Good Samaritan Society - Stillwater

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and provide appropriate clinical oversight of a urinary collection device used to manage chronic urinary incontinence for 1 of 1 resident (R1) reviewed for urinary incontinence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess pain, re-evaluate the effectiveness of the pain regimen, ensure accurate and complete documentation, and notify the physician of break through pain for 1 of 1 resident (R1) reviewed for pain management.

Inspectors wroteBased on interview and document review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service. This had the potential to affect all 34 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure weekly wound assessments and measurements were completed for 1 of 1 resident (R3) reviewed for pressure ulcers (PU).

Inspectors wroteBased on interview and document review, the facility failed to ensure a root cause analysis was completed and implement new interventions following a fall for 1 of 3 residents (R11).

Inspectors wroteBased on interview and document review, the facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization and failed to develop a care plan to include individualized trauma-informed approaches for 1 of 1 resident (R1) who had a history of trauma.

Inspectors wroteBased on observation, interview, and document review the facility failed to identify prior appropriate interventions prior to use of grab bars, assess for risk of entrapment, and obtain consent 1 of 1 resident (R12) reviewed for the use of grab bars.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff used appropriate personal protective equipment (PPE) for 2 of 2 residents (R3, R27) observed for enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the daily staff posting displayed accurate data regarding the resident census, along with the total number and actual hours worked per shift by nursing staff. This had the potential to affect all 34 residents residing in the facility and their visitor who may wish to review the information.

Inspectors wroteBased on interview and document review, the facility failed to ensure liquid morphine (opioid analgesic used to treat severe pain) was administered per physician orders for 1 of 1 resident (R1) who was administered ten times the ordered dose.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure personal privacy was maintained to promote dignity for 1 of 1 resident (R21) observed with bare skin and undergarments visible from the hallway to other residents, visitors, and staff.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure 1 of 1 resident (R25) received assistance with shaving and nail care reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure bruising was monitored for 1 of 1 residents (R14) reviewed for bruises. The facility further failed to ensure interventions for edema care were implemented for 1 of 1 residents (R17) reviewed for edema.

Inspectors wroteBased on observation, interview, and document review, the facility failed to fully assess and implement fall prevention interventions for 2 of 2 residents (R21, R187) reviewed for falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to assess for and implement appropriate interventions to decrease the risk for falls for 4 of 4 residents (R189, R7, R29, R24) reviewed for falls. This failure led to actual harm for R189 when R189 obtained a right ankle fracture after a fall.

Inspectors wroteBased on interview and record review, the facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service. This had the potential to affect all 39 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient support staff with the appropriate competencies to carry out the functions of the food and nutrition services. This had the potential to affect all 39 residents who reside in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure frozen and refrigerated food items were properly stored, labeled, and dated and disposed of after expiration date. Furthermore, the facility failed to ensure the ice machine and air vents were clean and sanitary. This deficient practice had the potential to affect all 39 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow standard precautions, contact precautions, droplet precautions, and perform evidence-based hand hygiene for GI symptomatic residents for 4 of 4 (R4, R24, R13, and R91) reviewed for infection control practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's walk-in freezer was maintained to ensure water drippings and ice build up would not impact frozen food storage. This had the potential to impact all 39 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure adequate monitoring was in place for 3 of 3 residents (R24, R91, R31)reviewed for unnecessary medications. Furthermore, the facility failed to ensure duplicative medications were prescribed for 1 of 5 residents (R91) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to have a method or system to ensure the facility offered or provided updated vaccine per Centers for Disease Control (CDC) vaccination recommendations for 5 of 5 residents (R7, 18, R24, R30, R32) to ensure residents were appropriately vaccinated against pneumonia upon admission. This had the ability to affect all 37 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure facial hair was removed for 1 of 1 residents (R6) reviewed for dignity. R6's quarterly Minimum Data Set (MDS) dated [DATE], indicated R6 had cognitive impairment and diagnoses of multiple sclerosis and dementia. R6 had no refusals of care and required supervision for personal hygiene (combing hair, shaving, washing/drying face). R6's [NAME] as of 4/16/24, indicated R6 required assist of one for bathing and personal hygiene of washing face and upper body. R6's [NAME] lacked indication of any cares or preferences for chin hairs. R6's care plan revised on 6/21/23, indicated R6 had impaired assistance of daily living (ADL) performance related to multiple sclerosis and impaired mobility. R6 required assistance with personal hygiene and to encourage to wash face and upper body. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline careplan had been completed for 2 of 2 residents (R89, R189) reviewed for baseline care plans.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess 1 of 1 resident (R13) reviewed for demetia care and 1 of 1 resident (R3) reviewed for accidents.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure nail care was completed for 1 of 1 resident (R19) dependent on staff for nail care.

Inspectors wroteBased on observation, interview, and record review the facility to ensure weekly skin assessment was completed for 1 of 1 resident (R24) who had fall and sustained bruising and lacerations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure weekly skin assessments were completed for 1 of 1 residents (R8) reviewed for pressure injury.

Inspectors wroteBased on interview and record review the facility failed to ensure the consulting pharmacists recommendations were acted upon for 1 of 3 residents (R24) reviewed for taking anticoagulation medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to serve menu items as listed and planned for 2 of 2 residents (R25, R8) reviewed for nutrition services.