Good Samaritan - Hutchinson Village

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents. Based on record review and interview, the facility failed to ensure the required annual performance reviews were completed at least once every 12 months for one Certified Medication Aide (CMA) and three Certified Nurse Aides (CNA).

Inspectors wroteThe facility had a census of 51 residents. Based on observation, interview, and record review, the facility failed to provide sanitary food preparation and storage. This placed the 51 residents at risk for food-borne illness.

Inspectors wroteThe facility had a census of 51 residents. Based on observation, interview, and record review, the facility failed to remove or dispose of expired medication in the facility's north medication room.

Inspectors wroteThe facility identified a census of 51 residents. The sample included 14 residents with Resident (R) 6 reviewed for hospice services. Based on observation, record review, and interview, the facility failed to ensure a collaboration of care between R6's hospice provider and the facility, which included the information on what hospice services would be provided to the residents, as well as how often hospice staff would visit the facility.

Inspectors wroteThe facility reported a census of 53 residents. Based on observation, record review and interview, the facility failed to follow proper food handling practices to prevent the outbreak of foodborne illness.

Inspectors wroteThe facility reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to show respect and dignity to one Resident (R)4, by not having a dignity bag for the indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the urinary bladder to collect and drain urine) collection bag.

Inspectors wroteThe facility reported a census of 53 residents which included 12 residents sampled for reviewed for transmission of Minimum Data Set, (MDS) assessments. Based on interview and record review, the facility failed to electronically transmit Resident (R)51's Discharge Return not Anticipated MDS, tracking no later than 14 days after the assessment Reference date (ARD) of 08/23/23, and/or seven days after the completion date of the MDS as required.

Inspectors wroteThe facility reported a census of 53 residents. The sample of 12 residents included one resident sampled for personal hygiene related to bathing. Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain good personal hygiene for Resident (R)24, related to bathing and hair care.

Inspectors wroteThe facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment by failing to implement interventions prevent Resident (R) 106, with moderately impaired cognition, from having repeated falls.

Inspectors wroteThe facility reported a census of 53 with 12 residents in the sample, and five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to follow recommendation of the pharmacist for Resident (R)17, related to Abnormal Involuntary Movement scale (AIMS- a clinician-rated scale to assess severity of dyskinesias [the inability to execute voluntary movements]) testing and on R6 and R24 regarding as needed (PRN) lorazepam (a medication used for severe agitation) to obtain a new prescription every 14 days.

Inspectors wroteThe facility census totaled 53 residents with 12 residents included in the sample, including five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Residents (R6 and R24).

Inspectors wroteThe facility reported a census of 53 resident with 12 residents in the sample. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program, related to one resident, Resident (R) 4, related to urinary catheter care and placement, to help prevent contamination and the spread of infection.

Inspectors wroteThe facility census totaled 50 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to follow consultant pharmacist recommendations to add Not to Exceed (NTE) cautions to Resident (R)16 and R17's orders for acetaminophen (medication used to treat minor pain and fever) to reduce the potential for liver damage, failed to add manufacturer's instructions for administration of Voltaren (topical anti-inflammatory gel used for pain relief) for R16, failed to follow recommendations to discontinue the use of as needed (PRN) Alprazolam (sedative medication) for R29, and failed to respond to the recommendation to attempt a Gradual Dose Reduction (GDR) of Mirtazapine (an antidepressant) and Seroquel (an antipsychotic) for R28.

Inspectors wroteThe facility census totaled 50 residents with 12 included in the sample. Based on interview and record review the facility failed to ensure one of five Certified Nurse Aide's (CNA) 12- hour annual mandatory in-service training included dementia training.

Inspectors wrote- R28's pertinent diagnoses from the Physician's Orders in the Electronic Health Record (EHR) dated 11/12/21 documented major depressive disorder (major mood disorder), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 11/28/21 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R28 received antipsychotic, antidepressant, and antianxiety medications daily in the seven-day look back period. The 11/28/21 Psychotropic Drug Use Care Area Assessment (CAA) documented R28 had a history of depression with mood/behavior. R28 received scheduled Seroquel (antipsychotic medication), mirtazapine (antidepressant medication), and Ativan (antianxiety medication). [...]