Marion and Bernard L Samson Nursing Center

Inspectors wroteBased on record review, staff interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for five (Residents #64, #16, #61, #103 and #98) out of seven residents sampled for PASARRs.

Inspectors wroteBased on observations and interviews, the facility failed to ensure Nurse Staffing Information was posted accurately for four of four days.

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed.

Inspectors wroteBased on observations, staff interviews, and medical record reviews, the facility failed to ensure that seven (#555, #28, #43, #87,#37, #58, and #96) seven randomly observed residents who received respiratory care, had their respiratory equipment (e.g., oxygen tubing, nebulizers) properly stored while not in use, and dates on the residents' oxygen tubing.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for six (Residents #56 #107, #54, #43, #133, and #407) on three of three floors (2nd, 3rd and 4th floors) and did not ensure medication and treatment carts were secured on two of three floors (2nd and 3rd floors). Photographic evidence was obtained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food according to food safety standards, as evidenced by the following: -Refrigerated ready-to-eat, pureed Time/Temperature Control for Safety Food was not dated correctly. -Raw chicken was not covered while stored in the walk in refrigerator to prevent contamination of other stored food and equipment. -Clean eating equipment was not inverted while being stored to prevent contamination. -Clean trays and cooking equipment was not stored to protect from contamination from impelled or falling dead insects and insect fragments from an insect electrocution device. -The facility dish machine did not have an affixed with an easily accessible and readable data plate by the manufacturer that indicated the machine's design and operation specifications. [...]

Inspectors wroteBased on observation and staff interview, staff failed to offer hand hygiene before meals to three (#30, #111, and #555) of three randomly observed residents, who ate in their rooms, during two of two facility meals on the same floor. Additionally, two nurses failed clean or disinfect the wrist blood pressure cuff before or after use and failed to perform hand hygiene before administering four (#12, #76, #141, and #445) of 13 residents' medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the dignity of one of one randomly observed resident (#39), who was not properly dressed in the hall way.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper fitting of a wheelchair for one resident (#514) out of eighty-four residents sampled for the abilities to maintain their independence.

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL) related to incontinence care for two dependent residents (#123 and #98) out of three sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document an accurate initial skin assessment and obtain orders for an open area of the skin for one (Resident #515) out of four residents sampled for skin conditions (non-pressure related).

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure care to prevent pressure ulcer development and promote the healing of existing pressure ulcers/injuries for two (Resident #47 and #144) of two residents sampled for skin and pressure ulcers. Findings Included: A review of Resident #47's admission record revealed an admission date of 10/12/23 with diagnoses not limited to dementia, chronic respiratory failure, high blood pressure, peripheral vascular disease, cerebral infarction with left side weakness, and bed confinement. The following orders: -Order dated 10/13/23, Do Not Resuscitate (DNR). -Order dated 11/29/23, Comfort measures only (CMO) include the following, transfer to hospital or ER if desired by resident and Health Care Surrogate. Initiate invasive artificial nutrition if desired by resident or Health care surrogate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-seven medication administration opportunities were observed, and eight errors were identified for five residents (#455, #56, #43, #125, and #12) of ten residents observed. These errors constituted a 21.62% medication error rate.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the immediate surrounding environment for one (Resident #61) of two residents with diet orders of nothing by mouth (NPO) was free of accident hazards.

Inspectors wroteBased on observation, interview and record review the facility failed to implement two (#108 and #17) of 44 sampled residents Comprehensive Resident Centered Care Plan interventions post falls related to floor mats 1. Observation on 10/07/20 at 5:15 p.m. Resident #108 was lying in bed dressed and groomed. There were no floor mats noted at the bedside. Observation on 10/08/20 at 11:00 a.m. Resident #108 was lying in bed with his oxygen in place. No floor mats were noted on the floor. Observation on 10/08/20 at 4:54 p.m. Resident #108 was lying in bed with his eyes closed. His head of the bed was elevated. No floor mats were noted beside the bed. Observation on 10/09/20 at 1:00 p.m. Resident #108 was lying in bed with oxygen in place. No floor mats were present. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice related to tracheostomy care for one (#117) of one resident with a tracheostomy and not maintaining tubing for oxygen off the floor for 5 (#108, #117, 99, 35, 104) of 18 residents on respiratory treatments.