Good Samaritan - Ellsworth

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify causative factors and implement effective interventions to prevent falls for Residents (R) 17, R25, and R30.

Inspectors wroteThe facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 38 residents who reside in the facility and receive meals from the facility kitchen, placing the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on record review and interview, the facility lacked evidence the required committee members, including the medical director, attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents in which five residents were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)25, R31, and R22 had an approved indication for the use of an antipsychotic-(class of medications used to treat major mental conditions that cause a break from reality), and failed to ensure R25's as needed (PRN) antipsychotic had a stop date. The facility further failed to ensure R32 had a risk versus benefit statement for the continued use of clonazepam (an antianxiety- class of medications that calm and relax people) and paroxetine (an antidepressant class of medications used to treat mood disorders) without a gradual dose reduction. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and, interview, the facility failed to revise the care plan with effective intervention to prevent re-traumatization for Resident (R)2 related to a diagnosis of post-traumatic stress disorder (PTSD-mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide nursing care that met the standards of practice for Resident (R) 25 when nursing staff failed to monitor the resident's intake and administer tube feedings per the physician's orders and failed to monitor urine output and report decreased output to the physician. This deficient practice placed the resident at risk for medical complications.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents with three residents reviewed for urinary catheter care. Based on observation, interview, and record review, the facility failed to provide urinary catheter (a tube inserted into the bladder to drain urine into a collection bag) care in a manner to prevent urinary tract infections (UTI-an infection in any part of the urinary system) for Resident (R) 22 and R91. This placed the two residents at risk for infections and catheter-related complications.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)2 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD-mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the resident at risk for unmet behavioral health care needs.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to follow up on the Consultant Pharmacist (CP) recommendations regarding antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and psychotropic (alters mood or thought) medication use for Resident (R)22, R32, and R25 and failed to ensure the CP identified and reported the lack of a stop date for R25's as needed psychotropic medication. This placed the three residents at risk to continue receiving unnecessary psychoactive medications without an explanation of why the benefits outweighed the risks.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for infection control were used when staff provided care for Resident (R) 22 and R91's urinary catheters (tube inserted into the bladder to drain urine into a collection bag). This placed residents at risk for potential infections and cross contamination.

Inspectors wroteThe facility had a census of 38 residents. The sample included 12 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic (medication used to treat infections) stewardship protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor the effectiveness of and identified inappropriate extended administration of an antibiotic for Resident (R) 25. This placed the resident at risk for complications related to antibiotic use.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to ensure a sanitary environment when Resident (R) 15's urinary catheter (a tube placed in the body to drain and collect urine from the bladder) drainage bag and tubing touched the floor int he common areas, creating the risk for communicable pathogens. This deficient practice placed R15 and the other residents using the area at risk for transmission of infectious disease.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, intervention, and record the facility failed to ensure Resident (R) 34 was free from staff abuse and/or mistreatment when Certified Nurse Aide (CNA) M forcefully took R34's bottle of apple juice from her. This deficient practice placed R34 at risk for injury or impaired psychosocial wellbeing.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to update the care plan with interventions aimed to prevent further falls for Resident (R) 9, who experienced 11 falls in the past 10 months. This deficient practice placed R9 at risk for further falls and potential injury.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with one reviewed for abuse. Based on observation, intervention, and record the facility failed to ensure staff assessed Resident (R) 34 for physical and psychosocial impact after an incident of staff to resident abuse and/or mistreatment which resulted in a bruise. This deficient practice placed R34 at risk for unidentified injuries and psychosocial impairment resulting from staff to resident abuse (Refer to F600).

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with five reviewed for accidents. Based on observation, interview, and record review the facility failed to provide care and services to prevent falls for Resident (R) 9, who experienced 11 falls in the past 10 months. This deficient practice placed R9 at risk for further falls and potential injury.

Inspectors wroteThe facility had a census of 37 residents. The sample included 12 residents with one reviewed for urinary catheter (a tube placed in the body to drain and collect urine from the bladder). Based on observation, intervention, and record review, the facility failed to ensure Resident (R) 15's urinary catheter drainage bag and tubing did not touch the floor. This deficient practice placed R15 at increased risk for urinary infection related to the use of the catheter.