Golden Good Shepherd Home

Inspectors wroteBased on record review and interview the facility failed to ensure a resident was free of significant medication errors for one of one resident (R4) reviewed for significant medication errors in the sample of 28. These failures resulted in R4 ingesting a toxic amount of medication, experiencing increased lethargy, arrhythmia, sedation, and respiratory depression resulting in R4 requiring emergency department services and intravenous fluids.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure use of an effective sanitation solution and prevent spread of potential contamination to food and food preparation surfaces in the kitchen. This failure has the potential to affect all 35 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to cover a urinary catheter bag with a privacy bag for one of one resident (R21) reviewed for dignity in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light was in reach for one resident (R2) out of 12 residents reviewed for call lights in the sample 28.

Inspectors wroteBased on record review and interview the facility failed to ensure a resident's Physician Order and Practitioner Order for Life-Sustaining Treatment (POLST) DNR (Do Not Resuscitate) code status was updated and accurate within the resident's care plan for one of 12 residents (R35) reviewed for Advanced Directives in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement restorative range of motion programs for two of two residents (R4 and R6) reviewed for functional limitations in range of motion in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure physician ordered daily weights were obtained for a resident with congestive heart failure for one of one resident (R1) reviewed for hydration in the sample of 28.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to document a diagnosis and identify target behaviors to warrant the use of Risperidone (antipsychotic medication), complete a psychotropic medication assessment, and attempt a gradual dose reduction of Risperidone for one of three residents (R31) with a diagnosis of Dementia, reviewed for antipsychotic medications in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) and Universal Standard Precautions while providing incontinence cares to a resident with a pressure ulcer for one of 12 residents (R35) reviewed for Infection Control in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure their infection prevention antibiotic stewardship program addressed prophylactic antibiotic use. This has the potential to affect all 34 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure hand hygiene was performed during a dressing change for one of one resident (R182) reviewed for pressure ulcers in a sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two staff members were present and a safety transfer (gait) belt was used during a resident transfer for one resident (R27), and failed to ensure falls were thoroughly investigated to determine a root cause of the falls and develop new fall prevention interventions for one resident (R18) of two residents (R27, R18) reviewed for accidents in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify adverse target behaviors or document a diagnosis to warrant the use of an antipsychotic medication for one of four residents (R27) reviewed for psychoactive medication use in a sample of 20.

Inspectors wroteBased on record review and interview the facility failed to prevent occurrences of physical and verbal abuse for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy dated 2/2018 documents the definition of Abuse as, The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. [...]

Inspectors wroteBased on record review and interview, the facility failed to report allegations of physical and verbal abuse to the Administrator for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy dated 2/2018 documents all employees will be trained on, Communication of reports of resident mistreatment, neglect, and/or abuse, including injuries of unknown source and misappropriation of property. This policy also documents, Employees must always report any abuse or suspicion of abuse immediately to the Administrator. R5 and R6's Medical Records document that R5 and R6 are a married couple who were both admitted on [DATE], both with a diagnosis of Alzheimer's Dementia. [...]

Inspectors wroteBased on record review and interview, the facility failed to investigate allegations of physical and verbal abuse for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy dated 2/2018 defines verbal abuse as, The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. This policy further documents physical abuse as, Hitting, slapping, pinching, and kicking. This policy also documents, It is the policy of (This Facility) that reports of abuse are promptly and thoroughly investigated. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and remove a fall hazard for one resident (R5) of four residents reviewed for falls in the sample of 15.