Good Samaritan Health Care Ctr

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of COVID-19 were consistently implemented in the areas of proper donning (putting on), use of, and doffing (taking off) personal protective equipment [(PPE) equipment worn to minimize exposure to hazards that can cause injuries], providing readily available PPE for 3 of 5 teams (Team 4, Team 2, and Team 1), and cross contamination during catheter care for 1 of 4 Residents (Resident 71) reviewed for infection control. These failures placed the residents at risk for transmission of communicable diseases, illness, and death.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice [(ABN) a notification that provides an estimated cost of continued services which may no longer be covered by Medicare; beneficiaries may choose to continue services but may be financially liable] as required for 1 of 3 residents (Resident 32) reviewed for beneficiary notification. This failure placed the resident at risk for their inability to make informed financial and care decisions related to their continued stay.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) [an assessment used to identify people referred to nursing facilities with mental illness, intellectual disabilities, or related conditions] Level II assessment [a more in-depth screening, to identify whether nursing home services were needed and if specialized mental health services were required] was completed for 1 of 5 sampled residents (Resident 58), reviewed for PASARR services. This failure placed the resident at risk for inappropriate placement, and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications and vaccines were properly stored for 1 of 3 medication rooms (Team 4 medication room) and medications were properly labeled for 2 of 5 medication carts (Team 1 and Team 4 medication carts) reviewed for medication storage. This failure placed the residents at risk of receiving expired medications, experiencing compromised or ineffective medications and vaccines and negative health outcomes. Review of the policy titled, Storage of Medications, dated 01/01/2020, showed medications and biologicals were stored safely and properly, and expired medications were removed from supply and destroyed by the facility. The facility should maintain and monitor the refrigerator that stores vaccines at least twice daily per Centers for Disease Control (CDC). [...]

Inspectors wroteBased on interview and record review the facility failed to accurately assess and manage the diagnosis of congestive heart failure (CHF, a weakened heart condition, in which the heart doesn't pump blood as effectively as it should, and causes fluid build-up in the feet, arms, lungs and other organs) according to physician orders for 1 of 3 sample residents (Resident 1) reviewed for the management of CHF. This failure placed the resident at risk for fluid overload, respiratory complications, and exacerbation of (worsening of) heart failure.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set [(MDS) assement tool] accurately reflected the status for 6 of 7 sampled residents (Resident 32, 84, 79, 3, 29 and 96) reviewed for accuracy of assessments. This failure placed the residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure implementation of their abuse prohibition policy/procedures components of resident protection, identification, reporting and investigating for 1 of 3 residents (Resident 47) reviewed for abuse/neglect. This failure placed the resident at an increased risk for unidentified abuse/neglect, retaliation from the alleged perpetrator and the potential for continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of potential abuse and/or neglect to the State Agency, for 1 of 3 residents (Residents 47), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect, and the potential continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation into an allegation of abuse for 1 of 3 residents (Resident 47), reviewed for abuse and neglect. This failure placed the residents at risk for unidentified abuse, unmet care needs, and the potential for continued exposure to abuse and/or neglect.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents received treatment and services in accordance with professional standards of practice regarding monitoring of their cardiac status (issues related to the functioning of the heart). This included daily weights and physician notification of weight changes greater than three or more pounds (ibis, a unit of measure) in a 24-hour period for 1 of 2 residents (Resident 1) reviewed for quality of care. These failures placed residents at an increased risk for unidentified complications and a deterioration in their health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience) for 1 of 3 residents (Resident 47) reviewed for trauma informed care. This failure placed the resident at risk for unidentified triggers and re-traumatization.

Inspectors wroteBased on interview and record review the facility failed to ensure that 1 of 5 residents (Resident 1) reviewed for unnecessary medications, had an acceptable indication for use for a psychoactive medication (a class of medication that affects brain activity of mental functioning and behavior). Resident 1 was prescribed an antipsychotic medication (a psychoactive medication primarily used to treat psychosis with a high risk for adverse side effects [ASE's]) with no acceptable mental health diagnosis or identified individualized target behaviors to justify the use of an antipsychotic. This failure placed Resident 1 at increased risk for deterioration in their mental and physical health status.

Inspectors wroteBased on interview and record review, the facility failed to provide copies of personal and medical records, as required, to 1 of 3 residents (Resident 1), reviewed for resident rights. This deficient practice placed residents at risk of not having access to their complete medical history, potentially affecting their ability to make informed decisions, and violated their resident rights.

Inspectors wroteBased on interview and record review, the facility failed to maintain their Respiratory Protection Program (RPP) for N95 respirator masks (a respiratory protective device designed to filtrate airborne particles by achieving a very close facial fit) initial and annual fit testing for 4 of 5 staff (Staff D, E, F, and G) reviewed for infection control practices during a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) outbreak. This deficient practice placed residents and staff at continued risk of exposure and spread of COVID-19 during an active outbreak.

Inspectors wroteBased on interview and record review, the facility failed to prevent an avoidable accident when COVID 19 reagent solution (a chemical used in a test to determine if a person has COVID 19 [infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death]) was used as an eye drop for 1 of 1 resident (Resident 2) reviewed for accidents and hazards. This deficient practice placed residents at risk for unnecessary exposure to chemicals and potentially harmful outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors when physician's orders were not implemented timely for 1 of 2 residents (Resident 1) reviewed for medication administration. This deficient practice placed residents at risk for adverse side effects and an overall decline in medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had personal fund accounts established, received accrued interest on those accounts or accurate statements for 11 of 18 residents (Residents 1, 4, 5, 12, 21, 29, 32, 33, 50, 51, and 183) reviewed for personal funds. This failed practice caused residents not to receive or have access to monies owed to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Four medication errors were identified for 3 of 14 residents (Residents 6, 27 and 52) observed during 25 medication administration opportunities that resulted in an error rate of 16%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's personal refrigerators; 1. were free of expired foods, 2. temperatures were being monitored and maintained within acceptable standards of practice, and 3. cleaning schedules were followed for 4 of 4 residents (Resident 4, 5, 51, and 31) reviewed for safe food handling practices. This failed practice put residents at risk for being exposed to a food-borne illness (Illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement effective infection control practices for 2 of 4 dining rooms (West and Rehab Dining Rooms), reviewed for appropriate infection control practices during meal serve out. This failure placed residents at risk for infectious diseases and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment for unlocked and opened doors to soiled utility rooms and storage rooms that contained an electrical power source, cable hookups, exposed electrical wires, metal bars, shelves with loose miscellaneous metal parts and a basket of metal oxygen connectors on 4 of 6 hallways (Hallways main, 2, 4, and 5), reviewed for safe and sanitary environment. This failure placed residents at risk of injury, potential illness related to unclean conditions, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in a dignified manner when 1) tally marks (a form of numeral used for counting ongoing results) were placed on a whiteboard every time the call light button was turned on, and 2) the resident did not receive assistance with their care needs while out of the facility at an appointment (appt) for 1 of 3 sampled residents (Resident 71) reviewed for dignity. This failure resulted in Resident 71 feeling like they were part of undignifed interactions with the facility staff, they could not ask for help when they needed it, and embarrassed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain private medical information in a manner that ensured privacy, securtiy, and confidentiality for 2 of 2 residents (Residents 39 and 53) reviewed for confidentiality of medical records during medication pass. This failure placed residents at risk for loss of personal privacy and confidentiality of medical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for 2 of 2 residents (Resident 55 and 23), reviewed for comfortable room temperatures. This failure placed the resident in an uncomfortable room environment and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to recognize a resident's grievance as an allegation of abuse for 1 of 2 sampled residents (Resident 58), reviewed for abuse. This failure resulted in Resident 58 feeling bad and placed them at risk for unidentified abuse and psychosocial harm due to unrecognized allegations of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct thorough investigations for 2 of 2 residents (Residents 58 and 71) reviewed for allegations of abuse. This failed practice placed residents at risk for unmet care needs and decreased quality of life related to unrecognized abuse/neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently follow feeding guidelines for 2 of 2 residents (Residents 78 and 28), reviewed for safe swallowing guidelines. This failure placed the residents at risk for choking, aspiration (a condition where food or liquids are breathed into the lungs), and an overall decline in their health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis (a process that uses a machine to filter waste and fluids from the blood when the kidneys no longer function) received care and services consistent with professional standards of practice for 2 of 3 residents (Residents 333 and 26), reviewed for dialysis services. The facility did not ensure that communication forms were completed, and pre/post dialysis treatment weights were consistently available for facility staff to monitor for changes in the resident's condition. This failure placed the residents at risk for unidentified complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure culturally competent, trauma-informed care related to assessing for trauma, and identifying triggers for residents with a history of sexual assault for 2 of 2 residents (Residents 4 and 57), reviewed for mood and behavior. This failed practice put residents at risk for re-traumatization, unidentified triggers, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure as-needed (PRN) psychotropic medications (medications capable of affecting the mind, emotions, and behavior) were limited to 14 days without providing a physician-documented rationale or duration for 1of 5 residents (Resident 51) reviewed for unnecessary medication use. This failure placed the resident at risk of being over medicated, medical complications related to the side effects, and a diminished quality of life.