Good Samaritan Society - St. John's

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)(i)(1) Based on record review and interview, the facility failed to identify the causative factors in falls as they related to one of 3 sampled residents (Resident 3). The facility census was 40. Record review of the facility policy dated 6/2/26 Falls Resource Packet - Rehab /Skilled revealed that the facility requires that all locations have a fall reduction program the provides organized and sustained processes that are monitored by designated employees and understood and followed by all employees. A successful fall reduction program is the responsibility of all employees. Employees are required to complete fall prevention and fall management training with a purpose to provide an evidence-based collection of information and tools for an effective fall reduction program that results in well-being for residents and employees. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on record review and interview the facility failed to ensure medication errors with the potential to negatively impact a resident's health or safety did not occur and the potential for negative effects were monitored for 2 (Residents 17 and 54) of 3 sampled residents. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D)&(E) Based on record review and interview the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives prior to administering psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) for 3 of 5 residents reviewed (Residents 17, 2, and 6). The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to monitor for adverse drug reactions related to antipsychotic medication use for 1 (Resident 2) of 5 residents sampled. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G)(i) Based on record review and interview, the facility failed to complete a discharge summary for 2 (Residents 60 and 62) of 2 sampled residents who had been discharged from the facility. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D) Based on observation, record review, and interview the facility failed to ensure that the Minimum Data Set (MDS, a mandatory comprehensive assessment tool used for care planning) identified dialysis services (a life-sustaining medical treatment that filters waste, toxins, and excess fluids from the blood when kidneys have failed) as required for 1 (Resident 7) of 1 sampled resident. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview the facility failed to complete a baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed for staff to provide initial effective and person-centered quality care for a resident) for 2 of 3 residents reviewed (Residents 4 and 23) to identify immediate care needs of the resident. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview the facility failed to maintain a comprehensive care plan for 1 of 5 residents reviewed (Resident 11) to provide direction to staff for care required for resident diabetes (a disease characterized by high blood sugar levels when the body does not produce enough insulin to regulate blood sugar levels). The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(5) Based on record review and interview, the facility failed to follow practitioner orders to prevent constipation for 1 (Resident 2) of 1 sampled resident. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I)Based on observation, record review, and interview the facility failed to ensure that fall prevention interventions were implemented for 1 of 1 resident reviewed (Resident 17). The facility census was 46.

Inspectors wroteBased on observations, interviews ,and record review; the facility failed to ensure a physician's order for resident dialysis, ensure that pre-dialysis assessment and communication was completed, and failed to assess and monitor resident post dialysis as required for 1 (Resident 7) of 1 sampled resident. The facility census was 46. Findings Are: Record review of the facility policy titled Dialysis Services dated 9/30/25 revealed that facilities caring for residents receiving dialysis services must have an agreement with the provider of the service. Record review of the facility's Outpatient Dialysis Services Agreement dated 9/10/19 revealed that the company will provide outpatient renal dialysis services to the facility. The agreement revealed that renal dialysis services shall include items and services when ordered by the physician. [...]

Inspectors wroteLicensure Reference Number NAC 175 12-006.09(H) Based on record reviews and interviews, the facility failed to follow physician orders, and ensure follow up assessments were completed for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 51.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on record reviews and interviews, the facility failed to implement a plan of care to prevent potential injuries for 1 (Resident 9) of 3 sampled residents. The facility identified a census of 51.

Inspectors wroteLicense Reference Number 175 NAC 12-006.04(A)(iii) Based on record review and interview the facility failed to ensure that employee healthcare questionnaires were completed, reviewed, and maintained prior to the hire dates for 5 of 5 sampled employees. This had the potential to affect all residents in the facility. The facility census was 44.

Inspectors wroteLicense Reference Number 175 NAC 12-007.01(B)(ii) Based on observations and interviews, the facility failed to provide a sanitary environment in the laundry area (three specific areas which are ante room, storage room, and dirty laundry) for staff. This had the potential to affect all laundry staff and all residents. The current facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 1-009.01(B) Licensure Reference Number 175 NAC 12-006.19(A) Based on observation, interview, and record review; the facility failed to ensure that resident equipment was cleaned and maintained for 5 residents (Residents 15, 17, 29, 7, and 18) of 8 residents sampled. This affected the residents' right to a dignified existence. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on record review, interviews, and observations, the facility failed to ensure bathing was offered and completed for residents who needed assistance. This affected 4 (Residents 1, 20, 203, and 252) of 5 sampled residents. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(iii) Based on record review and interview, the facility failed to ensure that the resident/resident representative were provided the opportunity to participate in quarterly care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) review as required for 1 resident (Resident 29) of 5 residents reviewed. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iv)(5) Based on record reviews and interviews, the facility failed to follow physician orders on bowel protocols for 1 resident (Resident 38) of 1 sampled resident. Facility census was 44.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09(J)(i)(1) Based on record reviews, interviews, and observations; the facility failed to identify and monitor ongoing weight loss and implement new and/or revise interventions to prevent further weight loss for 1 (Resident 38) of 1 sampled resident. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(i-vi) Based on record reviews and interviews, the facility failed to provide a clinical rationale and monitoring of psychotropic medication use for 1 Resident (Resident 27). The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7b Based on observation, interview and record review, the facility failed to ensure that interventions to prevent falls were implemented for 2 residents (Residents 4 and 2). The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-0006.11E Based on observation, record review, and interview the facility failed to maintain food temperatures at a level to prevent the potential for foodborne illness; and failed to ensure proper sanitization of dishes and cookware. This had the potential to affect 48 of 49 residents that ate food prepared by the facility kitchen. The facility had a census of 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation, record review and interview; the facility failed to maintain walls, fixtures and floors in good condition as evidenced by: scrapes and gouges on the walls, areas of repair on walls that had been patched but not painted, cracked, broken and stained areas surrounding the base of the toilets and carpet in the North hall that was loose from the floor. These conditions were found in 7 (North hallway rooms [ROOM NUMBER], South Hallway rooms 7, 13, and15, and East Hallway rooms 16, 23) of 49 occupied resident rooms and the north hallway of the facility. The facility census was 49.

Inspectors wroteLicensure Reference Number 175NAC 12-006.02(8) Based on interview and record review the facility failed to implement policies and procedures for ensuring the reporting of serious bodily injury and an allegation of abuse and neglect within the required timeframe for 2 (Residents 152 and 158) of 3 sampled residents; and failed to submit an investigation of potential abuse and neglect for 1 resident (Resident 153) within the required timeframe. The facility census was 49.

Inspectors wroteLicensure Reference Number 175NAC 12-006.09D1c Based on observation, interview, and record review the facility failed to ensure that resident bathing was provided as required for 3 residents (Residents 22, 26, and 7). The facility census was 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on observation, record review and interviews, the facility failed to identify and monitor specific target behaviors for the continued use of Antipsychotic medications (medications used to manage behavioral symptoms) for 2 residents (Residents 31 and 8) of 5 residents reviewed for unnecessary medication reviews; and the facility failed to ensure a psychotropic medication was used to treat a medically accepted/indicated condition for 1 resident (Resident 10). The facility census was 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C Based on observation, interview, and record review the facility failed to develop the resident care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) to ensure that it contained the necessary focus for quality care required for 1 resident (Resident 152) and failed to develop a comprehensive care plan related to respiratory care and use of a CPAP (Continuous Positive Airway Pressure. A method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep apnea and other respiratory disorders.) for 1 resident (Resident 8). The facility census was 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-0006.09D3(5) Based on observation, record review, and interview the facility failed to ensure interventions were utilized to promote routine bowel movements for 1 resident (Resident #11). The facility stated census was 49.

Inspectors wroteLicensure Reference Number 175 NAC 12-0006.09D Based on observation, record review, and interview, the facility failed to provide interventions to prevent or manage pain for 1 resident (Resident #3) of 6 sampled residents. The facility stated census of 49.