Good Samaritan Society - Maplewood

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident assessments were accurate for 1 of 1 resident (R61) reviewed for dental.

Inspectors wroteBased on interview and document review, the facility failed to ensure quarterly care conferences were provided or offered for 1 of 1 resident (R61) reviewed for care planning.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the resident's fall interventions were in place for 1 of 1 (R9) residents reviewed for falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 resident (R31) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that the required personal protective equipment (PPE) was used for 1 of 1 resident (R73) reviewed for Contact Precautions.

Inspectors wroteBased on observation, interview, and documentation, the facility failed to assess and monitor non-pressure skin conditions for 2 of 3 residents (R1 and R2) reviewed for skin management. R1R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had intact cognition, no mood or behavior concerns, and no rejection of care. R1 required setup or clean-up assistance with eating, oral hygiene, personal hygiene; substantial/maximal assistance for upper body dressing, lower body dressing, putting on/taking off footwear, rolling left and right, sit to lying/lying to sitting on bed side, sitting to standing, chair/bed-to-chair transfers; and dependent on staff for toileting hygiene, showering, toilet transfers. R1 had an indwelling catheter and was frequently incontinent of bowel. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor urine output for 2 of 3 residents (R1 and R2) and failed to report, monitor, and document urine characteristics for 1 of 1 (R2) resident who was observed for staff emptying catheter bag. In addition, the facility failed to document catheter cares for 3 of 3 residents (R1, R2, and R3) and failed to store a catheter bag in a manner to reduce risk of infection for 1 of 1 resident (R3) who was observed to have a leg drainage bag during the day and larger catheter bag overnight.

Inspectors wroteBased on interview and document review, the facility failed to ensure medications were available for administration per physician order for 2 of 3 residents (R1 and R2) reviewed for medication errors.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBPs) and infection control measures were followed for 1 of 1 resident (R2) reviewed for urinary catheters.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for two out of four residents (R5, R7) when the care plan did not include dialysis services, goals/outcomes, and interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who required dialysis receive such services that were consistent with professional standards of practice for three out of five (R1, R5, R7) residents when the facility failed to assess the residents before and after dialysis. The facility failed to ensure licensed nurses had appropriate education to care for and assess residents who received dialysis for 26 out of 34 licensed nurses.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure unpasteurized eggs were fully cooked and prepared in a manner to prevent/decrease the risk of foodborne illness. This had the potential to affect up to 40 residents residing at the facility who ate undercooked eggs weekly.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure insulin pens were stored in a manner to prevent cross-contamination in 3 of 3 medication carts on the transitional care unit (TCU). This deficient practice had the potential to affect all residents who required insulin administration via an insulin pen who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident specific advanced directive orders were accurately reflected throughout the medical record for 1 of 1 resident (R75) investigated for advanced directives (AD). R75's face sheet (undated) indicated diagnoses of wedge compression fracture of the T11-T12 vertebra, congestive heart failure (CHF), and chronic kidney disease (CKD). R75's Brief interview of Mental Status (BIMS) assessment dated [DATE], indicated intact cognition. R75's Functional Ability assessment dated [DATE], indicated R75 required assistance from staff with most activities of daily living (ADL) and mobility. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure range of motion (ROM) was completed according to therapy recommendations for 1 of 1 resident (R4) reviewed for ROM.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assessment and Assurance (QAA)/Quality Assurance Process improvement (QAPI) committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to weekly skin assessments which resulted in deficiencies identified during this survey. This deficient practice had the potential to affect all 61 residents in the facility. The Certification and Survey Provider Enhanved Reports (Casper)-3 assessment (data was converted to quality measures (QM) to evaluate nursing homes performance) dated 8/11/24, identified the following previous deficiency by month and year. -F686 Treatment/services to prevent/heal pressure ulcers at a scope and severity level of a D. [...]

Inspectors wroteR42 R42's face sheet printed [DATE], indicated diagnoses of pneumonia, heart failure, and diabetes R42's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R42 had moderate cognitive impairment, no upper or lower extremity impairment, uses a wheelchair, dependent on staff for toileting hygiene, bathing, lower body dressing, and substantial assist for personal hygiene and bed mobility. R42 was frequently incontinent of urine and always incontinent of bowel. R42 has moisture associated skin damage (MASD) R42's careplan indicated R42 required enhanced barrier precautions related to open wounds. Interventions included wearing gown and gloves when performing high contact are activities including dressing, bathing, transferring, providing hygiene, changing linens, repositioning, and/or wound care. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure reclining foot rests functioned appropriately for 1 of 1 resident (R212) and failed to ensure a clean communal shower room which had the potential to affect all residents who used the shower room.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 of 4 residents (R18, R4, R12) reviewed for skin alterations had weekly skin observations completed. Furthermore, the facility failed to ensure bruising was assessed and monitored for 1 of 3 resident (R12 ) reviewed for bruising and a skin tear was assessed and monitored for 1 of 2 residents (R18) reviewed for pressure injury.

Inspectors wroteBased on interview and document review the facility failed to ensure comprehensive care plans were developed for 1 of 1 resident (R50) and failed to ensure non-pharmacological interventions were developed and implemented for 1 of 1 resident (R110) reviewed for psychotropic drug use.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure routine incontinent care was provided for 1 of 3 residents (R18) reviewed for dependent activities of daily living (ADL's).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 2 residents (R18) who were at risk for pressure ulcers were repositioned in a timely manner to prevent pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure speech therapy recommendations were followed for 1 of 3 residents (R18) reviewed for nutrition.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess 1 of 1 residents (R12) reviewed for bedrails. R4's significant change Minimum Data Set (MDS) dated [DATE], indicated, intact cognition and diagnoses of displaced bicondylar fracture of right tibia, atrial fibrillation, and chronic kidney disease (CKD). It further indicated R4 required assistance from staff with most activities of daily living (ADL) and mobility. R4's physician's order dated 5/7/24, indicated okay to install assist bar. Follow manufacturers recommendations and specifications to promote independence with bed mobility. Risk vs benefit have been reviewed and consent form signed. No directions specified for order. R4's Informed Consent for Bed Rails, was signed by R4 on 5/13/24. [...]

Inspectors wroteBased on interview and document review, the consulting pharmacist (CP) failed to address an appropriate indication for an antidepressant for 1 of 1 resident (R212) reviewed for psychotropic medications.

Inspectors wroteR50's admission Minimum Data Set, dated [DATE], indicated severe cognitive impairment, did not have little interest or pleasure in doing things, and did not feel down, depressed, or hopeless, did not have physical, verbal, or other behaviors, had diagnoses of dementia and depression and took an antipsychotic and antidepressant medication. R50's care area assessment (CAA) worksheet dated 7/16/24, indicated R50 took duloxetine (an antidepressant) and aripiprazole (an antipsychotic) for depression and psychotropic drug use would be addressed in the care plan in order to minimize risks. R50's physician orders indicated the following orders: • 7/4/24, aripiprazole 20 milligrams (MG) by mouth once daily. • 7/4/24, duloxetine 30 mg by mouth every evening, and 60 mg by mouth every morning. R50's orders lacked any monitoring for side effects of duloxetine and aripiprazole. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmacy services for one of one resident (R1) reviewed for medication administration. R1 did not receive her oxycodone (pain medication) when it was available in the facility's medication dispensing kit.

Inspectors wroteBased on interview and document review the facility failed to comply with resident rights to refuse treatment for 1 of 4 residents (R1) reviewed when staff proceeded with a urinary straight catheterization while R1 verbally and physically refused the procedure. R1 has had increased anxiety since the straight catheterization procedure.

Inspectors wroteBased on observation, interviews, and document review the facility failed to follow transmission-based precautions to prevent the spread of SARS-CoV2 (Covid-19), influenza, and clostridium difficile (c. diff) for 4 of 4 residents evaluated for infection control. The facility failed to practice proper hand hygiene, post the proper signage at a doorway, adhere to proper personal protective equipment (PPE), sanitize medical equipment following resident usage, and have proper doffing (taking off PPE) areas. This deficient practice had the potential to infect all 61 residents who resided at the facility. [...]

Inspectors wroteBased on interview and document review, the facility failed to immediate report, but not later than two hours after the allegation is made, to the state agency (SA) allegations of employee to resident physical and verbal abuse for 1 of 1 resident (R1) reviewed for abuse. R1's admission Minimal Data Set (MDS) date 11/5/23 indicated R1 had no cognitive deficits. R1 was dependent with toileting and lower body dressing and transfers. She required maximum assistance with upper body dressing and showering. R1's pertinent diagnoses were metastatic breast cancer, anxiety disorder, morbid obesity, and a pathological fracture of the left tibia (shin bone). A facility incident report dated 11/22/23 indicated R1 reported NA-A had yelled at her, telling her that no one liked her. R1 also stated NA-A ripped her brief off and hurt her hip during cares. NA-A made her feel bad for needing help. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure allegations of verbal and physical abuse were thoroughly investigated for 1 of 1 resident (R1) reviewed. R1 reported allegations of rough treatment leading to pain when staff would not stop a catheter procedure upon her request. In addition, R1 reported allegations of verbal and physical abuse by a nursing assistant (NA). A thorough investigation was not completed. Neither complaint allegations were reported to the state agency.

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive person-centered care plan for mental and psychosocial needs including prevention, interventions, measurable objectives, and goals for 1 of 1 resident (R1) reviewed.

Inspectors wroteBased on interview and document review the facility failed to ensure a medical record was complete and accurately documented for nursing and/or other licensed professional notes for 1 of 1 resident (R1) reviewed when R1 had a straight catheterization procedure that was not recorded in the medical record for R1.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident records that contained private, medical, and personal information were not accessible to unauthorized personnel when two unsecured cardboard boxes were left at a nurse's station that contained resident care plans and other resident medical information. The facility also failed to safeguard personal and medical information contained in the Electronic Medical Record (EMR) when three computers were left open in an area where any staff, visitor, or resident could view on three separate occasions. These deficient practices had the potential to affect all 61 residents who reside in the facility.