Good Samaritan Society Augusta Place a Prospera Co

Inspectors wroteBased on observation, review of manufacturer's instructions and staff interview, the facility failed to sanitize surfaces in 1 of 1 facility kitchen. Failure to ensure the concentration of quaternary (quat) sanitizing solution is within manufacturer's guidelines may result in an incorrect solution concentration. Inadequate sanitization of the kitchen surfaces places residents at risk for foodborne illness.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 13 sampled residents (Resident #20, #30, #36, #38 and #200) and one supplemental resident (Resident #2) observed during cares and medication pass. Failure to practice infection control standards related to enhanced barrier precautions (EBP), droplet precautions, and hand hygiene, has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 2 of 13 sampled residents (Resident #33 and #39). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, review of facility policy, review of manufacturer's instructions, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #33) observed for insulin preparation and administration. Failure to properly prime an insulin pen and administer insulin correctly may result in residents receiving an inaccurate dose of insulin.

Inspectors wroteBased on record review, review of the facility reported incident investigation, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 4 sampled residents (Resident #1) receiving insulin. Failure to administer insulin according to a physician's order may have contributed to Resident #1's hyperglycemia (elevated blood sugar level) and hospitalization. This citation is considered past noncompliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on observation, record review, review of the facility reported incident investigation, and resident and staff interview, the facility failed to ensure an environment free of hazards for 1 of 1 sampled resident (Resident #1) injured while consuming a hot beverage. Failure to place the hot beverage lid securely to the cup resulted in an injury to Resident #1. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on observation, review of facility policy, review of food temperature logs, review of resident council meeting minutes, and resident, family, and staff interviews, the facility failed to serve hot foods at palatable temperatures on 3 of 3 units (Pine Ride, [NAME] Hills, and Eagle Bend). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 01/19/23 Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #29 and #44) and one supplemental resident (Resident #12). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of the North Dakota Provider Manual Preadmission Screening and Resident Review (PASARR) and Level of Care Screening Procedures for Long Term Care Services, and staff interview, the facility failed to complete a status change assessment for 1 of 2 sampled residents (Resident #29) reviewed for PASARR. Failure to complete a change in status assessment with a newly diagnosed mental illness may result in the delivery of care and services inconsistent with the resident's needs.

Inspectors wroteBased on observation, record review, review of manufacturer's instructions, and staff interview, the facility failed to provide adequate supervision and assistive devices necessary to prevent accidents for 1 of 4 sampled residents (Resident #9) observed during a transfer utilizing a sit-to-stand mechanical lift transfer. Failure to ensure proper use of a stand lift during transfers placed the resident at risk for accidents and injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 1 of 3 sampled residents (Resident #44) reviewed for antipsychotic medications. Failure to consistently monitor residents while on the medication may result in the residents experiencing adverse consequences related to the antipsychotic medication.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate labeling of medications for 1 of 6 residents (Resident #45) observed during medication administration. Failure to ensure medication cards contain the correct administration information may result in medication errors and adverse drug effects.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to maintain sanitary food service in 1 of 3 kitchenettes (Eagle Bend). Failure to ensure safe transportation of foods to resident rooms and ensure utilization of sanitary food service equipment has the potential to result in contamination of food and spread illness to resident, staff, and visitors. Findings Include: Review of the facility policy titled Safe Meal Service occurred on 01/18/24. This policy, reviewed 01/11/23, stated, . Meals served in resident's rooms . need to be covered during transportation. Upon completion of the meal by the resident in their room, nursing will document the necessary detail of food consumption before placing the used tray into the enclosed 'dirty' cart in the kitchenette. [...]