Good Samaritan - Atwood

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to deliver mail to the facility residents on Saturdays. This deficient practice placed the residents at risk for not having reasonable access to send or receive written communications.

Inspectors wroteThe facility had a census of 26 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for 25 residents who reside in the facility and receive their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on observation and interview, the facility failed to serve the midday meal within 45 minutes of the designated time of 11:30 AM. This deficiency placed the residents at risk of an impaired dining experience.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store and prepare food in a sanitary manner for the residents who resided in the facility and received meals from the facility's kitchen. This placed the residents at risk for foodborne illness.

Inspectors wrotehe facility had a census of 26 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 23 gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach). This placed the resident at risk for possible exposure to infection.

Inspectors wroteThe facility had a census of 26 residents. The sample included 12 residents. Based on record review and interview, the facility failed to provide Resident (R) 18 or their representative the completed Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, and failed to provide R27 or their representative the completed CMS Notice of Medicare Non-Coverage (NOMOC) form 10123. This placed the resident at risk of uninformed decisions about their skilled services.

Inspectors wroteThe facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to investigate an allegation of sexual abuse and initiate protective measures until an investigation was completed. On 07/24/24 at 09:37 PM Resident (R)1 told her daughter that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. LN G told R1's representative she would go down and talk to R1 and report the incident to Administrative Nurse D. At 11:00 PM, R1 asked LN G if she had told the nurse that she was molested. [...]

Inspectors wroteThe facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported Resident (R)1's allegation of sexual abuse to the Licensed Nursing Home Administrator (LNHA) and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. On 07/24/24 at 09:37 PM, R1 told her representative that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. [...]

Inspectors wroteThe facility identified a census of 27. The sample included three residents reviewed for pressure injuries/ulcers. Based on record review and interview, the facility failed to ensure adequate treatment to prevent the worsening of a facility acquired pressure ulcer and failed to promote healing. On 12/15/23, Resident (R) 1, who required assistance from two staff for bed mobility, developed a facility acquired unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer to her left heel. The facility applied heel protectors but did not involve the provider until seven days later. The provider ordered a dressing to the wound, changed every seven days. The wound became stagnant and lacked any signs of healing from 12/22/23 through 03/23/24 when a new treatment was started. [...]

Inspectors wroteThe facility identified a census of 34 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to prevent a fall with major injury to Resident (R) 1. On 12/11/23 at approximately 07:45 AM, Certified Nurse's Aide (CNA) M failed to apply the safety belt in the bath chair. As a result of this failure, R1 sustained a displaced intertrochanteric (area between the greater and lesser hip bone) fracture (broken bone) of the right femur (the bone of the thigh). This deficient practice also placed R1 at risk for pain, decreased mobility, and impaired quality of life.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure all nurse aides received the required number of in-service training hours per year. This placed the residents at risk for impaired quality of care.

Inspectors wroteThe facility had a census of 33 residents. Based on observation, interview, and record review the facility failed to employ a full time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 33 residents of the facility at risk for inadequate nutrition or food borne illness.

Inspectors wroteThe facility had a census of 33 residents. Based on observation, interview, and record review, the facility failed to ensure appropriate sanitation of dishware used for preparing and serving residents' meals, and failed to monitor cold temperature storage of resident foods. This deficient practice placed the 33 residents of the facility at risk for food borne illness.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the environment remained free of accident hazards related to unlocked chemicals and unsecured hydocollator for five cognitively impaired, independently mobile residents. This placed the residents at risk for preventable accidents and injuries.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents with two reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide personal grooming assistance and cares for Resident (R) 28. This placed the resident at risk for poor hygiene and impaired dignity

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, interview, and record review the facility failed to involve the physician and Registered Dietician (RD) in an adequate timeframe after Resident (R) 26 experienced a large weight loss in 11 days in April 2023. This deficient practice placed R26 at risk for further weight loss or health issues.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident(R)1's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen, stored in the medication room, with the date openedand discard date. This deficient practice placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 33 residents. The sample included 12 residents. Based on record review and interview, the facility failed to ensure the results of the most recent survey (the last standard survey, extended surveys, or subsequent complaint suveys with citations) results were available for public review. - On 09/26/23 at 08:30 AM, surveyors reviewed the Survey Result Binder in the plastic storage container on the East wall close to the Administrator's office. The facility failed to ensure the Statement of Deficiencies (SOD) from the 10/12/23 complaint survey which resulted in a citation was available for review. On 09/26/23 at 08:32 AM, Administrative Staff A verified the 10/12/22 complaint survey SOD was not in the survey binder. Administrative Staff A then retrieved the results and added them to the binder. [...]

Inspectors wroteThe facility had a census of 34 residents. Based on observation, record review and interview, the facility failed to treat the resident's with dignity promoting quality of life when the facility failed to serve meals at the same time to all residents seated at the same table. This placed the residents at risk for impaired dignity and decreased psychosocial wellbeing.

Inspectors wroteThe facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide activities of daily living (ADL) assistance at mealtime for seven residents who required staff assistance with eating. This placed the residents at risk for poor nutrition and weight loss.

Inspectors wroteThe facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to provide weekend activities. This deficient practice placed the residents in the facility at risk for boredom and decreased socialization.

Inspectors wroteThe facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review and interview dietary staff failed to effectively carry out the meal preparation and food service in a manner which allowed for prompt meal delivery and facilitated social dining for the 34 residents residing in the facility, placing them at risk for impaired nutrition and decreased quality of life.

Inspectors wroteThe facility had a census of 34 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for four residents who received pureed diets placing the residents at risk for inadequate nutrition. The facility further failed to ensure appropriate temperatures for food items served in the dining room. This placed the residents at risk for food borne illness.

Inspectors wroteThe facility identified a census of 34 residents. The sample included 14 residents with one reviewed for discharge. Based on record review and interview, the facility failed to notify the State office of Long-Term Care Ombudsman (LTCO) of a facility-initiated transfer for Resident (R) 8. This placed the resident at risk for impaired coordination of care, and loss of rights related to facility-initiated discharge and/or transfer. Findings Included: - R8's Electronic Medical Record included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors, insomnia (inability to sleep) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R8's Annual Minimum Data Set dated 03/09/22 recorded R8 had a brief interview for mental Status score of three which indicated severe cognitive impairment. [...]

Inspectors wroteThe facility had a census of 37 residents. The sample included 14 residents with six reviewed for accidents. Based on observation, record review and interview, the facility failed to provide a safe environment and adequate supervision for one of the six sampled residents, Resident (R) 6, who had an unsupervised fall and sustained a minor injury. This placed the resident at risk for further accidents and injuries.

Inspectors wroteThe facility had a census of 34 residents. The sample included 14 residents with one reviewed for hospice services. Based on observation, record review, and interview the facility failed to ensure coordination between the hospice provider and the facility for Resident (R) 34, who was admitted to hospice on 02/12/22, which included a plan of care from the hospice and a description of the services provided including visit frequency, medications and medical equipment. This placed the resident at risk of delayed or inadequate care.