Good Samaritan - Ellis

Inspectors wroteThe facility identified a census of 37 residents, with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to prevent a hot liquid burn to Resident (R) 1. The facility failed to evaluate the temperature of the liquid from the hot water/coffee machine, relying on a temperature regulator that had failed, and allowed the hot water dispensed from the machine to be too hot.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents, with four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment when the facility failed to assess Resident (R) 26 for safe use of an electric recliner.

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility's Consultant Pharmacist failed to identify staff were not obtaining Resident (R) 7's blood pressure before the administration of losartan, as ordered. Findings Included: - The Electronic Medical Record (EMR) for R7 documented diagnoses of hypertension (elevated blood pressure), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), and atrial fibrillation (rapid, irregular heartbeat). The Five-Day Medicare Minimum Data Set (MDS) dated [DATE] documented R7 had intact cognition. The MDS further documented R7 received diuretic (a medication to promote the formation and excretion of urine) medication. The Quarterly MDS dated 10/23/25 documented R7 had intact cognition. [...]

Inspectors wroteThe facility had a census of 34 residents. The sample included 12 residents, with seven reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to administer medications as ordered by the physician for one resident. The facility failed to obtain weekly blood pressures as ordered for Resident (R) 7, who received hypertension (high blood pressure) medication.

Inspectors wroteThe facility had a census of 35 residents. The sample included 14 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 35 residents of the facility at risk for inadequate nutrition or food-borne illness.

Inspectors wroteThe facility had a census of 35 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 35 residents. Based on record review and interview, the facility failed to ensure one of the five Certified Nurse Aides (CNA) employed at the facility for at least one year completed the minimum 12 hours of in-service training per year and lacked a system for accurately tracking CNA education.

Inspectors wroteThe facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to promote care in a manner to maintain and enhance dignity and respect when staff administered an injection to Resident (R) 2 beside the front entry to the facility and in view of other residents and when residents were served meals in Styrofoam bowls instead of regular dinnerware. This placed the residents of the facility at risk for impaired dignity.

Inspectors wroteThe facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to ensure the residents' dinnerware was not broken or chipped. This placed the 35 residents at risk for unsafe food service.

Inspectors wroteThe facility had a census of 35 residents. The sample included 14 residents with three reviewed for weight loss. Based on observation, interview, and record review the facility failed to identify and implement interventions to prevent weight loss for Residents (R) 14. This deficient practice placed the resident at risk for further weight loss or health issues.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 31 residents who resided in the facility and received their food from the facility kitchen when the facility failed to ensure dietary staff followed hand hygiene and failed to ensure clean and sanitary food prep areas. This placed the 31 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 31 residents. The sample included five residents. Based on observation, record review, and interview the facility failed to provide ongoing communication to the resident council group about their rights and location of State Long Term Care Ombudsman (LTCO-an official appointed to investigate individual's complaints against maladministration), State Survey Agency (a group which assess whether nursing homes are operating with a quality of care that is in line with standards, applicable laws, and industry regulations) information and the location of the last survey report. This placed the residents at risk for impaired dignity due to decreased autonomy.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to treat Resident (R) 16 with dignity when staff applied Voltaren gel (a topical medication used to treat arthritis pain) on her shoulders, twice, at the dining room with two other residents present. This placed the resident at risk for an undignified dining experience.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to notify Resident (R)11's physician after R11 made the statement she wished she was dead. This placed the resident at risk for further decline of her emotional well-being and delayed mental healthcare treatment. Findings Included: [...]

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to immediately respond and investigate a report of alleged inappropriate interaction between a male resident, (R)10 and R11. This placed the residents at risk emotional distress.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents with one reviewed for hospitalization. Based on observation, record review, and interview the facility failed to provide Resident (R)14 or her representative in writing a notice of transfer to the hospital, which included the reason for transfer, the date, and where R14 was transferred. The facility failed to send a copy of R14's notice for transfer to the hospital to the State Long Term Care Ombudsman.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to provide Resident (R)14 or her representative with written information regarding the facility bed hold policy, when R14 was transferred to the hospital. This placed R14 at risk for not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to develop a discharge care plan for Resident (R) 33, to reflect current needs, goals, treatment and discharge preferences. This placed the resident at risk for miscommunication or interruptions in the continuum of care.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to place interventions on the care plan to prevent falls for Resident (R) 24. This deficient practice placed the resident at risk for further falls due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions for accidents for one sampled resident, Resident (R) 24, who had multiple falls and failed to use two staff when transferring R27 with a full mechanical lift (used to assist with transfers and movement of individuals who require support for mobility). This placed the residents at risk for injury.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents which one was reviewed for hydration. Based on observation, record review, and interview the facility nursing staff failed to monitor Resident (R) 15's, who was on a physician ordered fluid restriction, fluid intake. This placed R15 at risk for fluid overload.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents, with four reviewed for behaviors. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one sampled resident, Resident (R) 11, who stated she wished she was dead. This placed the resident at risk for further decline of her emotional and mental-wellbeing and risk for self-harm.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one sampled resident, Resident (R) 11, who had made a statement that she wished that she was dead and had an alleged inappropriate interaction with a male resident ,R10. This placed the resident at risk for further decline of her emotional and mental-wellbeing.

Inspectors wroteThe facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 17 medication administration was free from significant errors when staff crushed one extended release medication. This placed R17 at risk for side effects related to the medication being improperly released and decreased therapeutic effect.