Good Samaritan Society - Inver Grove Heights

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident's advance directives were accurately and consistently documented in the resident's electronic health record (EHR) banner, Provider Order for Life-Sustaining Treatment (POLST), and physician orders to ensure the resident's wishes would be followed in the event of a cardiac arrest for 3 of 35 residents (R8, R36, R40) reviewed for code status.

Inspectors wroteBased on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 2 of 3 residents (R14 and R38) reviewed whose Medicare Part A coverage ended and then remained in the facility. The facility further failed to ensure an appropriate 48-hour notice was given for 1 of 3 residents (R51) who discharged from the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to monitor for resident specific target behaviors related to psychotropic medications use for 1 of 5 residents (R50) and failed to ensure appropriate medication side effect monitoring for potential daytime sleepiness/drowsiness was completed for 1 of 5 residents (R4) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper cleaning and maintenance of a non-invasive ventilation machine to reduce the risk of complications (i.e., respiratory infection) for 1 of 1 resident (R1) observed for a continuous positive airway pressure (CPAP) machine.

Inspectors wroteBased on interview and document review, the facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic to promote continuity of care and reduce the risk of complications (i.e., missed orders, insufficient preparation for treatment) for 1 of 1 residents (R4) reviewed for dialysis care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to the administration of as-needed (PRN) pain medication to help facilitate person-centered care planning and reduce the risk of complication (i.e., constipation, sedation) for 1 of 5 residents (R50) reviewed for unnecessary medication use.

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure a safe, sanitary, and comfortable environment for 1 of 1 residents (R40) observed whose headboard and footboard of their bed was not maintained in good repair and whose personal fan was not clean.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 2 of 3 residents (R1, R2) reviewed for dignity.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nail care was provided for 2 of 3 residents (R1, R2) and bathing/shower assistance was provided for 2 of 3 residents (R2, R3) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed to ensure a provider order for a TSH (thyroid-stimulating hormone - a protein produced in the brain that regulates the thyroid gland's production of thyroid hormones) blood draw was performed as ordered for 1 of 3 residents (R3) reviewed for services performed as ordered.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper hand hygiene was completed for 1 of 3 residents (R1). Additionally, the facility failed to secure a leg bath for a catheter off the floor for 1 of 1 resident (R2) reviewed for infection control.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure final cooking temperatures were checked or obtained in a manner to reduce the risk of cross-contamination between food items prepared in the main production kitchen. This had potential to affect all 36 residents who were served the meal.

Inspectors wroteBased on interview, and document review, the facility failed to provide the opportunity for 4 of 4 residents (R22, R31, R1, R15) reviewed to participate in care planning and care conferences.

Inspectors wroteBased on interview and document review, the facility failed to immediately report incidents of potential staff to resident abuse to the state agency (SA) within two hours, as required for 1 of 3 residents (R29) reviewed for abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure voiced complaints of potential abuse were acted upon, and investigated to ensure an adequate protection plan was provided to ensure freedom from abuse for 1 of 3 residents (R29) reviewed for abuse and neglect.

Inspectors wroteBased on interview and document review, the facility failed to develop a baseline care plan for smoking for 1 of 1 residents (R189) reviewed who smoked.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure routine personal care (i.e., bathing, nail care) were provided for 1 of 3 residents (R11) reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure vision needs were met for 1 of 1 residents (R31) reviewed for missing eye glasses.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide timely assistance with repositioning for 1 of 1 residents (R22) with a history of pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to provide appropriate side effect monitoring of psychotropic medication consumption for 1 of 5 residents (R26) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 3 (R1) residents reviewed for medication errors did not have properly transcribed orders for an antibiotic for an infected pressure ulcer. This medication error resulted in actual harm to R1 when she developed sepsis and was hospitalized . The facility implemented corrective action prior to the survey, so the deficiency was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to notify the physician directly and immediately regarding changes in lower extremity movement for 1 of 3 residents (R1) reviewed for change of condition, additionally nurse practitioner failed to notify the medical doctor regarding change of condition concerns brought to her attention by her nurse.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dignity was maintained for 1 of 1 residents (R135) who utilized a urinary catheter.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess and care plan to ensure competency and safety with self-administration of medication for 1 of 1 resident (R26) observed to be storing and self-administering medication in their room.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident resuscitation wishes were updated in the electronic medical record (EMR) based on a signed Physician Orders for Life Sustaining Treatment (POLST, a medical order indicating treatments a person would like to receive in case of serious illness and/or cardiac arrest) for 1 of 1 residents (R23) reviewed for advanced directives.

Inspectors wroteBased on interview and document review, the facility failed to accurately complete the comprehensive assessment of a resident's needs, strengths, goals, life history and preferences to determine a resident's functional capacity. In addition, the facility failed to ensure cognitive mood and needs were completed for 1 of 1 residents (R285) reviewed for assessment accuracy.

Inspectors wroteBased on interview and document review, the facility failed to complete quarterly Minimum Data Set (MDS) in a complete, accurate manner to ensure cognitive, mood, and bowel and bladder statuses were evaluated for 4 of 4 residents (R8, R10, R27, R30) reviewed for assessment accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure an incomplete Level I Pre-admission Screening and Resident Review (PASARR) was conducted for 1 of 1 (R2); and failed to ensure a Level II PASARR was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 2 of 2 residents (R4, R11) reviewed for PASARR.

Inspectors wroteBased on interview and record review the facility failed to ensure timeliness of person-centered care conferences for 1 of 1 resident (R11) to include review and revision of the care plan by an interdisciplinary team and the resident.

Inspectors wroteBased on observation, interview and document review the facility failed to provide general daily grooming tasks, including shaving, for one of one resident (R4) observed with facial hair.

Inspectors wroteBased on observation, interview and document review the facility failed to properly care plan for and monitor a wound VAC (vacuum-assisted closure of a wound is a type of therapy to help wounds heal and is also known as wound VAC) for 1 of 1 resident reviewed for quality of care. In addition, the facility failed to comprehensively assess, and create and implement interventions for a new, non-pressure related skin injury for 1 of 1 residents (R23) reviewed for wounds. In addition, the facility failed to perform neurological evaluations on a resident following a fall with a head strike and subsequent change in mentation for 1 of 1 residents (R26) reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide timely assistance with repositioning for 1 of 1 (R135) who was at risk for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure oxygen orders were received and tubing was changed and dated timely for 1 of 1 resident (R11) reviewed for respiratory care. Furthermore, the facility failed to create a comprehensive plan of care for oxygen therapy for 1 of 1 resident (R11) reviewed for respiratory care.

Inspectors wroteBased on interview, observation and document review the facility failed to assess and monitor for complications per standard of practice before and after dialysis for 1 of 1 resident (R29) reviewed for dialysis care.

Inspectors wroteBased on interview and document review, the facility failed to ensure non-pharmacological interventions were attempted and recorded prior to administration of as-needed (PRN) narcotic medication to reduce the risk of potential complications for 1 of 1 residents (R30) reviewed for unnecessary medication use.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring was completed, in accordance with the care plan and standard of care, related to antipsychotic medication use despite an increase in abnormal involuntary movement scoring for 1 of 5 residents (R14) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Two medication administration errors occurred out of 27 opportunities resulting in a 7.41 % medication error rate for 1 of 5 residents (R8) observed during medication pass.

Inspectors wroteBased on observation and interview the facility failed to ensure standard infection control practices were in place during administration of intramuscular (IM) seasonal flu injection for 1 of 1 (R135) observed for injection practices. In addition, facility failed to ensure contaminated lancets for 1 of 1 (R11) were secured in a sharps container.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the most recent survey results were posted in a prominent location and readily accessible to person wishing to review such information. This had potential to affect all 29 residents residing in the nursing home or any visitors who wanted to review this information.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure nurse staffing information was posted on the weekend and in a timely manner at the start of the shift. This had potential to affect all 29 residents, staff, and visitors who could wish to review this information.