Good Samaritan Society - Blackduck

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure mechanically altered diets were served as prescribed for 6 of 6 residents (R1, R2, R3, R4, R5, R7) with a physician ordered modified texture diet. This resulted in R1 receiving the incorrect diet, an unaltered piece of pizza, on 6/10/26. R1 required the Heimlich maneuver to dislodge the pizza from her throat. The immediate jeopardy (IJ) began on 6/10/26, at approximately 5:30 p.m., when facility staff served R1 the incorrect diet resulting in R1 needing the Heimlich maneuver performed to dislodge a piece of pizza from her throat. The IJ was identified on 7/1/26, the administrator was notified of the IJ on 7/1/26, at 3:15 p.m. The immediate jeopardy was removed on 6/11/26, the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance.

Inspectors wroteBased on interview and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect pressure ulcer staging for 1 of 3 residents (R1) reviewed with pressure ulcers.

Inspectors wroteBased on interview and document review the facility failed to ensure a baseline care plan related to pressure ulcers was developed for 1 of 3 resident (R1) who admitted to the facility with a pressure ulcer and developed pressure ulcers.

Inspectors wroteBased on interview and document review the facility failed to perform ongoing and accurate assessment of pressure ulcers for 2 of 3 residents (R1,R3) who were at risk for pressure ulcer development. In addition, the facility failed to implement interventions to reduce the risk for new or worsening pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to ensure there was a comprehensive assessment and monitoring for prescribing a psychotropic medication for sleep for 1 of 6 (R26); and failed to provide evidence a gradual dose reduction (GDR) or a clinical justification of a psychotropic medication was completed for 1 of 6 residents (R26, R7) reviewed for unnecessary medication and were taking psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 3 residents (R2) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to assess and analyze a resident fall with major injury to identify specific hazards and/or risks and to develop targeted interventions to reduce the potential for falls for 1 of 1 resident (R27) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a physician order for indwelling urinary catheter; and failed to ensure urinary catheter care was provided in a manner to prevent contamination and potential urinary tract infection (UTI) for 1 of 4 residents (R4) reviewed for urinary catheter.

Inspectors wroteBased on interview and document review, the facility failed to ensure the consulting pharmacist recommendations were addressed and acted upon and documented in the medical record for 2 of 5 residents (R26, R7) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain clean and sanitary conditions in the dry storage of the kitchen. This practice had the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on interview, and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities and develop and implement appropriate plans of action to correct quality deficiencies identified during the survey that the facility was aware of or should have been aware of that had the potential to adversely affect all 29 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 4 of 4 residents (R4, R23, R22, R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (R12, R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had the potential to affect all 29 residents, visitors and staff.

Inspectors wroteBased on interview and document review, the facility failed to ensure there was a qualified infection preventionist (IP) to adequately assess, develop, implement, monitor, and maintain the infection prevention and control program. This had the potential to affect all 29 residents residing in the facility including staff and visitors.

Inspectors wroteBased on interview and document review, the facility failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of a facility-initiated transfer for 1 of 1 resident (R14) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to provide the resident/responsible party a written bed hold policy at the time of hospital transfer for 1 of 1 resident (R14) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review the facility failed to follow care planned interventions to reduce the risk for falls for 1 of 3 residents reviewed during the survey.

Inspectors wroteBased on interview and document review, the facility failed to provide a face to face provider evaluation for continued use of a as needed (PRN) psychotropic medication for 1 of 1 residents (R26) with a PRN psychotopic medication; and failed to ensure a gradual dose reduction occured as warrented for 1 of 4 residents (R10) reviewed with psychotopic medications.

Inspectors wroteBased on interview and document review, the facilty failed to ensure a Minimum Data Set (MDS) was submitted timely for 1 of 1 resident (R180) reviewed for failure to submit the MDS.

Inspectors wroteBased on interview and document review, the facility failed to provide a recapitulation of stay for 1 of 1 residents (R28) reviewed for discharge.

Inspectors wroteBased on interview, and document review, the facility failed to ensure the facility followed up and act upon the consulting pharmacists identified and reported medication irregularities for 1 of 5 residents (R10); and the pharmacist failed to identify an irregularity for 1 of 5 residents (R26) Ireviewed for unnessary medications.

Inspectors wroteBased on interview and document review, the facility failed to provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 2 of 5 residents (R179, R4) reviewed for immunizations.

Inspectors wroteBased on interview and document review the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 6 of 6 residents (R4, R11, R180, R5, R12, R14) reviewed for restraints; and 1 of 1 residents (R14) reviewed for catheter.