Good Samaritan Society - Oakes

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 2 sampled residents (Resident #2 and #4) observed during cares and transfers. Failure to practice infection control standards related to enhanced barrier precautions (EBP), glove use, cleaning/sanitizing surfaces, and catheter and perineal cares has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 1 of 3 sampled residents (Resident #4) on oxygen. Failure to clean personal fans does not provide a safe and clean environment and has the potential to place the residents at risk of illness.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from unnecessary psychotropic medications for 1 of 2 sampled residents (Resident #29) who received an as needed (PRN) psychotropic. Failure to limit PRN psychotropic use to 14 days unless reevaluated by a practitioner placed the resident at risk of receiving unnecessary medications, experiencing adverse drug effects, and possible chemical restraint.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 2 residents (Resident #40) observed for insulin preparation and administration. Failure to properly prepare and prime an insulin pen may result in contamination of the pen and administration of an inaccurate dose of insulin.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide services to prevent skin breakdown and/or minimize the development of pressure ulcers for 1 of 3 sampled residents (Resident #2) with pressure ulcers. Failure to ensure the resident received treatments as ordered and reassess wounds in a timely manner may result in delayed healing of current pressure ulcers and/or the development of new pressure ulcers.

Inspectors wroteBased on record review, review of the hospice agreement, and staff interview, the facility failed to ensure resident records contained the hospice election form for 1 of 2 sampled residents (Resident #6) receiving hospice services. Failure to obtain the hospice election form limits staff's ability to ensure coordination of care between the facility and the hospice agency.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 14 sampled residents (Resident #4, #6, and #7) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), donning/doffing of personal protective equipment (PPE), and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, staff interview, and review of a Vulnerable Adult Protective Services (VAPS) report, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #1 and #2) who experienced nonconsensual sexual contact. Failure to protect residents from sexual abuse placed all residents at risk for psychosocial harm, physical harm, and mental and emotional distress. This citation is considered past non-compliance based on the review of the corrective actions the facility implemented immediately following the incident. During the on-site complaint survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/04/25 when Resident #1 entered Resident #2's room, kissed the resident, and laid on his bed. [...]

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report an incident of resident-to-resident sexual abuse to the State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #1 and #2) who experienced nonconsensual sexual contact. Failure to report incidents of abuse may result in unwanted physical and/or sexual contact, fear, anxiety, and psychosocial harm.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services for 1 of 2 sampled residents (Resident #2) with a pressure ulcer and 1 closed record (Resident #3). Failure to routinely assess and monitor progression of pressure ulcers has the potential to result in complications.

Inspectors wroteBased on record review, confidential resident and family interviews, and staff interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs for 4 of 4 confidential residents (Resident A, B, C, and D) and family members (Family member #1 and #2). Failure to provide sufficient nursing staff may result in residents experiencing falls, poor hygiene, incontinence, and skin issues and may negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control practice for 4 of 12 sampled residents (Resident #17, #22, #32 and #39) and 5 supplemental residents (Resident #2, #6, #13, #21, and #31) observed during cares. Failure to follow infection control practices during resident cares related to hand hygiene, glove use, and enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of facility policy and resident interview, the facility failed to provide care in a manner that maintained, enhanced, and respected the resident's dignity and individuality for 1 of 1 confidential resident (Resident B) who voiced concerns regarding nighttime toileting preferences Failure to honor the resident's choice for toileting does not enhance the resident's quality of life and may result in decreased self-esteem, decreased quality of life, emotional harm and increased pain.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or the resident's representative a written bed hold notice for 1 of 5 sampled residents (Resident #35) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on record review and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete a significant change in status assessment (SCSA) for 1 of 3 sampled residents (Resident #26) who experienced a significant change in status. Failure to determine the need for and complete a SCSA in response to a resident's decline limited the facility's ability to accurately assess the resident's status and identity and implement appropriate care approaches.

Inspectors wroteBased 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 3 of 12 sampled residents (Resident #25, #32, and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of facility policy and resident interview, the facility failed to assist in obtaining dental services to meet the needs of 1 of 1 resident (Resident #3) with a lost bottom denture. Failure to promptly refer for dental services and/or assess the resident's ability to eat and drink adequately without a bottom denture may result in decreased intakes, unplanned weight loss, and choking.

Inspectors wroteBased on review of the daily staffing information, review of the nurse schedule, and staff interview, the facility failed to post daily staffing data for all shifts on 9 of 11 days reviewed (September 22 - October 2, 2024). Failure to post accurate staffing data does not allow residents and visitors to be aware of the number of licensed and unlicensed staff on duty each shift.

Inspectors wroteBased on information provided by the complainant, record review, review of facility policy, and staff interview, the facility failed to ensure adequate supervision for 1 of 5 sampled residents (Resident #2) who experienced falls. Failure to provide supervision put the resident at risk of falls and/or injury.