revealed the facility should receive consent for the restraint, physician's order, remove every 2 hours, and document in the Care Plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review the facility failed to obtain bed hold notifications for 2 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review the facility failed to obtain bed hold notifications for 2 of 2 residents (Residents #3, Resident #20) reviewed. The facility reported a census of 40 residents.
Findings Include:
1. Review of Resident #3's Minimum Data Set (MDS) assessment dated [DATE] revealed a most recent reentry date from a short-term general hospital on 5/14/24.
Review of Resident #3's Clinical Census in the Electronic Health Record (EHR) provided a Paid Hospital Leave from 5/11/24 to 5/14/24.
Review of the Progress Notes in the EHR dated 5/11/24 revealed Resident #3 fell while at home and was transferred to the hospital where she was admitted with a right fractured hip.
Review of the Notice of Transfer Form to Long Term Care Ombudsman for 5/24 revealed Resident #3 was transferred to the hospital on 5/11/24.
On 12/4/24 at 12:05 PM Staff E, Social Worker, indicated the facility did not have a signed bed hold for the resident. The staff stated she was not present when the resident left the facility for completion of the document.
2. Review of Resident #20's MDS dated [DATE] revealed a most recent reentry date from a short-term general hospital on [DATE].
Review of Resident #20's Clinical Census in the EHR provided a No Pay Hospital Leave from 10/19/24 to 10/24/24.
Review of the Progress Notes in the EHR dated 10/19/24 at 10:43 AM revealed the resident was found on the floor in the living room. The Emergency Management System (EMS) and Primary Care Physician (PCP) were notified and the resident was transferred to the hospital. The resident was admitted with a right hip fracture.
Review of the Notice of Transfer Form to Long Term Care Ombudsman for 10/24 revealed Resident #20 was transferred on 10/19/24 to the hospital.
On 12/4/24 at 12:05 PM Staff E, Social Worker, indicated the facility did not have a signed bed hold for the resident. The staff stated she was not present when the resident left the facility for completion of the document and a nurse was supposed to complete the document.
On 12/4/24 at 2:00 PM the Director of Nursing (DON) stated bed holds were primarily completed by Social Services or other administrative personnel. The DON stated charge nurses have not completed bed holds in the past but could be trained to complete them. When asked about the process after hours, the DON indicated it had been discussed but no clear answer/plan had been developed. The DON acknowledged in both instances a bed hold should have been completed.
On 12/4/24 at 2:15 PM the Administrator stated nurses (charge) could likely complete the bed hold forms after hours, and they could contact the Social Worker or other administrative personnel for assistance.
The facility provided document, Bed-Hold Policy, reviewed/revised 12/7/23, revealed that the facility is to ensure the resident/resident ' s representative is made aware of the bed hold and reserve bed payment policy before and upon transfer to the hospital. The document further revealed that in the case of an emergency transfer the Notice of Bed-Hold Policy is sent with other papers accompanying the resident to the hospital, and should be provided to a family member/representative within 24 hours of transfer. The policy indicated the document should be mailed if the family member or representative does not come to the facility to receive a copy. The document provided that the charge nurse is responsible for completion of notification procedures if the Social Worker/designee is not available, and the Social Worker/designee will contact the resident/representative regarding the decision for holding a bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to practice safe transfer techniques for 1 of 3 residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to practice safe transfer techniques for 1 of 3 residents reviewed. On 12/3/24, Staff I transferred Resident #36 to and from the toilet without the use of a gait belt. The facility reported a census of 42 residents.
Findings include:
According to the Minimum Data Set (MDS) dated [DATE], Resident #36 had a Brief Interview for Mental Status (BIMS) score of 4 (severe cognitive deficit.) He required partial assistance for bed to chair and toilet transfers, and he was occasionally incontinent of urine and always continent of bowel. His diagnoses included, cancer, Anemia, renal insufficiency, Non-Alzheimer's Dementia and anxiety disorder.
The care plan updated on 5/3/24, showed that Resident #36 had falls related to poor balance and unsteady gait on 4/18, 5/12, 8/15, 9/11, 9/25 and 9/29. An audio monitor was used to alert staff of any movement for safety. He had limited weight bearing ability due to a right patella fracture, required one person assist with toilet use, transfers and he did not use his call light due to decreased cognitive ability. Staff were directed to use assistive devices with transfers.
In an observation on 12/03/24 at 6:57 AM, Staff I, Certified Nurse Aide (CNA), pushed Resident #36 down the hallway and to his restroom in a wheel chair. The resident was very anxious to go the bathroom and as he tried to rise out of the wheel chair, Staff I grabbed onto his right arm and pants to stand him up. When he was done on the toilet, she grabbed his arm and shirt to help him stand. He couldn't bear weight for long and sat down quickly into the wheelchair, on his side with left hip on the seat. The CNA then pushed him out of the bathroom and assisted him to sit up straight in the wheel chair.
On 12/05/24 at 6:28 AM, Staff H, CNA, said that the residents have their own gait belts kept in the room or sometimes in the pocket on the back of the wheel chairs.
On 12/05/24 at 8:35 AM, The Director of Nursing (DON) said that she expected staff to follow the care plan and know how a resident was to be transferred. She said that staff were taught to use a gait belt with every transfer where a resident required the assistance of staff for transfers and ambulation.
According to the facility policy titled: Gait-Transfer Belt, last reviewed on 5/2/24, The purpose of gait belt use was to safely stabilize a transfer, to ambulate with residents and to aid resident in maintaining balance. The gait belts were used with assisted ambulation unless medically contraindicated.
Sept 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on record review, facility investigative file review, surveillance footage, resident and staff interview and policy review the facility failed to ensure 1 of 3 resident (Resident #1) was free fr...
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Based on record review, facility investigative file review, surveillance footage, resident and staff interview and policy review the facility failed to ensure 1 of 3 resident (Resident #1) was free from abuse. The facility reported a census of 37 residents.
Findings include:
According to the quarterly Minimum Data Set (MDS) assessment tool, with a reference date of 7/2/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 11 suggested moderate cognitive impairment. The MDS documented Resident #1 displayed no physical, verbal or other behavioral symptoms during the review period. The MDS indicated he had bilateral upper and lower extremity impairment on both sides and utilized a wheelchair. The MDS documented the following diagnoses for Resident #1: hypertension, renal failure, obstructive uropathy, stroke, hemiplegia, depression, and spinal stenosis.
The Care Plan focus area with a revision date of 7/26/2023 documented Resident #1 had an activities of daily living (ADLs) self-care performance deficit related to impaired mobility. The care plan documented Resident #1 required the assistance of one staff for bathing. A second Care Plan focus area with a revision date of 7/18/2023 documented the resident had behavior symptoms related to anger and frustration as evidenced by pinching and attempting to hit staff during cares. The care plan instructed staff to: intervene as necessary to protect the rights and safety of others and staff are to approach/speak in a calm manner. A third Care Plan focus area with a revision date of 10/16/2023 documented the resident is resistive to care related to adjustment to the nursing home as evidenced by refusal of cares, eating, treatments, and bathing at times. The care plan instructed staff to leave and return 5-10 minutes later and try again if the resident is resistant with ADLs.
The following Progress Notes documented the following:
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8/27/24 at 11:38 AM called the Primary Care Provider (PCP) to report possible abuse. Described new physical injuries, see Skin Assessment. Resident is reporting pain, especially to his 5th finger on left hand. When asked how he obtained injuries the resident stated, she hit me! Active bleeding to small lacerations under both eyes was stopped with light pressure. The primary care provider (PCP) gave order to send Resident #1 to the emergency room (ER) for evaluation.
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8/27/24 at 4:09 PM the ER nurse called with report. Diagnostic studies were performed including CT scan of his c-spine, CT scan of his head, chest x-ray and x-ray of his left hand. There were no acute fractures noted. Resident returned to the facility via facility vehicle with transport staff at 3:20 PM.
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8/28/24 at 3:21 PM resident denies any pain this shift. Resident out for all meals, good appetite. Resident pleasant mood today and no behaviors noted.
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8/29/24 at 2:08 AM resident cooperative with cares. Voiced no complaints of pain or discomfort at this time. Call light is in reach but resident chooses to tap chew can on bedside table when needing assistance. Resident was in a good mood.
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8/30/24 at 1:43 PM resident chooses to stay in his room for breakfast. Stated that he was tired and was being lazy. Resident denied any pain or discomfort this shift. He did get up for lunch and came out to the dining room. No negative behaviors noted.
The following Skin Assessments documented the following:
- 8/22/24 no skin conditions observed/skin condition resolved.
- 8/27/24 at 10:22 AM skin observations noted: face: 3 centimeter (cm) x 2.5 cm abrasion under R eye with 1 cm x 0.1 cm shallow laceration. Slight amount of bleeding noted. Face: 1 cm x 0.1 cm shallow laceration noted to under L eye. Scant amount of bright red blood noted. Other: 5th finger on left hand and all joints very swollen and painful for Resident. Purple bruising noted to entire finger up to proximal joint. Chest: 8.5 cm x 4 cm area of bruising to L chest. Within area is 5 cm x 4 cm yellow fading bruising, and 3.5 cm x 4 cm bright purple bruising with marked swelling, warmth, and tenderness. Comments: Resident sent to ER for evaluation and treatment, per PCP. Family notified via phone.
- 8/29/24 skin observations noted: face: abrasion under right eye measuring 0.8 cm x 1.0 cm. Face: abrasion under left eye measuring 1.0 cm x 0.1 cm. Chest: Yellowish bruising measuring 7 cm x 4.5 cm. Other: dark purple bruise on left 5th finger
and knuckles measuring 7 cm x 6 cm
- 9/5/24 skin observations noted: face: abrasion under right eye is resolved. Only small area of pink new skin remains where abrasion was. Face: abrasion under left eye is resolved, with the exception of a 0.1 cm x 0.1 cm dark red scab area
where abrasion was is pink in color and shiny. Chest: yellow/green bruising remains to left chest. Swelling and heat has resolved. Other: 5th digit on left hand remains edematous but much less than previous assessment. Knuckle is most swollen
and painful. 3rd, 4th, and 5th digit have yellow/green bruising in healing stages. Left hand is contracted.
- 9.12.24 skin check completed-no skin conditions observed/skin condition resolved. Bruises on chest and hand have resolved.
- 9.19.24 skin check completed-no skin conditions observed/skin condition resolved.
Review of the resident's clinical record revealed a hospital document titled Physician Clinical Report with an arrival date and time of 8/27/2024 at 12:03 PM. The report documented a chief complaint of reported physical abuse. Location of injuries-face and left hand and left ring finger. This occurred just prior to arrival. Occurred at a nursing home. He has dementia at baseline by reportedly went into the shower with an aid and came out with new bruises, telling staff that the aid hit him while in the shower. He does not give much detail to physician during exam. He only answers yes and no questions and is confused with orientation questions. This was reported to be baseline. Noted to have a scratch to the left side of his nose, with mild swelling over the bridge of his nose, new bruising to his chest, left hand, and elbow. He reports pain with palpitation of the bridge of his nose and hand. He had a previous stroke and has contractures of the left hand and elbow. Wheelchair bound and use of a mechanical lift to get up. Physical exam: extremities- left elbow small abrasion with controlled bleeding and bruising. Left forearm medium sized bruising. Left little finger: moderate tenderness and swelling and medium sized ecchymosis. Eyes: right periorbital area: small ecchymosis (small scabbed abrasion to upper check). Ears, Nose Throat (ENT): left ear small abrasion behind the ear. Nose: mild tenderness and swelling and small abrasion with controlled bleeding. Neurologic: altered mental status: confused (at baseline mental status per nursing home). Chest x-ray: no trauma. Left hand x-ray: no trauma. Head CT: no trauma. C-Spine CT: no trauma.
The facility provided the following statements from their investigation:
- On 8/27/24 Staff B Certified Nursing Assistant (CNA) wrote while she was walking up Hall 300 to the dining room to assist with breakfast, she heard from the shower room Resident #1 yell you're hurting me, followed by Staff A CNA saying
I am just washing our f****** face. Resident #1 was known to yell out frequently and would say you are hurting me when touched. Staff B did not think anything of it until the resident was brought to the breakfast table by Staff A. His face was swollen and discolored around his nose, eyes and a sore under his right and left eyes. Blood seemed to be draining from the area between his eyes and nose. Staff B then immediately reported to the Staff C Registered Nurse (RN) charge nurse and the MDS Coordinator. Her hand-written statement was signed and dated 8/27/24.
- On 8/27/24 the MDS Coordinator typed Staff B CNA came to her and reported that she had heard Staff A in the bathhouse with Resident #1. Staff B reported she heard Resident #1 state stop you are hurting me. Staff A then stated to Resident #1 I am just washing your face. Resident #1 stated again stop it you are hurting me. Staff A stated I am just washing your f****** face. Staff A came out of the bathhouse with the resident and took him to the dining room for breakfast. The MDS Coordinator went to assess the situation and observed Resident #1 at the dining room table. His face and eyes were red. He had a small area on the left side of his nose/eye area with small amount of blood on it. The MDS Coordinator took Resident #1 into the family room and asked him about his bath and the situation that had just occurred. Resident #1 stated to her that Staff A was washing his face too hard and asked her to stop but she didn't stop. He stated she was too rough even though he asked her a couple times to stop. Staff A told him I am just washing your f****** face. The MDS Coordinator asked Resident #1 if he was harmed in any other way or was hurting, he denied any other pain and stated she is always rough when she moves me. He did not visibly have any other signs of injuries so she asked Staff C to complete a head to toe assessment then he was taken to his room by Staff C for that assessment. Staff A was in the dining room at this time with another CNA assisting residents with breakfast. The MDS Coordinator asked Staff A not to start any further baths and that the Director of Nursing (DON) will be here in a few minutes to speak with her. Prior to this she had notified the DON and Administrator of the potential abuse situation. The MDS Coordinator signed and dated the typed statement on 8/27/24.
- On 8/27/24 Resident #1 was interviewed. What happened in the bath today? Resident #1 stated she washed my face too hard and wouldn't stop. Did Staff A hit you? Resident #1 said no. Did the girl that gave you a bath hit you. Resident #1 said no. Did Staff A pinch you? Resident #1 said no. Did Staff A put your head in the water? Resident #1 said no. Did Staff A push you? Resident #1 said no. Did Staff A harm or hurt you in any other way? Resident #1 stated she was always rough when she moved him. How is she rough? Resident #1 stated she doesn't listen. Are you hurting anywhere? Resident #1 stated no. Do you need to go to the hospital? Resident #1 stated no reason to. Do you feel safe? Resident #1 stated yes.
- On 8/27/24 Staff A wrote she was giving Resident #1 his bath. As she was undressing him he asked her over and over what are you doing and to stop it. Staff A kept explaining she was giving him a shower. She turned on the water and grabbed a wash rag to wash his face. As she was doing that he was grabbing my arm saying what are you doing. She explained she was washing his face trying to get the dry boogers out of his eyes. He kept saying what are you doing, that hurt, pounding on the shower chair and grabbing her. She hurried and finished the shower, got him dressed and took him out to breakfast. She signed her statement.
- During resident interviews the following residents stated: Resident #4 was asked how staff treat her and she stated good except Staff A.
Review of Staff A's employee file revealed the following disciplinary actions:
- 5/1/24 discussed tone of voice and approach to residents
- 5/14/24 discussed approaching residents differently and/or having another aide to bath specific resident.
- 6/1/24 had discussion with charge nurse at nurse's station. Witnesses stated both were unprofessional.
- 6/4/24 the DON and MDS Coordinator sat down with Staff A to discuss recent complaints from residents, staff and family members. Staff A admitted to having a bipolar disorder and that since she is currently taking fertility drugs, she hasn't been great about taking her medications. She also reported not always being aware of her tone, she has difficulty recognizing when she needs to watch her tone. She agreed to be receptive to coaching from her co-workers when they recognize an increase in her stress level affect her tone of voice.
- 6/30/24 heated discussion at nurse's station with charge nurse. Witnesses stated that the charge nurse did not de-escalate the situation, but seemed to escalate it when Staff A was trying to calm down after being asked to by the other charge nurse.
- 7/25/24 heated discussion at nurse's station with charge nurse regarding Staff A's care given to charge nurse's mother who is a resident. Several residents complain that she is rude and hurried while giving them their baths. Discussion: Staff A was calm and receptive to concerns voiced regarding tone of voice (rudeness), making the residents feel as if she did not want to take care of them and altercations that continue with her charge nurses at the nurse's station in front of residents and families. She stated that she has not been getting much sleep lately and could see why she appears to not want to be here or to take care of the residents. We revisited the discussion about not making the residents feel rushed while she is doing their cares. Regarding the heated discussions with the charge nurse, the DON instructed her that from now on if she believes the discussion is going to be heated, if she cannot walk away, please take it away from the nurse's station to be in private. The DON asked her to repeat what we discussed and she was able to state watch my tone, slow down and take it away from the station. Staff A stated that she felt like she is not doing anything right and so she just does not say anything at all. The DON informed Staff A she would be submitting a formal verbal warning regarding performance/behavior. She acknowledged understanding. Expectations: to slow down with resident cares, choose words wisely and walk
away if things begin to escalate at the nurse's station or in front of residents/families. With all of the discussions they have had with Staff A since hire, she has shown improvement, but continues to require guidance.
- On 8/27/24 an employee overheard a resident yelling from the shower room you are hurting me. This employee stated it is not unusual for that resident to yell during his cares. That employee then heard Staff A yell I am just washing your f****** face. When the resident came out of the shower, this employee noted that the resident's face was swollen and discolored around his eyes and near left eye appeared to have some blood draining. The CNA reported this and Staff A was suspended. The resident was questioned after he came out of the shower about this and confirmed Staff A provided rough care in the shower. The resident was sent out for evaluation due to some concerns about his finger as well. Staff A denied that she said the word f****** to the resident but states the resident was asking her over and over what she was doing, he was pounding on the shower chair saying that hurts and she had to keep explaining that she was giving him a shower. We have been addressing on-going behavior concerns with Staff A for concerns with her attitude toward staff and her approach with residents. As a result of these on-going concerns and this egregious concern with resident care, we have made the decision to end Staff A's employment, effective immediately.
On 9/20/24 at 1:26 PM reviewed the facility's security camera footage from 8/27/24 with the DON. The footage revealed at 6:34 AM Staff A walked out of Resident #1's room with wheelchair and clothes on it. She walked up the hall to smaller that led to the 300 hall (per the DON) to the bath house. Per the DON there is not camera footage from the 300 hall. At 6:38 AM Staff A went back to Resident #1's room with a mechanical lift and exited the room with Resident #1 in the wheelchair at 6:46 AM. Staff A then propelled the resident up the 200 hall to the adjoining hall that led to the 300 hall. No other staff members were observed to enter or exit the resident's room other than Staff A between 6:34 AM and 6:46 AM. At 7:03 AM Staff A assisted Resident #1 out of the 300 hall by the nurse's station and to the dining room table with peers and Staff B present. Unable to see Resident #'1 face clearly on the video footage.
On 9/20/24 at 10:36 AM Resident #1 was observed to be sitting in his recliner watching television. Noted a bruise to his left hand between his index finger and thumb. The bruise was deep purple/maroon in color. No skin issues noted to his face or under his eyes. Resident #1 agreed to speak with surveyor and for his door to be shut. He then offered a chair to sit on. Resident #1 stated he had breakfast and it was pretty good. When asked what happened a few weeks ago while he was receiving a bath he stated he fell. When asked how that happened he stated the floor was wet. When asked if he had any injuries from that fall he stated his ribs hurt but that was it. Eye contact was made during this part of the conversation. When asked what else happened in the bath house he stated nothing. When asked how the staff are with him during his baths he stated fine. He was asked if anyone was ever rough with you during your bath he stated no. When asked how are staff are when they are washing his face he stated he had no concerns. When asked if staff had ever washed his face in a rough manner he stated no and denied staff being rough during his bath. Resident #1 was asked if anyone had ever hurt him in any way, he stated no. When Resident #1 was informed of bruising and open areas to his face documentation in his file from last month, he stated he did not know what happened. Resident also denied knowing why he had bruising on his chest and hands. During this part of the conversation he made no eye contact with me. When asked how things were going here at the facility and he stated it's very peaceful here. When asked if he wanted to talk about anything else he stated no. Resident #1 was thanked for his time and to have a great day.
On 9/20/24 at 12:34 PM the MDS Coordinator stated Staff B came to her about what she heard in the bath house. She heard Resident #1 say you are hurting me and Staff A said I am washing your face. Resident #1 said it again and Staff A said I am just washing your f****** face. Staff B had asked her to come look at Resident #1 because she was concerned about his face. When she went to the dining room, Staff A was assisting other residents with their meal with other staff members present. When she saw Resident #1, she asked Staff A which baths she had left. She wanted to get a game plan on how to talk with her because Staff A has a history of blowing up when confronted. So she told Staff A the DON wanted to speak with her before she completed more baths. She asked Staff B not to leave the area where Staff A was at. The MDS Coordinator did not want Staff A blowing up in front of residents so she made sure Staff B knew to basically supervise her until they figured out a plan. She then called the DON and Administrator to come in. When she went back to the dining room, Resident #1 was done eating so she pulled him into the conference room, closed the door and talked with her for a bit. About the same time the DON had arrived and had Staff A at the front of the building. When asked what happened-he said she was washing his face too hard and could not breath. She noticed a scratch on his face, when asked if he scratched himself he stated she washed my face too hard. Resident #1 said Staff A was rough with him. He denied other physical occurrences while she was washing his face The MDS Coordinator also noted his eyes were reddened, blood shot. But did not see other injuries because the DON and Administrator had arrived and Staff C had completed the head to toe assessment upon request. She has been with Staff A when she has assisted Resident #1 before. He is contracted and would say he was in pain while assisting him and he would yell. She also has had to sit in while the DON talked with her before about concerns and she would do good after speaking with her. She never thought Staff A would be mean with residents as she seemed to care about them. She had been educated previously on slowing down with residents. Staff A did tell them she has mental health issues and stopped taking her medications because she is currently doing fertility injections. When asked how Staff A was as an employee she indicated she can be loud and boisterous. Resident #1's behaviors can be combative at times; swat at staff, nice out of nowhere then back to pinching staff out of the blue. The MDS Coordinator indicated Staff A had told her she gets overstimulated and is task oriented, so what she thinks happened was Resident #1 was saying stop you are hurting me. Staff A may not have understood what she was doing and just wanted to get his eye burgers out, not realizing he has sensitive skin. The MDS Coordinator indicated she has sat in when Staff A would be educated on not rushing residents, slowing down with them. Staff A would be remorseful when spoken to. She did call in a lot, would pick up extra shifts and stay over to help.
On 9/20/24 at 1:07 PM Staff C RN stated she was told by Staff B she walked by the bath house and heard Resident #1 yelling. Staff B stated she then heard Staff A tell Resident #1 to shut up, I am trying to wash your f****** face. When he came to the dining room Staff C noticed he had two black eyes, cuts under his eyes, with brand new bruising on his chest, and the left side of his hand was swollen. Resident #1's pinky on his left hand was 3 times bigger than normal and had bruising originating at the joint. She completed a full head to toe assessment to make sure she saw everything. When she asked happened he stated she hit me then five seconds later he could not remember what happened. But that was normal for him. He was sent to the ER for a full evaluation and they noted no broken bones. Staff C indicated she had given him his medications prior to his bath and did not notice these injuries at that time. When asked about Staff A as an employee, she stated she is very loud, can be disrespectful with other residents. Staff C stated she reported these concerns before. Staff A would yell at residents, was always on her phone when giving baths or supposed to be doing other things. When assisting residents, she would yell at them to hurry up, or would not pay attention at all. When asked to describe his behaviors she stated he would pinch or hit staff's butt, yell a lot. When asked how Resident #1 has been since this she stated good, appears much happier now since she is gone, coming out of his room more often.
On 9/20/24 at 1:37 PM Staff B CNA stated she was working on the 300 hall that day. She indicated that is where the bath house is located. When she walked by the bath house she heard Resident #1 tell Staff A to stop hurting my face. Then she heard Staff A say I am just washing your f****** face. Staff B reported the resident tends to yell in pain so she did not think anything of it. She continued to go to the dining room to assist residents with their breakfast. When Staff A brought Resident #1 to the dining room table where those that need assistance sat, she thought his nose looked crooked so she called another staff member over to look. Staff C came over and Staff B stated below his eye was bleeding and under both of his eyes the skin appeared dark in color and puffy. Staff B went and got the MDS Coordinator because it looked like someone punched him in the face. She came to the dining room and took over after that. Staff B indicated the corner of his left eye was rubbed raw with blood in the corner of it. Both of his eyes were dark and puffy. When asked if the resident said anything to her she stated no. When asked how he was while in the dining room during his breakfast she stated he seemed ok but was more shaky than normal. He ate his breakfast then they sent him to the hospital to be evaluated. When she left at 2:00 PM he was still gone. Since then he appears to be fine and never said anything to her about Staff A or that day. When asked how Staff A was as an employee she stated she is rude and acts like she does not care, rough around the edges type of person. She had never witnessed her being rough with residents but were times where she was in a hurry and rushing with residents. When asked if Resident #1 had any behaviors she stated he was not good at expressing himself without yelling out. When she has assisted with his baths he would grab her hair, with cares assist he would smack at them. But if you talk him through what is going on he would stop. Residents have reported to her that Staff A was rude and acted like she did not care. Staff B stated she has noticed other residents appear happier since Staff A was let go.
On 9/24/24 at 10:39 AM Staff A CNA stated she was completing Resident #1's shower and he became very combative: hitting, screaming, and pinching her. So, she rushed through his shower to get him out and to breakfast. He had a bunch of gunk in his eyes that she was trying to get out. As she was rubbing his eyes, he was hitting her, she acknowledged to being overstimulated at that point in time. Staff A admitted she rubbed his eyes with the washcloth too rough and she feels really bad about it. She indicated the bruising to his chest and fingers were there before the bath. When asked if she had told anyone about the bruising on his chest and fingers she stated she let Staff C know about it when she brought him to the dining room that morning. Staff A also stated she told the DON during her interview about the bruising on his chest and finger, during her interview. She brought him to the dining room for breakfast she saw a little mark on the side of his nose, she knew she rubbed too hard to get the gunk out of his eyes. When asked what staff are to do when he has these behaviors she stated she would report them the nurses were supposed to do behavior charting but not sure if they were. She added staff just dealt with Resident #1's behaviors. When explained to her his care plan advised staff to step away from 5-10 minutes she indicated she did not know that. She indicated she would normally step out to get another aide but did not do that, that day because everyone was busy. She denied using foul language with Resident #1 or any resident for that fact. Staff A stated at the time of this incident she was taking a lot of fertility treatments and would get overwhelmed. Staff A also stated she has Polycystic Ovarian Syndrome (PCOS), with the extra hormones, plus anxiety/depression medications, it all made her overstimulated and overwhelmed. Staff A stated she did not mean to hurt him at all, she feels really bad. She stated she again was just overwhelmed/overstimulated that day. When asked what time she gave Resident #1 his bath she stated he was usually done first thing in the morning, so about 6:30 AM-7:00 AM (ish). She indicated Staff D CNA had assisted her with his transfer from his bed to the wheelchair that morning. Staff A acknowledged she had been talked to about rushing prior to this incident. Before she started working at the facility she had worked for a facility that was very short staffed, so she was used to rushing to get things done. She indicated she never stepped back and just relaxed while working at this facility. Staff A admitted to becoming overwhelmed at work and would go speak with the DON about it for guidance and she would tell her to breath.
On 9/24/24 at 10:46 AM Resident #2 was sitting in her room working on a diamond art photo. Resident #2 was asked how staff are with her and she stated better now that one is gone. When asked what was going on she stated Staff A would put her socks on and was very rough about it. When Resident #2 would ask her to stop she would not. Resident #2 stated her feet are very tender/sensitive but Staff A would not listen when she asked her to stop. Resident #2 also would not help her when she wanted to move about in her room. She indicated she required assistance of staff when moving out of her chair/bed and with walking. Staff A stood in the doorway while she tried to get up but would not come to help her. Resident #2 indicated she told Staff A she needed help and her doctor had filled out paperwork that stated this. Resident #2 also stated she was using the restroom before she had to leave the facility for an appointment. She activated her bathroom light and could hear Staff A talking outside of her room but would not come in to assist her off the toilet and assist her with getting ready for her appointment. Resident #2's daughter came in for her appointment and had to assist her off the toilet to get ready for the appointment. They ended up being late that day. When Staff A came in to Resident #2's room the next day, she asked Staff A why she did not help her when she heard her talking outside of her room, Staff A did not say anything. Resident #2 indicated she has not had further issues since Staff A was let go.
On 9/24/24 at 1:55 PM the DON stated when she got here Resident #1 was out of the dining room. She indicated staff made a comment that Resident #1's nose was cricked so she pulled up his picture from his Electronic Health Record (EHR) and his nose was cricked in the picture as well. She did not notice any redness or bruising when she arrived. The ended up sending him to the ER because of other bruising that was noted during his head to toe assessment. She let Staff A know she was suspended pending investigation. She did not talk to Resident #1, the MDS Coordinator interviewed him. When they spoke to Staff A about the incident with Resident #1 Staff A stated she did not want to hurt him. She was washing his face and he was not letting her do so. Staff A stated she honestly did not see him bleeding. When asked what happened to his left pinky Staff A did not say anything to that. Staff A told them she was overstimulated that day. The DON indicated they had previously provided education to Staff A before and wanted to believe in her that things would change. The told her she needed to slow down with residents and ask for help. They had formally completed did some disciplinary actions for her attendance, behavior and performance. The DON was asked if Staff D was working that day, she indicated she was scheduled to work but called in. The DON stated Staff A never reported that Resident #1 had bruising to his chest that day. If he was having behaviors during his bath, she should have stepped away from the situation and asked for help.
The facility provided a document titled Abuse and Neglect with a revision date of 7/22/24 documented the purpose of the policy was to ensure that residents are not subjected to abuse by anyone, including, but not limited to, location employees, other residents, consultants or volunteers, employees of other agencies service the individual, family members or legal guardians, friends or other individuals. The resident has the right to be free from abuse.
The facility provided a document titled Resident-Dignity with a revision date of 11/16/2023 documented the purpose of the policy was to maintain the dignity of all residents and to assist with respecting and ensuring resident rights. The location will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Ideas for maintaining a resident's dignity may include, but not be limited to:
a. Grooming residents as they wish to be groomed
f. Treating residents with respect
Sept 2023
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review, and staff interviews the facility failed to provide replac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility policy review, and staff interviews the facility failed to provide replacement tracheostomy device for emergent unplanned extubation for 1 of 1 residents reviewed (Resident #141). The facility reported a census of 39 residents.
Finding include:
The Minimum Data Set (MDS) dated [DATE] for Resident #141 documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 indicating no cognitive impairment. The MDS documented diagnoses of acquired absence of larynx.
On 9/11/23 at 1:39 PM an observation in Resident #141's room revealed no emergency tracheostomy equipment present.
On 9/13/23 at 2:36 PM Staff A stated there was not an emergency tracheostomy appliance available in Resident #141's room. Staff A stated she did not know where another appliance would be located to reinsert if needed.
On 9/13/23 at 2:38 PM Staff B stated there was no emergency trach appliance present in Resident 141's bedroom. Staff B stated the facility's expectation is that there would be an emergency trach appliance available in Resident #141's room.
Review of policy titled Tracheostomy, Suctioning, Dressing Change and Reinsertion of Tube revealed decannulation is an emergency situation. The Tracheostomy tube must be reinserted quickly to maintain a patent airway. A licensed nurse who has undergone training or a respiratory care practitioner performs this procedure.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews the facility failed to implement gradual dose redu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interviews the facility failed to implement gradual dose reductions (GDR) instead continued psychotropic medications without review and failed to ensure as needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for 3 of 5 residents reviewed (Resident #10, #11, and #31). The facility reported a census of 39 residents.
Finding include:
1. The Minimum Data Set (MDS) dated [DATE] for Resident #10 documented a Brief Interview of Mental Status (BIMS) of 15 out of 15 indicating no cognitive impairment. The MDS documented diagnoses to include generalized anxiety and depression.
Review of document titled Consultant Pharmacist's Medication Regimen Review (MRR) dated 4/25/23 for Resident #10 revealed a request for mandated dosage decrease attempt on the orders of Alprazolam 0.5mg TID, Mirtazapine 7.5 mg at bedtime, and Sertraline 50mg at bedtime.
Review of document titled Note To Attending Physician/Prescriber for Resident #10 related to the 4/25/23 MRR revealed the physician response portion was incomplete.
Review of Resident #10's electronic health records (EHR) for the month of April revealed orders for Alprazolam 0.5mg TID, Mirtazapine 7.5 mg at bedtime, and Sertraline 50mg at bedtime.
Review of Resident #10's electronic health records (EHR) for the month of May revealed orders for Alprazolam 0.5mg TID, Mirtazapine increased to 15 mg at bedtime on 5/26/23, and Sertraline 50mg at bedtime.
On 9/13/23 at 9:15 AM Staff B stated April's GDR for Resident #31 was sent by the pharmacy. Staff B stated the physician did not return a fax. Staff B stated she was not sure the fax was sent to the physician. Staff B stated all faxes should be sent to the physician in a timely manner. Staff B stated not sure about the time frame for refaxing the order recommendations but initial fax should have been sent that day. Staff B stated the clipboard has hall one and hall two. Staff B stated it is the facility's expectation that nurses should be going through faxes every couple days and refaxed recommendations that were not returned.
2. The MDS dated [DATE] for Resident #31 documented a BIMS of 4 out of 15 indicating severe cognitive impairment. The MDS documented diagnosis of schizoaffective disorder, depression, anxiety, mood disorder, and dementia.
Review of a document titled Consultant Pharmacist's Medication Regimen Review dated 8/19/23 for Resident #31 revealed a request for mandated dosage decrease attempt on the orders of Seroquel 25 mg BID, Trazadone 50 mg BID, and Buspirone 15 mg TID.
Review of document titled Note To Attending Physician/Prescriber for Resident #31 related to the 8/19/23 MRR revealed the physician response portion was incomplete.
Review of Resident #31's electronic health records (EHR) revealed current orders for Seroquel 25 mg BID, Trazadone 50 mg BID, and Buspirone 15 mg TID.
On 9/13/23 at 9:45 AM Staff B stated she was unaware if August's GDR recommendations were sent. Staff B stated facility's expectation is that GDR recommendations for August would have been sent by 9/13/23. Staff B stated the clipboard with documents that have been faxed that are awaiting return fax had no documents from August GDR recommendations. Staff B stated the facility's expectation is that a response to GDR recommendations from 8/19/23 would have been received prior to 9/13/23. Staff B stated GDR recommendations for Resident #31 were refaxed 9/13/23. Staff B stated she could not find a returned fax with physicians response to recommendations.
Review of policy titled Medication Drug Regimen Review (DRR) revised 2/10/23 revealed The pharmacist will complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The pharmacist will also complete the Medication Regimen Review Summary for the QAPI Committee document. Both reports will be given to the director of nursing services upon completion of each monthly DRR. The reports must be shared with the attending physician and the location ' s medical director, and these reports must be acted upon.
3. A review of Resident #11's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 06 out of 15, indicating severe cognitive impairment. The MDS also included diagnoses of Non-Alzheimer's dementia and Bipolar disorder. It revealed the resident had hallucinations and received antipsychotic medications within the 7-day look-back period.
The Care Plan for Resident #11 initiated 6/5/23 indicated the resident was on antipsychotic medication related to the Bipolar disorder and directed staff to administer the medication as ordered by the primary care physician.
On 9/11/23 at 11:36 AM, a review of the resident #11's electronic health record (EHR) revealed an active order dated 6/7/23 for Seroquel (an antipsychotic medication) one (1) tablet by mouth every 8 hours as needed (PRN) for agitation or aggression with no end date.
On 9/12/23 at 11:07 AM, a review of Resident #11's Progress Notes revealed the Pharmacist consultant documented recommendations for the PRN antipsychotic medications on 6/23/23, 7/20/23, and 8/18/23. The progress notes also revealed no contact attempts to the primary care physician were documented by the facility staff.
On 9/13/23 at 4:29 PM, a review of documents for Resident #11 titled Consultant Pharmacist's Medication Regimen Review dated 6/23/23, 7/20/23, and 8/18/23 indicated the consultant pharmacist noted the 14-day limitation for PRN antipsychotic medications and recommended the physician either discontinue the medication or provide documentation every 14 days to support the continued use.
On 9/13/23 at 4:51 PM, a document titled Note to Attending Physician/Prescriber dated 6/23/23 for Resident #11 indicated no response or signature from the physician.
Resident #11's Medication Administration Record for June, July, August, and September revealed the PRN antipsychotic medication was administered on 6/8/23, 6/11/23, 6/13/23, 7/14/23, 7/15/23, 7/17/23, 8/14/23, 9/1/23, and 9/6/23.
On 9/14/23 at 9:30 AM, the MDS Coordinator, acting on behalf of the Director of Nursing (DON) stated the pharmacist's antipsychotic medication recommendations should be faxed to the physician every 24 hours. The physician should have been called when no response was received after the second fax was sent.
A document titled Medication: Drug Regimen Review revised 2/10/23 indicated the pharmacist's monthly Medication Regimen Review (MRR) must be shared with the DON and drug irregularities were to be reported to the medical director and attending physician by the director of nursing services or designee.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to maintain essential kitchen equipment. T...
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Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to maintain essential kitchen equipment. The facility reported a census of 39 residents.
Findings include:
During an initial kitchen observation on 9/11/23 at 8:50 AM, the following findings were identified.
a) An accessed, undated carton of Orange Juice.
b) An accessed, undated half-gallon of chocolate milk.
c) An accessed, undated carton of Apple Juice thickener.
d) An unlabeled, small, pink pitcher containing white liquid.
e) An opened bag inside an opened box of fish strips.
During a follow-up kitchen observation on 9/12/23 at 7:45 AM, the pink pitcher of white liquid was still in the refrigerator with no label.
On 9/12/23 at 8:00 AM, the Dietary Manager (DM) stated all stored food should be sealed or closed and dated.
A policy titled Food-Supply Storage- Food and Nutrition Services revised 5/11/23 indicated foods that have been opened or prepared were to be placed in an enclosed container, dated, labeled and stored properly.
During a dishwashing observation on 9/12/23 at 9:38 AM, the temperatures of the heat sanitation dishwasher were 148 degrees during the wash cycle and 176 degrees during the rinse cycle.
On 9/13/23 at 12:11 PM, the dishwashing machine representative stated the manufacturer's specifications required two (2) wash and rinse pre-cycles before dishes were washed. He stated the wash cycle temperature was set at 140 degrees and the rinse cycle temperature was set at 180 degrees.
An excerpt from the dishwashing machine representative's sales support indicated the manufacturer recommended three (3) warm-up cycles as part of a typical daily start-up to ensure all of the cold water was out of the equipment system.
On 9/14/23 at 8:45 AM, the DM stated the expectation was the dishwasher temperatures should meet the 150 degree wash cycle and 180 degree rinse cycle requirements.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee file review, facility policy review, and staff interviews the facility failed to provide in-service training t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee file review, facility policy review, and staff interviews the facility failed to provide in-service training to nurse aides at least 12 hours yearly. The facility reported a census of 39 residents.
Finding include:
Review of a document titled Completion Report for Staff C revealed only 9.92 hours of training had been completed in the last 12 months.
On 9/14/23 at 8:27 AM Staff D stated the facility's expectation is that the end of the month report was sent by September 1st with the employee that needed to complete training. Staff D stated she emails the facility's exception report to the DON, and the Administrator. Staff D stated an exception report was emailed on September 1st to the facility with the number of hours that needed completed by all employees.
On 9/14/23 at 9:24 AM the Administrator stated all employees are responsible to complete training. The Administrator stated emails are sent to employees with needs to complete hours. The Administrator stated he tried to follow up with those who are behind in the needed training hours. The Administrator stated computers are available all the time for the employees to use. The Administrator stated the facility's expectation is that all employees complete the required 12 hours of training yearly.
Review of policy titled Competency and Mandatory Education Requirements revised 5/22/23 revealed that [NAME] is responsible to provide processes for ongoing education and competency achievement. Employees are responsible to attain and maintain competency and complete mandatory education required within their specific job description. [NAME] requires organizational mandatory education. Additional mandatory education may be required at the department/clinic or the specific job level.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Iowa facilities.
- • 12% annual turnover. Excellent stability, 36 points below Iowa's 48% average. Staff who stay learn residents' needs.
Concerns
- • 12 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.
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About This Facility
What is Good Samaritan Society - Villisca's CMS Rating?
CMS assigns Good Samaritan Society - Villisca an overall rating of 3 out of 5 stars, which is considered average nationally. Within Iowa, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Good Samaritan Society - Villisca Staffed?
CMS rates Good Samaritan Society - Villisca's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 12%, compared to the Iowa average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Good Samaritan Society - Villisca?
State health inspectors documented 12 deficiencies at Good Samaritan Society - Villisca during 2023 to 2025. These included: 1 that caused actual resident harm and 11 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Good Samaritan Society - Villisca?
Good Samaritan Society - Villisca is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by GOOD SAMARITAN SOCIETY, a chain that manages multiple nursing homes. With 46 certified beds and approximately 40 residents (about 87% occupancy), it is a smaller facility located in Villisca, Iowa.
How Does Good Samaritan Society - Villisca Compare to Other Iowa Nursing Homes?
Compared to the 100 nursing homes in Iowa, Good Samaritan Society - Villisca's overall rating (3 stars) is below the state average of 3.1, staff turnover (12%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Good Samaritan Society - Villisca?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Good Samaritan Society - Villisca Safe?
Based on CMS inspection data, Good Samaritan Society - Villisca has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Iowa. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Good Samaritan Society - Villisca Stick Around?
Staff at Good Samaritan Society - Villisca tend to stick around. With a turnover rate of 12%, the facility is 33 percentage points below the Iowa average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.
Was Good Samaritan Society - Villisca Ever Fined?
Good Samaritan Society - Villisca has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Good Samaritan Society - Villisca on Any Federal Watch List?
Good Samaritan Society - Villisca is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.