Good Samaritan - Loveland Village

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's representative about a change in condition. Specifically, the facility failed to ensure staff reported a change in condition to the resident representative for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to notify the resident's provider about a change in condition. Specifically, the facility failed to ensure staff reported a change in condition to the resident's provider for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to protect one (#3) of three residents reviewed for abuse out of eight sample residents. Specifically, the facility failed to ensure Resident #3 was kept free from physical abuse from Resident #2.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#1) of three residents reviewed for neglect out of eight sample residents. Specifically, facility staff failed to report an allegation of injury of an unknown origin to the facility's abuse coordinator and the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#108) of eight residents reviewed for accidents out of 35 sample residents remained free from accidents. Specifically, the facility failed to ensure staff consistently implemented fall interventions for Resident #108, which resulted in a fall with major injury. Resident #108 was admitted to the facility on [DATE] with diagnoses of severe obesity, pain in the right knee, muscle weakness, and a right lower extremity hematoma (a solid swelling of clotted blood within the tissue) sustained prior to admission to the facility due to a fall at home from rolling out of bed while asleep. Resident #108 had moderate cognitive impairments, per staff interview, and was at risk for falls related to obesity, right lower extremity hematoma and muscle weakness. [...]

Inspectors wroteBased on record review and interviews, the facility failed to prevent abuse for one (#44) of three residents reviewed for abuse out of three sample residents. Specifically, the facility failed to protect Resident #44 from mental abuse involving certified nurse aide (CNA) #4, CNA #5 and CNA #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for three (#1, #4 and #110) of 10 residents out of 35 sample residents. Specifically, the facility failed to: -Ensure an assessment was conducted to determine whether the self-administration of inhaler medications was clinically appropriate for Resident #1 and Resident #110; and, -Ensure an assessment was conducted to determine whether the self-administration of nasal sprays was clinically appropriate for Resident #4.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, clean, sanitary and comfortable environment on the 700 unit. Specifically, the facility failed to ensure the common area at the end of the 700 hallway was available to residents for activities.

Inspectors wroteBased on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for two of three certified nurse aides (CNA) reviewed. Specifically, the facility did not complete a performance review for CNA #1 and CNA #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on one of four units. Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during wound care for Resident #10.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents out of three sample residents. Resident #1, who was known to be at risk for falls, fell seven times between 12/8/24 and 2/1/25. The resident suffered a hip fracture as a result of one of the falls. The facility could not determine which fall resulted in the hip fracture. Resident #1 had one fall because his bed moved and six falls were because he attempted to self-transfer in or out of bed. Most of his falls were before or after meals and the resident was often incontinent at the time. According to staff, Resident #1 was very routine and would want to go to meals early, return to his room, use the urinal on the edge of his bed and lay down. He would self propel in his wheelchair to and from the dining room. [...]

Inspectors wroteBased on record review and interviews, the facility failed to prevent two of six sample residents (#2 and #3) from sexual abuse by certified nurse aide (CNA) #1. Record review and interviews revealed Resident #2, cognitively impaired and physically dependent, was sexually abused by CNA #1 on 7/27/24. The CNA was suspended immediately and terminated on 8/13/24. Resident #3, cognitively intact but visually impaired, reported on 10/11/24, that she, too, was sexually abused by CNA #1 before his suspension.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#58) of six residents reviewed for accidents out of 39 sample residents remained free from accidents. Resident #58, who was known to be a fall risk and had care planned fall interventions in place, sustained a fall on 4/20/24 which resulted in a fracture of her left femur (upper leg). During the facility's investigation of the fall, it was discovered the floor alarm, which was care planned as an effective fall intervention for the resident, had been in the off position at the time of the resident's fall and did not sound, therefore staff had not been alerted to the resident's movements in her room. Staff was aware that in order to reset the alarm after it had been triggered, it was necessary to reset the alarm by switching it to the off position and returning it to the on position. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was not five percent (%) or greater. Specifically, the facility's medication error rate was 7.7% or two errors out of 26 opportunities for error.

Inspectors wroteIII. Resident #47 A. Professional reference Reference for safe use of the sit to stand the resident must be able to stand on his feet to ensure proper placement of the sit to stand seat halves. https://safetyucsf.edu/sites/g/files/tkssra256/f/Arjo%20Sara%20Stedy%20Instructions%20for%20Use.pdf accessed 2/6/23 read in pertinent part, the sit to stand lift is intended to transfer a resident to and from a chair, a wheelchair, a bed and a toilet. Instructions for safe use of a sit to stand are -Position resident near the sit to stand; -Ask the resident to stand up; -Pivot the two seat halves on the sit to stand upward; -Ask the resident to sit down back down on the chair while holding the sit to stand crossbar. B. Resident status Resident #47, age [AGE], was admitted on [DATE]. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for two of three medication storage rooms. Specifically, the facility failed to discard expired medications.