Good Samaritan - Wamego

Inspectors wroteThe facility identified a census of 39 residents with three residents reviewed for elopement. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision to cognitively impaired Resident (R) 1, who had a history of wandering and elopement, to prevent R1 from exiting the facility unsupervised through an unlocked kitchen area and door. On 05/04/24 at approximately 05:58 PM R1 sat in the dining room finishing his supper. The only Certified Nurse Aide (CNA) in the dining room assisted another resident out of the dining room. R1 then got up from his table and, with his walker, walked to the dishwasher room. R1 attempted to open the door but it was locked. R1 left his walker at that doorway and walked back towards the front of the dining room. R1 walked to the next doorway, which was open and permitted R1 to enter the kitchen. [...]

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and service food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchen which placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with trauma triggers and coping strategies for Resident (R)19 and failed to address sexual behaviors for R3. The placed R19 and R3 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with one reviewed for discharge. Based on interview and record review, the facility failed to develop a discharge plan for one sampled resident, Resident (R) 40, who discharged to home with family. This placed the resident at risk for unidentified discharge goals and impaired discharge planning.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R)40. This placed the resident at risk for impaired care and services.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide cueing or assistance with eating for Resident (R) 17 who had weight loss. This placed the resident at risk of continued weight loss and unmet care needs.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22's personal alarm system was monitored as ordered to prevent elopement (when a cognitively impaired resident leaves the facility without staff knowledge or supervision). This placed the resident at risk for preventable accidents.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed R19 at risk for impaired quality of life.

Inspectors wroteThe facility has a census of 41 residents. The sample included 12 residents, with eight residents reviewed for behaviors. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 3 for sexual behaviors and failed to provide supervision for R11, who had resident-to-resident altercations. This placed the residents at risk for decreased quality of life. Findings Include: - The Electronic Medical Record (EMR) documented R3 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). [...]

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported that Resident (R) 8 lacked a 14-day stop date or specified duration with physician rationale for as-needed (PRN) psychotropic (alters mood or thought) medication and R3 lacked evidence of blood sugar checks and insulin administration as ordered. This placed the residents at risk for inappropriate use of medications.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to follow physician orders for Resident (3), who received insulin (controls the amount of sugar in the blood by moving into the cells), and failed to monitor R3's blood sugar as ordered. This placed the resident at risk for physical decline.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents of which six were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 8 had a stop date for the use of as-needed (PRN) lorazepam (antianxiety-class of medications that calm and relax people), R9 had an approved indication or the required documentation for the use of Seroquel (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality), and R19 had complete behavior documentation related the use of three psychotropic (alters mood or thought) medications. This placed the residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents, with three reviewed for nutrition. Based on observation, record review, and interview the facility failed to provide the correct physician ordered nutritional supplement for Resident (R)34, who had a significant unplanned weight loss. The facility failed to notify the Registered Dietician and/or physician when R34 continued to decline an ordered nutritional supplement. The facility further failed to identify and implement additional interventions to prevent weight loss, which included the resident's preferred meals and snacks and failed to attempt to fortify routinely consumed food items. These deficient practices placed R34, who had a significant loss of 15.54 percent in 30 days at continued risk for unintentional weight loss, malnutrition, and related complications.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to identify causative factors and implement resident-centered interventions to prevent falls for Resident (R) 30 and R14 who had falls which resulted in fractures, and R2, R36, R40 , and R42 who had multiple falls.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents, with eight reviewed for falls. Based on observation, record review, and interview, the facility failed to update interventions on the care plan to prevent falls for Resident (R) R2, and R30. This deficient practice placed the residents at increased risk for fall related injuries due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to appropriately treat Resident (R) 8's pain following a fall which resulted in a fractured right hip. This placed R8 at increased risk for unresolved pain and impaired comfort.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify Resident (R) 42's PRN (as needed) alprazalom (a sedative used to treat anxiety) did not have a stop date, and failed to identify an inappropriate diagnosis for R2's Seroquel (antipsychotic medication), placing the resident at risk for unnecessary psychotropic (altering mood or thought) medications.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to obtain from the physician, blood sugar parameters for Resident (R) 10, who received insulin (injectable hormone used to control blood sugar levels). This placed R10 at risk for hyperglycemic (high blood sugar) or hyperglycemic (low blood sugar) episodes.

Inspectors wroteThe facility had a census of 43 residents. The sample included 14 residents, with five reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 42's as needed (PRN) alprazolam (a sedative used to treat anxiety) and failed to ensure an appropriate diagnosis for R2's Seroquel (antipsychotic medication). This placed the residents at risk for adverse side effects.

Inspectors wroteThe facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to provide a certified dietary manager to carry out the functions of food and nutritional services for the 41 residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteThe facility had a census of 41 residents. Based on observation, record review, and interview, the facility failed to prepare, store, and serve meals under sanitary conditions for the 41 residents who received meals from the facility kitchen.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to follow Resident (R) 3's toileting plan as care planned and failed to implement fall interventions for R7, who rolled out of bed twice.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide bathing and shaving services as care planned for one of two sampled residents, Resident (R) 17.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents with six reviewed for accidents. Based on observation, record review, and interview, the facility failed to implement interventions to prevent falls for two of six sampled residents, Resident (R) 3, when staff did not follow her toileting care plan and R7, who rolled out of bed twice.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist failed to identify medication concerns for two of five sampled residents, Resident (R) 10's blood pressures (BP) and pulses out of physician ordered parameters, identify an inappropriate diagnosis for R10's Seroquel (antipsychotic), and lack of physician's response to recommended gradual dose reduction for R10's Seroquel and R18's Sonata (hypnotic).

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to follow physician orders for administration of Ramipril (blood pressure medication) and Metoprolol Succinate (blood pressure medication), and failed to notify the physician for blood pressures and pulses out of the physician ordered parameters for one out of five resident, Resident (R)10.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to ensure an appropriate diagnosis for Resident (R) 10's Seroquel (antipsychotic medication).