Good Samaritan - Decatur County

Inspectors wroteThe facility had a census of 18 residents. Based on the interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required.

Inspectors wroteThe facility had a census of 18 residents. The sample included eight residents. Based on observation, interview, and record review, the facility, in coordination with the licensed pharmacist, failed to provide a system of medication records that enabled periodic, accurate reconciliation and accounting for all resident medications when the emergency medication kit (E-Kit) was unlocked in the medication room. The facility staff failed to label and date Resident (R) 6's Insulin aspart (rapid acting) insulin (a hormone that lowers the level of glucose in the blood) pen (a device for giving insulin shots). This placed the residents at risk for being charged for a medication not administered to them from the e-kit.

Inspectors wroteThe facility identified a census of 18 residents. The facility had one main kitchen and one main dining room. Based on observation, interview, and record review, the facility failed to ensure that the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM).

Inspectors wroteThe facility had a census of 18 residents. The sample included eight residents, with one reviewed for hospitalization and one reviewed for discharge. Based on observation, interviews and record review, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) and failed to provide one resident, Resident (R) 20, with written information regarding the facility's bed hold policy when they were transferred to the hospital. The facility failed to complete a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) for R22.

Inspectors wroteThe facility identified a census of 18 residents. The sample included eight residents, with two residents reviewed for activities of daily living (ADL) care. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 18 had a functional pair of glasses needed for her impaired vision.

Inspectors wroteThe facility had a census of 18 residents. The sample included eight residents, with six reviewed for unnecessary medications. Based on observation, interviews, and record review, the facility failed to obtain blood pressure parameters from the physician for one resident, Resident (R) 1, who received medication to treat hypertension (high blood pressure).

Inspectors wroteThe facility had a census of 18 residents. The sample included eight residents. Based on observation, interview, and record review, the facility failed to date Resident (R) 6's Insulin Aspart (rapid acting) insulin (a hormone that lowers the level of glucose in the blood) pen (a device for giving insulin shots).

Inspectors wroteThe facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and activities of daily living (ADL). Based on record review, observation, and interview, the facility failed to provide sufficient nurse staffing with the appropriate skill sets and competencies to treat Resident (R) 2, R3, R4, R5, and R7 with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life to maintain the highest practicable physical, mental, and psychosocial wellbeing. (Refer to F677)

Inspectors wroteThe facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with the resident's right to a dignified existence by ensuring the residents were well groomed, clean, and dressed appropriately for the day. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for impaired dignity and psychosocial impairment.

Inspectors wroteThe facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with appropriate ADL care for each resident to maintain a dignified existence and quality of life to maintain the highest practicable physical, mental, and psychosocial wellbeing. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for an undignified existence and a decline in their mental and psychosocial well-being. (Refer to F725)

Inspectors wroteThe facility identified a census of 14 residents, with five residents reviewed for resident rights, activities, staffing, and Activities of Daily Living (ADL). Based on record review, observation, and interview, the facility failed to provide Resident (R) 2, R3, R4, R5, R6, and R7 with a resident-centered activities program that incorporated the resident's interests, hobbies, and cultural preferences to maintain or improve the resident's physical, mental, and psychosocial well-being. This deficient practice placed R2, R3, R4, R5, R6, and R7 at risk for decline in meaningful interaction, meaningful activities, and psychosocial well-being.

Inspectors wroteThe facility identified a census of 31 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from abuse and/or neglect. On 02/09/24, Certified Nurse Aide (CNA) M forcefully grabbed R1's wrist, took the glass of orange juice out of R1's hand, and slammed the orange juice on the table. Then CNA M aggressively grabbed R1's wheelchair to start moving her, and R1 put her foot down on the floor. CNA M yelled at R1 and aggressively placed R1's feet on the foot pedals. Social Services X attempted to intervene, but CNA M ignored Social Services X and continued to try and wheel R1 out of the dining room. CNA M treated R1 in a manner that did not uphold the resident's sense of self-worth and individuality. [...]

Inspectors wroteThe facility identified a census of 32 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 was free from abuse when R2 touched R1 in a sexually inappropriate manner. R1, who was severely cognitively impaired, was unable to consent. This deficient practice placed R1 at risk for continued abuse and impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full time certified dietary manager for the 32 residents who resided in the facility and received meals form the facility kitchen. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 32 residents. The facility had one kitchen. Based on observation, record review, and interview, the facility failed to prepare food in accordance with professional standards for food service safety when staff failed to check temperatures of food items prior to serving and failed to ensure clean and sanitary refrigerators and food preparation areas. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to investigate Resident (R) 16's bruises of unknown origin on her left arm and left breast area. This deficient practice placed the resident at risk for unidentified and ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to assess one of 12 sampled residents, Resident (R)12's cognition on the Minimum Data Set (MDS) assessment. This placed the resident at risk for an inaccurate care plan and unmet care needs.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 21 appropriate activities of daily living (ADL) care, which included incontinence care, for R21 placing the resident at risk for poor hygiene and impaired quality of life.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 21 the necessary care and services for positioning when in the wheelchair, or assessment and care of R21's skin. This deficient practice placed the resident at risk for discomfort and potential skin breakdown.

Inspectors wroteThe facility had a census of 32 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing for the two residents' pureed diets. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 32 residents. The sample included 12 residents with one reviewed for bladder and bowel incontinence. Based on observation, record review and interview the facility staff failed to follow acceptable infection control practices when staff failed to change gloves and perform adequate hand hygiene when providing Resident (R)23 incontinent cares. This placed the resident at increased risk for infection.

Inspectors wroteThe facility identified a census of 30 residents with three reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure interventions were implemented to prevent Resident (R) 1 from falling out of bed and failed to ensure intervention in place to prevent injuries for R1 who had multiple falls from her bed. As a result, R1 fell out of bed and sustained an acute left hip fracture. This deficient practice also placed R1 at risk for further falls and injuries.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to identify the risk for pressure injuries and implement preventive interventions for Resident (R)8 who had pressure areas on her buttocks and had a decline in health. As a result, R8 developed a pressure injury to her left heel, which progressed to an open wound. The facility further failed to ensure weekly monitoring of skin conditions in order to assess wound status including wound bed, healing, and effectiveness of treatments for R7 and failed to review and offer treatment options to R31. [...]

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to submit a completed investigation to the State Agency (SA) within the required five days for Resident (R) 17 for whom the facility reported an injury of unknown origin. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate an injury and fall for one resident, Resident (R) 17, who had a fracture of her pubic ramus (pelvis bone). This placed the R17 at risk for further injury and unidentified abuse and mistreatment.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for hypertension (high blood pressure) with signs and symptoms of side effects from the antihypertensive medication. This placed the resident at risk for physical decline and complications related to high blood pressure. The facility further failed to develop a comprehensive care plan which addressed the risk for pressure injuries and interventions and treaments related to a recurring pressure wounds for R7. This placed the resident at risk for delayed healing, recurring wound and uncommunicated care needs.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with five reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to revise the comprehensive care plan for Resident (R)8 to include interventions to prevent pressure injuries to R8's heels and failed to revise to add treatments once a pressure injury developed on R8's left heel. This placed the resident at risk for delayed healing related to uncommunicated care needs.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents with one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 184's skin condition including wound size and effectiveness of treatment which placed R184 at risk for delayed healing and treatment.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents with two reviewed for catheter (tube placed into the bladder to drain urine) related urinary tract infection (UTI). Based on observation, record review and interview the facility failed to prevent recurrent UTI for Resident (R)31, who had an indwelling catheter which placed the resident at risk of further infections.

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify and report multiple episodes of Norvasc medication not administered when the resident's blood pressure was out of parameters for Resident (R) 2. This placed R2 at risk for physical decline and complications related to high blood pressure. - The Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). [...]

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to administer Norvasc (a medication that treats high blood pressure) when blood pressures were out of parameters for one of five sampled residents, Resident (R) 2. This placed R2 at risk for physical decline and complications related to high blood pressure. - The Electronic Medical Record (EMR) documented diagnoses of hypertension (high blood pressure), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2 (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). [...]

Inspectors wroteThe facility had a census of 35 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to maintain the catheter (tube inserted directly into the bladder to drain urine) drainage bag for Resident (R)31, who had an indwelling catheter and a history of urinary tract infections (UTI) which placed the resident at risk of bacterial contamination and further infections.