Good Shepherd Health and Rehabilitation

Inspectors wroteBased on observation and interview it was determined the facility failed to properly label biological and medications to facilitate safe administration of medications to include open dates for 2 of 2 sampled Residents (R ), R53 and R70. Additional observation determined the facility failed to remove expired testing supplies. This deficient practice had the potential to affect the entire census of 84. Observation on [DATE] revealed one opened tube of Diflonanac1% for R70 did not have an open date label. Observation on [DATE] revealed one opened tube of Nystatin 100, 000 units for R53 did not have an open date label. Observation on [DATE] revealed 5 unopened culture tubes were outdated.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of 22 sampled residents (Resident (R) 6). R6 utilized a Broda chair (a specialized reclining wheelchair) when out of bed. Staff interviews revealed the resident's foot would frequently fall off the edge of the Broda chair footrest. However, the facility failed to effectively address the positioning of the resident's foot/leg in the Broda chair. On 08/04/2024, the resident leg was bumped/hit by another resident's wheelchair, which resulted in a fracture to R6's left tibia.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an alleged violation of an injury of unknown origin was immediately reported to the State Survey Agency (SSA) and to other officials (Adult Protective Services) in accordance with state law for one of three residents (Resident (R) 6) sampled for abuse. Specifically, the facility failed to report to the SSA and the Adult Protection Agency (Department for Community Based Services/DCBS) on 08/04/2024, when R6 was sent to the hospital for a suspected injury and it was discovered the resident had sustained a fracture to the left tibia which was of unknown origin.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to assist residents in obtaining routine dental care for one of 22 sampled residents (Resident (R) 89). Further, the facility failed to provide or obtain from an outside resource routine dental services to meet the needs of R89 after he requested to be seen by a dentist.

Inspectors wroteBased on interview, record review, review of the facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement the comprehensive person-centered care plan, for one (1) of fourteen (14) sampled residents, (Resident #1). Resident #1's Comprehensive Care Plan (CCP), revealed a focus of Wandering/Elopement and impaired safety awareness, initiated on 12/06/2022, due to the resident's history of pacing up and down hallways, making verbal statements about leaving, and packing up belongings. Interventions included providing resident redirection when exhibiting exit seeking behavior or when wandering near exits; use of a code alert monitoring device on resident's right lower extremity; avoid events that lead to wandering behavior, (i.e., crowded events); [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's policies and investigation, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of four (4) sampled residents (Resident #1). On 12/06/2022, Resident #1 was noted to go to the B wing door and attempt to open the door before being re-directed by staff. On that date, the facility assessed the resident to require the utilization of a code alert (monitoring device) due to exit seeking behaviors. However, on 08/22/2023 at approximately 7:30 PM, Resident #1 participated in church service with a group of church volunteers with no activities' staff or nursing staff to provide oversight of the resident. Following the church service, Resident #1 exited the facility without staff's knowledge. [...]

Inspectors wroteBased on interview, record review, review of the facility's policy, and review of the Administrator's Job Description, it was determined the facility's Administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services related to accidents and supervision for one (1) of fourteen (14) sampled residents (Resident #1). The facility failed to maintain substantial compliance, as repeat deficiencies were identified. During the Abbreviated Survey, with an exit date of 04/20/2023, the facility was cited in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care; Free of Accident Hazards/Supervision (F689). Additionally, the facility alleged substantial compliance on 06/16/2023. However, the administration failed to utilize its resources, to maintain substantial compliance. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the Governing Body, or designated persons, functioning as a Governing Body, that were legally responsible for establishing and implementing policies regarding the management and operation of the facility, was responsible and accountable for the Quality Assurance Performance Improvement (QAPI) program, related to the facility's repeated deficient practice. Repeat deficiencies were cited in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656) and 42 CFR 483.25 Quality of Care; Free of Accident Hazards/Supervision (F689) on the Abbreviated Standard Surveys with exit date 06/08/2021, 04/20/2023, and 11/17/2023. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's policy, and review of the facility's Plans of Correction (PoC) submitted for the 04/20/2023 survey, it was determined the facility failed to have effective processes in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. As a result, the facility failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were sustained. This was evidenced by deficient practice cited at 42 CFR §483.21, Comprehensive Resident Centered Care Plan (656) and 42 CFR §483.25, Free of Accident Hazards/Supervision/Devices (F689). [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review it was determined the facility failed to develop and implement a person-centered comprehensive care plan for one (1) of twenty-five (25) sampled residents (Resident #36, who received oxygen). Per the physician order, Resident #36 was to receive oxygen at three (3) liters per minute (LPM) via nasal cannula continuously. However, on 10/30/19 the resident was observed lying in bed with his/her eyes closed and the oxygen was running at three (3) LPM while the nasal cannula was observed to be inside the top drawer of the resident's nightstand and not in the resident's nose. Although Resident #36's comprehensive care plan included providing oxygen to the resident per physician's order, the care plan did not address the actual liter flow of the oxygen nor the route of the oxygen to be administered to the resident.

Inspectors wroteBased on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of twenty-five (25) sampled residents (Resident #36, who received oxygen) received respiratory care (oxygen therapy) according to the physician's orders and the comprehensive care plan. Review of the care plan for Resident #36 revealed the resident had an intervention for the facility to provide oxygen as ordered by the physician. Review of the physician orders for Resident #36 revealed an order for oxygen at three (3) liters per minute (LPM) via nasal cannula continuously. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an infection control program was established and maintained to provide a sanitary environment and help prevent the development and transmission of disease and infection for one (1) of five (5) residents with urinary catheters (Resident #36) out of twenty-five (25) sampled residents. Observation during indwelling urinary catheter care on 10/30/19 at 1:30 PM for Resident #36 revealed State Registered Nurse Aide (SRNA) #1 failed to wash/sanitize her hands after providing indwelling urinary catheter care. After performing indwelling urinary catheter care, the SRNA was observed to touch her dirty gloved hands to the resident's closet and the resident's bed, and to touch her hair before washing/sanitizing her hands.