Good Samaritan-Olathe

Inspectors wroteThe facility identified a census of 123 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage and food temperature checks. This deficient practice placed the residents at risk related to foodborne illnesses and food safety concerns.

Inspectors wroteThe facility had a census of 123 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to secure chemicals in a safe, locked area, and out of reach of the twelve cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with one resident reviewed for dignity. Based on observation, record review, and interviews, the facility failed to provide services in a dignified manner for Resident (R) 31 when staff stood over R31 while feeding her a yogurt cup. This deficient practice placed R31 at risk for impaired dignity and decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents. One resident was sampled for reasonable accommodations of the resident's needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 38's call light was within his reach. This deficient practice left R38 vulnerable to unmet care needs due to the inability to call for staff assistance.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to report an unwitnessed injury fall of Resident (R) 58 (severely cognitively impaired), resulting in emergency medical treatment to the state investigative agency. This placed the residents at risk for potentially unidentified and ongoing abuse and /or neglect.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents. Based on observation, record review, and interview, the facility failed to ensure a bed hold and notification was provided to Resident (R) 1, and her representative was provided with a bed hold policy that included the facility's per diem rate to hold a bed. The facility failed to ensure R1 and her representative were provided a written notification of transfer upon her transfer to the hospital. This placed R1 at risk of miscommunication between the facility and the resident's representative, and the possible missed opportunity for healthcare services.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with four residents reviewed for activities of daily living (ADL) for dependent residents. Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was provided for Resident (R) 52, who was dependent on staff assistance with ADLs. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with one resident reviewed for quality of care. Based on observation, record review, and interview, the facility failed to complete weekly wound assessments, including wound measurements, for Resident (R) 11's right knee wound. This placed R11 at increased risk for worsening pressure or skin injuries and delayed wound recovery.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with three residents reviewed for treatment and services to prevent or heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to effectively implement interventions to reduce the risk or promote healing of pressure injuries for Resident (R) 74 and R31, the facility further failed to ensure R3's offloading boots were placed on his heels. This placed R74, R31, and R3 at increased risk for pressure ulcer development.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with two residents reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 45's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep), and nasal oxygen tubing (medical device used to deliver supplemental oxygen therapy to individuals with low oxygen levels) were stored in a sanitary manner. This placed R45 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported when Resident (R) 54's hypotension (a medication that treats low blood pressure) medication Midodrine order lacked a diagnosis. The CP failed to identify and report when R54's Midodrine was administered by facility staff outside of the physician-ordered parameters. This placed R54 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with six sampled residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 54's hypotension (a medication that treats low blood pressure) medication order, Midodrine, included a diagnosis for use. The facility failed to ensure R54's physician-ordered parameter for Midodrine was followed before the medication was administered. This placed R54 at risk of unnecessary medication administration and related complications.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with five reviewed for nutritious diets. Based on observation, record review, and interviews, the facility failed to ensure meals were served at a palatable, safe, and appetizing temperature for Residents (R) 80 and R104. This deficient practice placed the residents at risk for risks related to impaired nutrition and weight loss.

Inspectors wroteThe facility identified a census of 123 residents. The sample included 24 residents, with two residents reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to update Resident (R) 49's plan of care to reflect the services, medication, and equipment provided to R49 by hospice. This deficient practice created a risk for missed opportunities for services and delayed physical, mental, and psychosocial needs for R49.

Inspectors wroteThe facility identified a census of 120 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to notify Resident (R) 1's representative of care plan changes and/or results. This deficient practice had the risk of miscommunication between R1, their representative, and the facility.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with eight reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to provide consistent weight monitoring per the professional standards of practice after admission, failed to obtain weekly weights as ordered by the physician, and failed to provide cueing for meals as needed for Resident (R) 38. The facility further failed to implement nonpharmacological interventions to prevent weight loss for R38 until after a significant unplanned loss occurred. These deficient practices resulted in a loss of 12.15% in three months. Findings Included: [...]

Inspectors wroteThe facility identified a census of 114 residents with one kitchen and two main dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleanliness of the kitchen/dining room equipment, clean ventilation, equipment storage, hygienic serving practices, and food storage. This placed the residents at risk for food borne illness. Finding Included- - On 12/06/23 at 07:02AM an initial walkthrough of the kitchen was completed. An inspection of the air conditioning vents above the food warming station, stove/grill, food prep table, sink, and clean plates storage revealed layered debris/dust covering the vents. An inspection of the spice storage shelf revealed spilled spice particles covering the bottle and shelf. [...]

Inspectors wroteThe facility reported a census of 114 residents. Five Certified Nurse Aide's (CNA) were sampled for prevention of abuse, neglect, and exploitation training. Based on record review and interview the facility failed to provide evidence of the required prevention of abuse, neglect, and exploitation training for one of the five CNAs that were sampled. This placed the residents at risk for abuse.

Inspectors wroteThe facility had a census of 114 residents. Five Certified Nurse Aides (CNA) were sampled for required in-service training. Based on record review and interview, the facility failed to ensure two of the five CNA staff reviewed had the required 12 hours of in-service education which included dementia (progressive mental disorder characterized by failing memory, confusion) care training. This placed the residents at risk for decreased quality of life and/or inadequate care.

Inspectors wroteThe facility identified a census of 114 residents. The sample include 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent activities for Resident (R) 7 and the other cognitively impaired residents who resided outside of the locked unit. This deficient practice placed the affected residents at risk for decreased psychosocial wellbeing and boredom.

Inspectors wroteThe facility identified a census of 114 residents. The facility had three medication rooms and seven medication carts. Based on observation, record review and interview the facility failed to ensure accurate labeling of medications to facilitate consideration of precautions and safe administration of medications in accordance with professional standards. The facility failed to ensure safe and secure storage of medications. This deficient practice created a risk for adverse side effects and ineffective medication administration.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents. Based on observation, interview, and record review, the facility failed to implement appropriate infection control practices. This placed the residents at risk for transmission of infectious disease.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with three residents reviewed for accommodation of needs. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60 and R209 each had a call light within reach. This placed the residents at risk for impaired care.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to develop a person-centered baseline care plan for Resident (R) 209 related to his bathing preferences. This deficient practice placed R209 at risk of impaired care related to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60's Care Plan was revised to include his use of insulin (hormone that lowers the level of glucose in the blood). This placed R60 at risk for complications related insulin use due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to provide consistent bathing for Resident (R) 7 and R209. This deficient practice had the risk for poor hygiene, skin infections, decreased self-esteem and impaired dignity.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with one resident reviewed for. Based on observation, record review, and interviews, the facility failed to follow a physician order for daily weights to monitor for fluid overload for Resident (R) 97. This deficient practice placed R97 at risk for delay in treatment related to fluid overload and untreated illness.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with seven reviewed for accidents. Based on observation, record review, and interviews, The facility failed to provide consistent Roam Alert (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) functionality checks on Residents (R) 25's Roam Alert band. This deficient practice placed the resident at risk for elopement. The facility additionally failed to prevent avoidable accidents during R33's Hoyer (full body lift) lift transfers resulting in minor injuries and failed to utilize R87's care planned Hoyer lift while transferring her to her bed resulting in a non-injury fall. These deficient practices placed the residents at risk for preventable accidents and injuries.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with two reviewed for incontinence management and urinary catheters. Based on observation, record review, and interviews, the facility failed to provide individualized incontinence interventions based on Resident (R)55's significant status change. The facility additionally failed to provide consistent monitoring of urinary catheter care for R101. This deficient practice placed the residents at risk for complications related to incontinence and/or urinary tract infections (UTIs). Findings Included: [...]

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities with Resident (R) 60's insulin (hormone that lowers the level of glucose in the blood). This placed R60 at risk for complications related to insulin use.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with five residents review for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 60 received his insulin (hormone that lowers the level of glucose in the blood) as ordered by the physician and failed to ensure blood glucose levels outside of physician ordered parameters were reported to the physician as ordered. This placed R60 at risk for complications related to insulin use.

Inspectors wroteThe facility identified a census of 114 residents. The sample included 23 residents with two residents reviewed for hospice services. Based on observation, record review and interview, the facility failed to establish a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours per day for Resident (R) 47 and R202. The facility failed to ensure that R47 and R202's written plan of care included both the most recent hospice plan of care and a description of the services furnished by both the facility and hospice. This placed R47 and R202 at risk of decline and/or from maintaining the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteThe facility reported a census of 108 residents. Based on observation, record review and interview, the facility failed to store food in accordance with professional standards for food service safety, when kitchen observation revealed numerous expired food items. This placed the residents who received meals from the facility kitchen at risk for foodborne illness.

Inspectors wroteThe facility reported a census of 108 residents with 22 sampled including one reviewed for an indwelling catheter. Based on observation, interview, and record review the facility failed to promote dignity when staff failed to provide a privacy bag for the indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) drainage bag for Resident (R) 22. This placed R22 at risk for impaired dignity and psychosocial wellbeing.

Inspectors wroteThe facility reported a census of 108 residents with 22 sampled including one for an indwelling catheter. Based on observation, interview, and record review the facility failed to provide safe, sanitary, and hygienic catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care by allowing Resident (R) 22's indwelling catheter drainage bag to touch the floor. This placed the resident at risk for improper catheter care.

Inspectors wroteThe facility reported a census of 108 residents with 22 sampled with three residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to provide safe and sanitary care for oxygen tubing to help prevent the development and transmission of diseases and infections for one Resident (R) 63. This placed R63 at risk for infections. Findings Included: - R63's Electronic Health Record (EHR) under the medical diagnosis tab documented the diagnosis of hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood). The 07/02/21 admission Minimum Data Set (MDS) documented R63 had a Brief Interview for Mental status (BIMS) score of 15, indicating intact cognition, with no use of oxygen noted. The 02/02/21 Care Plan documented R63 had altered respiratory status. [...]

Inspectors wroteThe facility reported a census of 108 residents with 22 sampled including one for dialysis care. Based on observation, record review, and interview the facility failed to monitor Resident (R) 258's dialysis (procedure where impurities or wastes were removed from the blood) treatments appropriately by not sending or collecting the dialysis communication forms. This placed the resident at risk for complications and health decline.