Inspection Reports for
The Evangelical Lutheran Good Samaritan Society
108 E. ASH STREET, OBERLIN, KS, 67749
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
147% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
40% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 29, 2025
Visit Reason
An off-site revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-11-26.
Findings
All deficiencies have been corrected as of the compliance date of 2025-12-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: Deficiencies cited on 2025-11-26, all corrected by 2025-12-15
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 7
Date: Nov 17, 2025
Visit Reason
The inspection was a Health Recertification Survey conducted to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including discharge process documentation, activities of daily living assistance, nursing staffing reporting, pharmacy services and medication management, unnecessary drug monitoring, drug labeling and storage, and dietary staff qualifications.
Deficiencies (7)
F0628 Discharge Process: The facility failed to notify the Office of the Long-Term Care Ombudsman and provide written bed hold policy information for a resident transferred to the hospital. The facility also failed to complete a discharge summary recapitulation and medication reconciliation for another resident.
F0676 Activities Daily Living: The facility failed to ensure a resident had a functional pair of glasses needed for impaired vision despite care plan and orders.
F0725 Sufficient Nursing Staff: The facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) for licensed nurse coverage on several dates.
F0755 Pharmacy Services: The facility failed to maintain a system for accurate reconciliation and accounting of medications in the emergency medication kit (E-Kit). The E-Kit was found unsecured and missing inventory documentation.
F0757 Drug Regimen Free from Unnecessary Drugs: The facility failed to obtain physician-ordered blood pressure parameters for a resident receiving antihypertensive medication.
F0761 Label/Store Drugs and Biologicals: The facility failed to date an opened insulin pen for a resident as required for medication safety and storage.
F0801 Qualified Dietary Staff: The facility failed to ensure the director of food and nutrition services met the required qualifications of a certified dietary manager.
Report Facts
Resident census: 18
PBJ noncompliance dates: 5
Residents reviewed: 8
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-04-28.
Findings
All deficiencies have been corrected as of the compliance date of 2025-06-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Apr 28, 2025
Visit Reason
This document is a Plan of Correction submitted by Good Samaritan Society Decatur County in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies related to resident dignity, assistance with activities of daily living (ADLs), activity programming, and staffing levels. Corrective actions include staff education, implementation of Angel Rounds for monitoring, updating care plans, scheduling wheelchair cleaning, and staffing adjustments to ensure adequate coverage.
Deficiencies (4)
F550-E: Residents' hair was combed, wheelchairs cleaned, clothes changed, and face/mouth cleaned immediately. Staff education on promoting resident dignity and rights was completed, and Angel Rounds will monitor residents weekly.
F677-E: Residents' hair was combed, wheelchairs cleaned, clothes changed, and face/mouth cleaned immediately. Care plans were updated to reflect ADL preferences and staff educated on promoting ADL preferences with Angel Rounds monitoring.
F679-E: Activity Interest UDAs were completed for affected residents, and the activity calendar was updated based on resident input. Staffing evaluation led to increased hours for activity staff and education on meeting resident needs.
F725-F: A comprehensive staffing review was conducted, resulting in adjustments to ensure adequate activities and nursing coverage. New care efficiencies and a Manager on Duty program will provide supervision during evenings.
Report Facts
Plan of Correction completion date: 2025
Audit frequency: 4
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Tamiklinedinst | NHA | Submitted the Plan of Correction. |
| Deb Harper | Added and modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 4
Date: Apr 28, 2025
Visit Reason
Complaint investigation regarding resident rights, activities, staffing, and activities of daily living (ADL) care.
Complaint Details
The investigation was triggered by complaints related to resident rights, activities, staffing, and ADL care deficiencies.
Findings
The facility failed to provide residents R2, R3, R4, R5, R6, and R7 with dignified care, adequate personal hygiene, and appropriate activities. Staffing shortages contributed to inadequate resident care and lack of meaningful activities.
Deficiencies (4)
Resident rights were not upheld as R2, R3, R4, R5, R6, and R7 were found unkempt, with poor hygiene and no staff interaction during observations.
The facility failed to provide appropriate ADL care to R2, R3, R4, R5, R6, and R7, resulting in undignified conditions and risk of psychosocial decline.
Resident-centered activities were inadequate for R2, R3, R4, R5, R6, and R7, with limited meaningful engagement and outdated, redundant programming.
The facility lacked sufficient nursing staff with appropriate skills to provide care ensuring resident safety and dignity for R2, R3, R4, R5, and R7.
Report Facts
Resident census: 14
Staffing: 14
Activity staff hours: 3.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Spoke about staffing issues and resident care deficiencies |
| Administrative Staff A | Administrative Staff | Commented on staffing adequacy and resident dignity |
| Certified Nurse's Aide M | CNA | Reported staffing shortages and resident care issues |
| Certified Nurse's Aide N | CNA | Responsible for restorative program, reported staffing and activity concerns |
| Certified Nurse's Aide O | CNA | Reported insufficient staffing and lack of administrative support |
| Activities Staff/Social Services Staff Z | Activities and Social Services Staff | Responsible for activities and social services, reported staffing and activity program issues |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-02-28.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2024-03-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Feb 28, 2024
Visit Reason
The inspection was conducted as an abbreviated survey and complaint investigation related to allegations of abuse and neglect at the facility.
Complaint Details
The complaint investigation substantiated abuse by CNA M against Resident 1 on 02/09/24. The facility conducted interviews, reviewed records, and observed the resident. The CNA was suspended pending investigation and later quit. The police were notified.
Findings
The facility failed to ensure Resident 1 was free from abuse and neglect when a Certified Nurse Aide (CNA M) used aggressive force and verbal abuse during care, violating the resident's rights and placing her at risk for physical and mental harm. Multiple staff witnessed the incident, and the CNA was suspended and subsequently quit.
Deficiencies (1)
F 600: The facility failed to prevent abuse and neglect when CNA M forcefully grabbed Resident 1's wrist, took a glass of orange juice from her hand, slammed it on the table, and aggressively handled her wheelchair despite resistance. This conduct violated the resident's right to be free from abuse and caused risk of physical and mental harm.
Report Facts
Resident census: 31
Residents reviewed for abuse and neglect: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Named in abuse and neglect finding involving Resident 1 |
| Social Services X | Social Services Staff | Witnessed and intervened during abuse incident |
| Licensed Nurse G | Licensed Nurse | Witnessed part of the abuse incident |
| Dietary Staff BB | Dietary Staff | Witnessed part of the abuse incident |
| Administrative Staff A | Administrative Staff | Responded to and classified the incident as abuse |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 28, 2024
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection related to staff to resident abuse.
Findings
The facility failed to prevent an incident of staff to resident abuse involving Resident 1. Corrective actions include removal and monitoring of the resident, staff suspension and termination, and comprehensive staff education on abuse prevention and dementia care.
Deficiencies (1)
F600---G The facility failed to prevent an incident of staff to resident abuse to Resident 1. Immediate removal, assessment, and monitoring of the resident were conducted, and the staff member was suspended and later terminated.
Report Facts
Date of staff termination: Feb 9, 2024
Plan of Correction completion date: Mar 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Klinedinst | NHA | Submitted the Plan of Correction. |
| Felicia Majewski | Modified the Plan of Correction. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 26, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 12/11/23.
Findings
All deficiencies have been corrected as of the compliance date of 01/17/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-11-30.
Findings
All deficiencies have been corrected as of the compliance date of 2024-01-05, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Jan 5, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory inspection.
Findings
The facility failed to implement required interventions related to skin injury measurement, comprehensive MDS completion, assistive ADL care, assistive positioning, dietary management certification, pureed diet preparation, food service safety, and hand hygiene during incontinence care. Corrective actions including staff education, audits, and process updates were initiated to achieve substantial compliance by January 5, 2024.
Deficiencies (8)
F610-D The facility failed to ensure interventions were implemented with measuring of injuries of unknown origin. Skin assessment and staff education were immediately completed.
F641-D The facility failed to ensure interventions were implemented with completion of comprehensive MDS. Resident 12's MDS was reviewed, corrected, and resubmitted.
F677-D The facility failed to ensure interventions were implemented with providing assistive ADL care as directed in the care plan. Resident 21 was immediately checked and changed.
F684-D The facility failed to ensure interventions were implemented with providing assistive positioning as directed in the care plan. Resident 21’s care plan was updated and positioning device put in place.
F801-F The facility failed to ensure interventions were implemented with professional standards for employment of a full time certified dietary manager. Dietary manager is currently enrolled in certification course.
F804-D The facility failed to ensure interventions were implemented to follow a recipe while preparing pureed diets. Dietary staff were educated and new menus with recipes were implemented.
F812-F The facility failed to ensure interventions were implemented with professional standards for food service safety including checking food temperatures and ensuring clean refrigerators and preparation areas.
F880-D The facility failed to ensure interventions were implemented with following hand hygiene during incontinence care and proper glove use. Staff education and audits were initiated.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The document is a plan of correction submitted in response to deficiencies cited related to an incident of resident to resident abuse at the facility.
Findings
The facility failed to prevent an incident of resident to resident abuse involving Resident 1 and Resident 2. Immediate actions included removal of involved residents, assessments, monitoring, education, and ongoing case management.
Deficiencies (1)
F600—D The facility failed to prevent an incident of resident to resident abuse to Resident 1. Immediate removal, assessments, monitoring, and education were conducted, with plans for ongoing interventions and discharge of Resident 2.
Report Facts
Complete Date for Plan of Correction: Jan 17, 2024
Visit Date: Dec 11, 2023
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Dec 11, 2023
Visit Reason
The inspection was conducted as an abbreviated complaint survey triggered by allegations of resident-to-resident abuse involving inappropriate touching.
Complaint Details
The complaint investigation was substantiated. Resident 2 was observed touching Resident 1's breast inappropriately. Staff intervened immediately, notified appropriate parties including the police, and implemented monitoring and care plan changes for Resident 2.
Findings
The facility failed to ensure Resident 1 was free from abuse when Resident 2 touched Resident 1 in a sexually inappropriate manner. The incident was investigated, and interventions were implemented to protect residents and monitor Resident 2.
Deficiencies (1)
F 600: The facility failed to prevent resident-to-resident abuse when Resident 2 touched Resident 1 in a sexually inappropriate manner. Resident 1 was severely cognitively impaired and unable to consent, placing her at risk for further abuse and impaired psychosocial well-being.
Report Facts
Resident census: 32
Brief Interview for Mental Status (BIMS) score: 3
Date of incident: Dec 5, 2023
Date of survey completion: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Witnessed and reported the inappropriate touching incident |
| LN G | Licensed Nurse | Received report of incident and assisted with resident assessment |
| Administrative Staff A | Administrator | Reported incident, oversaw investigation and resident protection |
| Administrative Nurse D | Administrative Nurse | Involved in care plan changes and resident monitoring |
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 8
Date: Nov 30, 2023
Visit Reason
The inspection was a Health Resurvey to verify correction of previously cited deficiencies related to abuse investigation, assessment accuracy, ADL care, quality of care, dietary staffing, food preparation, food safety, and infection control.
Findings
The facility failed to investigate bruises on a resident, accurately assess cognition on another, provide appropriate ADL care and positioning, employ a certified dietary manager, follow recipes for pureed diets, ensure food safety and sanitation, and maintain proper infection control practices during incontinent care.
Deficiencies (8)
F610: The facility failed to investigate bruises of unknown origin on Resident 16, risking unidentified abuse or mistreatment.
F641: The facility failed to assess Resident 12's cognition on the Minimum Data Set, risking inaccurate care planning.
F677: The facility failed to provide Resident 21 appropriate ADL care including incontinence care, risking poor hygiene and impaired quality of life.
F684: The facility failed to provide Resident 21 necessary positioning and skin care, including use of an elbow pillow, risking skin breakdown and discomfort.
F801: The facility failed to employ a full-time certified dietary manager for 32 residents, risking impaired nutrition.
F804: The facility failed to follow recipes when preparing pureed diets for two residents, risking impaired nutrition.
F812: The facility failed to ensure clean and sanitary refrigerators and food preparation areas and failed to check food temperatures prior to serving, risking foodborne illness.
F880: The facility failed to follow infection control practices by not changing gloves and performing hand hygiene during incontinent care for Resident 23, risking infection.
Report Facts
Resident census: 32
Sampled residents: 12
BIMS score: 7
BIMS score: 8
Braden Scale score: 8
Temperature: 149
Temperature: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff BB | Dietary Staff | Verified not a certified dietary manager and oversaw meal preparation |
| Dietary Staff CC | Dietary Staff | Prepared pureed diets without recipe and failed to check food temperatures prior to serving |
| Certified Nurse Aide P | Certified Nurse Aide | Failed to change gloves and perform hand hygiene during incontinent care for Resident 23 |
| Licensed Nurse G | Licensed Nurse | Verified skin assessment findings and care plan for Resident 21 |
| Administrative Nurse D | Administrative Nurse | Verified expectations for care plan adherence, investigation of bruises, and infection control practices |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 09/11/23.
Findings
All deficiencies have been corrected as of the compliance date of 10/01/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 11, 2023
Visit Reason
The document is a Plan of Correction submitted in response to a complaint survey conducted on 09/11/2023 regarding a resident fall incident resulting in an acute left hip fracture.
Complaint Details
The visit was complaint-related, triggered by a fall incident resulting in injury. The complaint survey was conducted on 09/11/2023 and the deficiency was substantiated as indicated by the Plan of Correction.
Findings
The facility failed to ensure interventions were implemented to prevent a resident from falling out of bed and sustaining an acute left hip fracture. The Plan of Correction outlines multiple corrective actions including staff education, care plan audits, and risk management updates to prevent future falls.
Deficiencies (1)
F689-G The facility failed to ensure interventions were implemented to prevent a resident falling out of bed and receiving injuries of an acute left hip fracture.
Report Facts
Resident care plans reviewed: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tami Klinedinst | NHA | Submitted the Plan of Correction to KDADS. |
| Felicia Majewski | Added and modified the Plan of Correction. |
Inspection Report
Abbreviated Survey
Census: 30
Deficiencies: 1
Date: Sep 11, 2023
Visit Reason
The inspection was conducted as an abbreviated survey and complaint investigation related to falls and accident hazards at the facility.
Complaint Details
The visit was complaint-related, triggered by complaints KS00182673 and KS00182633. The complaint was substantiated as the facility failed to prevent falls and injuries to Resident 1.
Findings
The facility failed to implement adequate interventions to prevent Resident 1 from falling out of bed, resulting in multiple falls and an acute left hip fracture. The motion sensor alarm was not consistently functional or responded to, placing the resident at risk for further falls and injuries.
Deficiencies (1)
F 689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure interventions were implemented to prevent Resident 1 from falling out of bed and to prevent injuries after multiple falls, resulting in an acute left hip fracture.
Report Facts
Resident census: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Assessed Resident 1 after falls and noted hip injury | |
| CNA M | Found Resident 1 on floor and reported fall | |
| Administrative Staff A | Expected appropriate fall interventions and reviewed fall investigation | |
| Administrative Nurse D | Investigated fall and found motion sensor alarm working | |
| Laundry Staff GG | Found Resident 1 on floor and reported fall; noted motion sensor alarm did not sound |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-05-10.
Findings
All deficiencies have been corrected as of the compliance date of 2023-06-10, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Abbreviated Survey
Census: 32
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The inspection was conducted as an abbreviated survey combined with a complaint investigation (KS00179229).
Complaint Details
The visit included a complaint investigation identified as KS00179229.
Findings
The facility failed to implement a turning/repositioning program and failed to contact the registered dietician for nutritional support to promote healing of a facility-acquired unstageable pressure ulcer on Resident 1's left heel.
Deficiencies (1)
F686: The facility failed to implement a repositioning program and failed to contact the registered dietician for nutritional support to promote healing for Resident 1 who had a facility-acquired unstageable pressure ulcer on the left heel.
Report Facts
Resident census: 32
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Stated Resident 1 had not been wearing pressure relieving boots until after the pressure ulcer developed. | |
| Licensed Nurse H | Verified Resident 1 was not on a turning/repositioning program. | |
| Certified Nurse's Aide M | Stated Resident 1 had not worn pressure relieving boots until after the pressure ulcer developed and was not on a turning/repositioning program. | |
| Administrative Nurse D | Verified no turning/repositioning task was in Resident 1's care plan and RD had not been contacted regarding the pressure ulcer. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 10, 2023
Visit Reason
The plan of correction addresses deficiencies identified during the survey visit completed on 2023-05-10 related to failure to implement a turning/repositioning schedule and failure to notify the Registered Dietician for additional nutritional needs.
Findings
The facility failed to implement a turning/repositioning schedule and failed to notify the Registered Dietician for additional protein or vitamin needs necessary to heal a resident's pressure ulcer, placing the resident at risk for impaired or delayed healing.
Deficiencies (1)
F686-D: The facility failed to implement a turning/repositioning schedule and failed to notify the Registered Dietician for additional protein or vitamin needs necessary to heal a resident's pressure ulcer, placing the resident at risk for impaired or delayed healing.
Report Facts
Deficiency cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Sep 12, 2022
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 07/14/22.
Findings
All deficiencies cited in the previous inspection have been corrected as of 08/06/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 10
Date: Jul 14, 2022
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to submit timely investigations of alleged abuse, failed to investigate injuries, failed to develop and revise comprehensive care plans for residents with hypertension and pressure ulcers, failed to monitor wound healing adequately, failed to prevent pressure injuries, failed to maintain catheter drainage systems properly, and failed to ensure medication administration per physician orders.
Deficiencies (10)
F609: Facility failed to submit a completed investigation to the State Agency within five days for Resident 17's injury of unknown origin, risking further injury and unidentified abuse.
F610: Facility failed to investigate an injury and fall for Resident 17 with a pubic ramus fracture, risking further injury and unidentified abuse.
F656: Facility failed to develop a comprehensive care plan for Resident 2's hypertension and pressure wounds, risking physical decline and delayed healing.
F657: Facility failed to revise Resident 8's care plan to include interventions and treatments for pressure injuries, risking delayed healing and uncommunicated care needs.
F684: Facility failed to monitor Resident 184's skin condition and wound treatment effectiveness, risking delayed healing and treatment.
F686: Facility failed to identify risk and implement preventive interventions for Resident 8's pressure injuries and failed to adequately monitor Resident 7 and Resident 31's wounds, risking delayed healing and complications.
F690: Facility failed to prevent recurrent urinary tract infections for Resident 31 by allowing catheter drainage bag to touch the floor, risking bacterial contamination and infection.
F756: Facility's Consultant Pharmacist failed to identify and report multiple episodes of Norvasc medication not administered when Resident 2's blood pressure was out of parameters, risking physical decline and complications.
F757: Facility failed to administer Norvasc medication as ordered for Resident 2 when blood pressures were out of parameters, risking physical decline and complications.
F880: Facility failed to maintain catheter drainage bag off the floor for Resident 31, risking bacterial contamination and infection.
Report Facts
Resident census: 35
Norvasc medication not administered days: 38
Pressure ulcer size: 2.5
Pressure ulcer size: 11
Pressure ulcer size: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified failure to administer Norvasc and inability to locate investigation for Resident 17's injury | |
| Administrative Nurse F | Verified failure to develop care plans and locate investigation paperwork | |
| Licensed Nurse I | Verified Norvasc medication order not followed | |
| Consultant Pharmacist HH | Consultant Pharmacist | Failed to identify and report medication irregularities for Resident 2 |
| Administrative Nurse E | Measured wounds weekly and verified catheter bag infection control issues | |
| Certified Nurse Aide M | CNA | Reported Resident 8 did not have heel protector until after skin breakdown |
| Licensed Nurse G | LN | Observed wound care for Resident 8 |
| Licensed Nurse H | LN | Reported skin breakdown and wound care for Resident 8 |
| Certified Nurse Aide N | CNA | Emptied and cleansed catheter drainage bag for Resident 31 |
| Certified Nurse Aide O | CNA | Emptied and cleansed catheter drainage bag for Resident 31 |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Jul 11, 2022
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a state survey visit conducted from July 11 to July 14, 2022, at Good Sam Decatur County.
Findings
The facility failed to timely submit investigations, develop comprehensive care plans for hypertension and pressure injuries, monitor skin conditions and wounds, prevent recurrent UTIs, and properly administer medications. Multiple residents were affected by these deficiencies, placing them at risk for injury, delayed healing, infections, and complications.
Deficiencies (10)
F609-D: The facility failed to submit the completed investigation related to resident R17's fracture within the required timeframe, risking further injury and unidentified abuse.
F610-D: The facility failed to investigate an injury and fall for resident R17 who had a fracture of her pubic ramus.
F656-D: The facility failed to develop comprehensive care plans for resident R2's hypertension and resident R7's pressure injury, risking physical decline and delayed wound healing.
F657-D: The facility failed to revise the care plan for resident R8 to include interventions and treatment for pressure injuries on the heels.
F684-D: The facility failed to monitor resident R184's skin condition and wound treatment effectiveness, risking delayed healing.
F686-G: The facility failed to identify pressure injury risks and implement interventions for resident R8 and failed to discuss treatment plans with resident R31, risking unhealed stage three pressure ulcers.
F690-D: The facility failed to prevent recurrent UTIs for resident R31 and failed to keep the urinary drainage bag from touching the floor.
F756-D: The consultant pharmacist failed to identify and report multiple episodes of Norvasc medication not administered for resident R2 when blood pressure was out of parameters.
F757-D: The facility failed to administer Norvasc when blood pressures were out of parameters for resident R2.
F880-D: The facility failed to maintain the catheter drainage bag for resident R31, risking bacterial contamination and infections.
Report Facts
Survey visit dates: Survey conducted from 2022-07-11 to 2022-07-14
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 6, 2021
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 01/27/21.
Findings
All deficiencies have been corrected as of the compliance date of 02/25/21, and no noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: Feb 25, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The plan addresses multiple deficiencies including missing fentanyl patches, pressure ulcer management, recliner risk assessments, medication management including psychotropic drugs, dietary manager progress, and infection control practices related to glucometer use.
Deficiencies (7)
F609-D: Missing fentanyl patch from 12-13-20 was reported and investigated. Staff were educated on patch application, disposal, and reporting procedures to prevent drug diversion.
F686-G: Physical therapy evaluation and interventions were implemented to manage a resident's pressure ulcer, including appropriate chair and cushion use and wound care nurse involvement.
F689-D: Recliner risk assessment was completed for a resident and care plans updated. All residents with recliners and low BIM scores will be assessed for chair appropriateness.
F756-D: Pharmacist was notified about PRN Xanax use and medication review processes were reinforced to monitor antianxiety medication use exceeding 14 days.
F758-D: Anti-anxiety medication was discontinued due to non-use. Charts will be reviewed to ensure psychotropic PRN drugs have 14-day stop orders and staff educated on related policies.
F801-C: Dietary manager is progressing through certification with extended time due to COVID. Dietician reviews resident data bi-monthly and reports findings to DNS.
F880-F: Glucometer cleaning procedures and infection control practices were reinforced with staff education and competency checks to prevent infections.
Report Facts
Complete Date: Feb 25, 2021
Audit frequency: 3
Audit frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| JENNATANDE | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Re-Inspection
Census: 40
Deficiencies: 7
Date: Jan 27, 2021
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to report a missing Fentanyl patch, did not provide adequate interventions to prevent a resident's pressure ulcer, failed to provide a safe environment to prevent falls from a lift recliner, did not ensure proper pharmacist review of psychotropic medication orders, lacked a full-time certified dietary manager, and failed to disinfect the blood glucose meter between resident uses.
Deficiencies (7)
F 609: The facility failed to report Resident 33's missing Fentanyl patch to the state agency as required by regulation.
F 686: The facility failed to provide interventions and weekly monitoring to prevent and treat Resident 13's facility-acquired unstageable pressure ulcer on the left scapula/vertebrae.
F 689: The facility failed to provide a safe environment for Resident 137 who fell twice from an electric lift recliner due to impaired cognition and lack of assessment for recliner use.
F 756: The facility's consultant pharmacist failed to report irregularities related to Resident 28's PRN Xanax order lacking a duration of use.
F 758: The facility failed to ensure Resident 28's PRN antianxiety medication Xanax had a 14-day stop date as required for psychotropic drugs.
F 801: The facility failed to employ a full-time certified dietary manager to plan and supervise meal preparation for 40 residents.
F 880: The facility failed to disinfect the blood glucose meter between resident uses, placing residents at risk for infection.
Report Facts
Deficiencies cited: 7
Resident census: 40
Sample size: 12
Resident falls: 2
Wound measurement: 6.3
Wound measurement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified failure to report missing Fentanyl patch, confirmed pressure ulcer development, and acknowledged safety concerns with lift recliner use. |
| Licensed Nurse J | Licensed Nurse | Administered medications to Resident 33 and verified patch removal issues. |
| Certified Nurse Aide O | Certified Nurse Aide | Reported Resident 33 frequently removed pain patches. |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted with mechanical lift transfer of Resident 137. |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted with mechanical lift transfer of Resident 137 and verified recliner use behavior. |
| Licensed Nurse G | Licensed Nurse | Verified falls from recliner and resident's impaired cognition. |
| Licensed Nurse I | Licensed Nurse | Performed wound care on Resident 13 and verified blood glucose meter cleaning failure. |
| Dietary Staff BB | Dietary Staff | Oversaw meal preparation and was not a certified dietary manager. |
| Administrative Staff A | Administrative Staff | Verified dietary staff certification status. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Dec 28, 2020
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-11-05.
Findings
All deficiencies have been corrected as of the compliance date of 2020-12-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 17, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection related to COVID-19 policies, infection prevention, and PPE use.
Findings
The facility implemented education and training for all staff on COVID-19 policies, infection prevention, and PPE procedures. Audits and competency checks will be conducted regularly, with ongoing training and review by the Quality Assurance/Assessment Committee.
Deficiencies (2)
F0000 The Statement of Deficiencies has been taken to the facility's Quality Assurance/Assessment Committee.
F880-F The facility completed education on COVID-19, infection prevention, and PPE policies with all staff and will conduct weekly PPE audits and monthly competency checks. Ongoing in-person training will be provided monthly and quarterly, including for new hires.
Inspection Report
Abbreviated Survey
Census: 38
Deficiencies: 1
Date: Nov 5, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found not in substantial compliance with infection control requirements, specifically failing to provide ongoing COVID-19 related training to staff, resulting in immediate jeopardy to residents. The immediate jeopardy was removed after the facility implemented a corrective plan.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to ensure ongoing staff training related to COVID-19 infection control practices and prevention, even after multiple residents tested positive and some died. Training documentation lacked dates and proof of staff attendance.
Report Facts
Residents positive for COVID-19: 14
Residents positive for COVID-19: 4
Residents positive for COVID-19: 2
Resident census: 38
Resident deaths: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Notified on 11/12/20 of immediate jeopardy and provided IJ template | |
| Certified Nurse Aide M | Interviewed about PPE training | |
| Licensed Nurse J | Interviewed about PPE training and recent hire | |
| Licensed Nurse G | Interviewed about mask use and training prior to outbreak | |
| Licensed Nurse I | Interviewed about lack of COVID-19 specific training |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 29, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by CMS on 06/29/2020 to assess compliance with COVID-19 preparation practices.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Deficiencies (1)
F0000: The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 during the targeted infection control survey.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Jan 16, 2020
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS due to a medication error involving Resident 1 receiving Resident 2's medications, constituting immediate jeopardy.
Complaint Details
The complaint investigation substantiated that Licensed Nurse G administered the wrong medications to Resident 1 on 01/04/2020, resulting in immediate jeopardy. The facility took corrective actions including suspension and re-education of the nurse involved.
Findings
The facility failed to administer medications according to professional standards, resulting in Resident 1 receiving the wrong medications that caused severe sedation, very low blood pressure, and hospitalization. The medication error was caused by Licensed Nurse G who administered Resident 2's medications to Resident 1.
Deficiencies (1)
F760 Residents are Free of Significant Med Errors. The facility failed to ensure Resident 1 was free of significant medication errors when Licensed Nurse G administered Resident 2's medications to Resident 1, causing severe sedation and very low blood pressure leading to hospitalization.
Report Facts
Census: 40
Fluid administered: 3250
Medication doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication error finding for administering wrong medications to Resident 1 |
| Administrative Nurse D | Administrative Nurse | Monitored medication administration after the error and provided statements about corrective actions |
| Consultant GG | Consultant | Verified the medication error and its impact on Resident 1 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 6, 2020
Visit Reason
This document is a Plan of Correction submitted in response to past noncompliance deficiencies identified during a prior inspection.
Findings
The plan addresses past noncompliance issues identified under tags F0000 and F760-J, both dated 01/06/2020.
Deficiencies (1)
Tag F0000 indicates past noncompliance requiring correction. Tag F760-J indicates past noncompliance related to a specific regulatory requirement.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 2, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-05-16.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2019-06-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Census: 41
Deficiencies: 9
Date: May 16, 2019
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including respect and dignity, comprehensive care planning, activities programming, quality of care related to skin integrity, accident hazard prevention, provision of social services, and medication management including psychotropic drug use and documentation.
Deficiencies (9)
483.10(e)(2) The facility failed to promote respect and dignity when staff discussed residents' personal medical information loudly in non-private areas.
483.21(b)(1) The facility failed to develop comprehensive care plans for residents #36 and #23, lacking interventions for skin integrity and depression management.
483.24(c)(1) The facility failed to provide an activity program supporting the physical, mental, and psychosocial well-being of Resident #9.
483.25 Quality of care was deficient as the facility failed to provide necessary care and treatment for skin integrity for Resident #36 with a large bruise.
483.25(d) The facility failed to investigate bruising of unknown origin for Resident #36 and lacked proper documentation and follow-up.
483.40(d) The facility failed to provide medically-related social services to Resident #9 to maintain psychosocial well-being and address discharge plan changes.
483.45(c) The facility failed to obtain an appropriate diagnosis and behavior monitoring documentation for Resident #8's use of Seroquel, an antipsychotic medication.
483.45(d) The facility failed to provide adequate reasoning and documentation for the use of an as needed antianxiety medication for Resident #13.
483.45(e) The facility failed to obtain an appropriate diagnosis and assessment for behaviors for Resident #8's use of Seroquel, placing the resident at risk for adverse effects.
Report Facts
Deficiencies cited: 9
Resident census: 41
Bruise size: 13.5
Bruise size: 16.5
Medication doses: 2
As needed medication administrations: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified lack of care plan for skin integrity and depression, lack of bruise investigation, and uncertainty about Seroquel diagnosis and monitoring. |
| Administrative Nurse E | Administrative Nurse | Verified Resident #8 received Seroquel twice daily and lack of behavior documentation; verified Resident #9 was not receiving Zoloft and facility lacked mental health provider. |
| Administrative Nurse F | Administrative Nurse | Verified Resident #36 did not have a care plan for skin integrity. |
| Nurse Aide M | Nurse Aide | Reported Resident #36 bruised easily and staff charted behaviors for Resident #13. |
| Licensed Nurse G | Licensed Nurse | Verified Resident #23 had periods of forgetfulness but was mostly happy; confirmed Resident #13 had anxiety and behaviors and received as needed medication. |
| Social Service Staff X | Social Service Staff | Verified Resident #9's discharge plan changed and psychosocial adjustment was not provided. |
| Nurse H | Nurse | Verified Resident #9 stayed in room most of the day and was unsure if encouraged to attend activities. |
| Nurse Aide N | Nurse Aide | Verified Resident #9 came out to meals and rested most of the day. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 15, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies were corrected as of 08/04/2017, with no uncorrected deficiencies noted at the time of this revisit.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jul 20, 2017
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a complaint investigation related to resident elopement and staff training issues.
Complaint Details
This Plan of Correction addresses deficiencies identified during a complaint investigation related to resident elopement and staff training compliance.
Findings
The facility identified deficiencies in reporting incidents, verifying nurse aide registry status, assessing residents at risk of elopement, ensuring adequate supervision and safety equipment, and providing required nurse aide continuing education. Corrective actions and audits were planned to address these issues.
Deficiencies (6)
F225-D: The facility failed to ensure all investigations were reported to the administrator and State Survey Agency within required timeframes.
F226-D: The facility failed to verify that certified nursing assistants were current on the nurse aide registry and had adequate training to prevent abuse and neglect.
F309-D: The facility failed to properly assess residents at risk of elopement at admission, change, and incident times, and document findings accordingly.
F323-J: The facility failed to ensure adequate supervision and safe operating condition of assistance devices to prevent resident accidents and elopements.
F456-E: The facility failed to verify that essential equipment, including wandergard door exits, were in safe operating condition to prevent resident elopement.
F497-F: The facility failed to ensure every nurse aide received at least 12 hours of required continuing education within a 12 month period.
Report Facts
Incident reporting timeframe: 5
Abuse/neglect reporting timeframe: 2
Audit frequency: 3
Nurse aide continuing education hours: 12
Compliance dates: Most corrective actions to be in compliance by 7/20/2017 or 8/4/2017
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 13, 2017
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not in substantial compliance and conditions constituted immediate jeopardy to resident health or safety related to F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3). Enforcement remedies including denial of payment for new admissions were imposed.
Deficiencies (1)
F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3) deficiency constituted immediate jeopardy and substandard quality of care.
Report Facts
Denial of payment effective date: Aug 6, 2017
Recommended termination date: Jan 13, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact for questions regarding the enforcement action. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 6
Date: Jul 13, 2017
Visit Reason
Complaint investigation and partial extended survey conducted due to allegations of abuse and elopement risks.
Complaint Details
Complaint investigation #116435 related to allegations of abuse and elopement risk.
Findings
The facility failed to report and thoroughly investigate allegations of abuse for one resident, failed to check nurse aide registry for two nurse aides, failed to assess and supervise residents at risk for elopement, and failed to maintain safe operating conditions for wander guard devices on exit doors.
Deficiencies (6)
483.12(a)(3)(4)(c)(1)-(4) The facility failed to report to the state agency and thoroughly investigate allegations of abuse for 1 of 3 residents reviewed for elopement risk.
483.12(b)(1)-(3), 483.95(c)(1)-(3) The facility failed to check the appropriate nurse aide registry for 2 of 3 nurse aides hired since 3/1/17.
483.24, 483.25(k)(l) The facility failed to assess residents for elopement risk and provide timely assessments for 2 of 3 residents who exited the facility, and failed to provide physical assessments after elopement incidents.
483.25(d)(1)(2)(n)(1)-(3) The facility failed to provide adequate supervision to prevent leaving the building for 2 of 3 residents who eloped, including failure to secure elevator and basement access.
483.90(d)(2)(e) The facility failed to ensure each exit door accessible to residents had a wander guard device installed and maintained in safe operating condition; the 500 hall exit door lacked a wander guard device.
483.35(d)(7) The facility failed to ensure 11 nurse aides received the required 12 hours of in-service training annually as required by the State.
Report Facts
Resident census: 40
Nurse aides lacking registry verification: 2
Nurse aides lacking required in-service hours: 11
Temperature of laundry room sink water: 166.4
Inspection Report
Follow-Up
Deficiencies: 5
Date: Jan 12, 2017
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Deficiencies (5)
Regulation 483.25 deficiency was corrected as of 01/12/2017.
Regulation 483.25(f)(1) deficiency was corrected as of 01/12/2017.
Regulation 483.25(l) deficiency was corrected as of 01/12/2017.
Regulation 483.60(c) deficiency was corrected as of 01/12/2017.
Regulation 483.65 deficiency was corrected as of 01/12/2017.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jan 12, 2017
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 01/12/2017. No other deficiencies are listed as outstanding.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected as of 01/12/2017.
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Dec 28, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies including pain management, behavioral health interventions, psychotropic medication monitoring, proper gloving during pericare, housekeeping training on disinfectants, laundry procedures for C. difficile, and dietary management progress.
Deficiencies (6)
F309-D: The facility failed to ensure residents received care to attain or maintain their highest practicable well-being, specifically regarding pain management timing and interventions for Resident #14.
F319-D: The facility failed to provide appropriate treatment and services for residents with mental or psychosocial adjustment difficulties, as seen with Resident #38's disruptive behavior.
F329-D: The facility failed to adequately monitor psychotropic medications to ensure residents were free from unnecessary drugs, specifically for Resident #38.
F428-D: The facility failed to ensure monthly pharmacist review of residents' drug regimens included current medications and irregularities were reported and acted upon.
F441-F: The facility failed to ensure nursing staff followed proper gloving procedures during pericare to prevent disease transmission.
S0600-C: The dietary manager was progressing toward certification with ongoing support and monitoring by the Registered Dietician.
Report Facts
Complete Date: Jan 12, 2017
Medication dosage increase: 4
Medication dosage increase: 100
Medication dosage increase: 50
Medication dosage increase: 2
Training completion date: Dec 31, 2017
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 13, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
Findings
The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective January 12, 2017.
Deficiencies (1)
The facility had a level "F" deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Nov 23, 2016
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #107908 to assess compliance with dietary services regulations.
Complaint Details
The visit was triggered by a complaint investigation #107908. The facility was found noncompliant regarding dietary services supervision.
Findings
The facility failed to provide services of a full-time certified dietary manager for the 41 residents receiving meals from one kitchen. Dietary staff serving meals was not certified, and the facility did not meet policy requirements for dietetic services supervision.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee food ordering, preparation, and storage for 41 residents. Dietary staff serving meals was not certified and only enrolled in an online course.
Report Facts
Census: 41
Sample size: 10
Inspection Report
Life Safety
Deficiencies: 1
Date: Aug 2, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited for Life Safety Code deficiencies at the 'F' level, indicating no harm but potential for more than minimal harm without immediate jeopardy.
Report Facts
Effective date for denial of payments: Nov 2, 2016
Provider agreement termination date: Feb 2, 2017
Plan of correction submission timeframe: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and is responsible for licensure certification and enforcement. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 10, 2015
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or Life Safety Code provisions were corrected by the revisit date of 09/10/2015 as indicated by the correction completion dates.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Sep 10, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior inspection.
Findings
The facility identified multiple deficiencies related to care planning, resident dignity, safety hazards, dental care, bowel management, and infection control. Corrective actions include staff retraining, care plan revisions, audits, and installation of safety mechanisms.
Deficiencies (11)
F225-D: Care plans for two residents will be reviewed and revised to reflect appropriate ADL care. Staff will be retrained on reporting incidents involving residents with dementia or injuries of unknown origin.
F241-D: All residents will be treated with dignity and respect. Mandatory staff inservice and ongoing training on resident rights will be conducted.
F243-E: Resident council meetings will be regularly scheduled and added to the monthly activities calendar. Completion will be audited monthly for six months.
F272-D: The facility will ensure timely completion of Care Area Assessments (CAA) and provide private work areas for unit leaders to meet deadlines.
F280-D: Resident care plans will include interventions for dietary and oral hygiene. Dental hygienist visits will be scheduled regularly and families will be notified for follow-up care.
F309-E: The facility will provide necessary care for positioning, pain management, and bowel care. Staff will be educated on monitoring and interventions using the PCC Dashboard.
F312-D: Care plans for dining assistance will be reviewed and communicated to staff. Mandatory training will be provided to assist residents during mealtime.
F323-E: Doors to hazardous areas will be locked and elevator key lock installed. Care plans will address supervision of residents at risk for falls during 'sleepy' times.
F329-D: Nursing staff will monitor bowel management using PCC Dashboard and follow protocol for residents with no bowel movements for three days.
F412-D: Residents will have timely access to dental services. Follow-up care will be ensured and dental hygienist visits scheduled every six months.
F441-F: The facility will ensure safe and sanitary environment by properly storing respiratory equipment and providing staff education. Audits will monitor compliance.
Report Facts
Audit duration: 6
Audit duration: 3
Training dates: 2
Elevator key lock installation deadline: Sep 30, 2015
Dental hygienist next visit: Feb 16, 2016
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 11
Date: Aug 11, 2015
Visit Reason
Health Resurvey and complaint investigation #89621 focusing on allegations of abuse, neglect, falls, dignity, dental care, infection control, and medication management.
Complaint Details
Complaint investigation #89621 focused on allegations of abuse, neglect, falls, dignity, dental care, infection control, and medication management.
Findings
The facility failed to thoroughly investigate and report falls with injury for two residents, maintain dignity during dining for one resident, ensure timely care area assessments, revise care plans for dental and pain management, provide adequate supervision to prevent accidents, monitor bowel management, and maintain infection control related to oxygen equipment storage.
Deficiencies (11)
F225: Facility failed to investigate and report falls with injury for 2 residents, including a cognitively impaired resident who fell and sustained a head laceration.
F241: Facility failed to maintain dignity and respect during dining for a cognitively impaired resident who exhibited food playing behaviors and was laughed at by staff.
F243: Facility failed to hold regular resident council meetings during the absence of the resident council president.
F272: Facility failed to complete Care Area Assessments timely for a resident with significant change MDS.
F280: Facility failed to revise care plan with appropriate interventions for dental and pain management for two residents.
F309: Facility failed to provide necessary care for pain management, wheelchair positioning, and bowel elimination for three residents.
F312: Facility failed to provide staff assistance as care planned to a resident requiring prompting during meals.
F323: Facility failed to provide adequate supervision to prevent falls and maintain an environment free of accident hazards, including malfunctioning elevator sensors and unsecured hazardous materials.
F329: Facility failed to adequately monitor bowel management and provide timely interventions as per physician orders for a resident.
F412: Facility failed to ensure provision of dental services for a resident with a jagged and broken tooth and no dental follow-up for 17 months.
F441: Facility failed to maintain infection control by improperly storing oxygen equipment for three residents receiving oxygen therapy.
Report Facts
Resident census: 36
Fall medication administration count: 40
Days without bowel movement: 6
Days without bowel movement: 9
Days without bowel movement: 6
Dental follow-up gap: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse E | Licensed Nurse | Named in fall injury finding for Resident #41 |
| Nurse Aide A | Nurse Aide | Named in dignity and respect finding for Resident #31 |
| Administrative Nurse F | Administrative Nurse | Named in fall supervision and pain management findings |
| Nurse I | Licensed Nurse | Named in fall and injury findings for Resident #2 |
| Nurse Aide K | Nurse Aide | Named in bowel management and fall findings for Resident #2 |
| Social Service Staff D | Social Service Staff | Named in resident council meeting findings |
| Therapy Aide P | Therapy Aide | Named in wheelchair positioning findings for Resident #35 |
| Administrative Staff C | Administrative Staff | Named in accident hazard and elevator sensor findings |
| Maintenance Staff J | Maintenance Staff | Named in accident hazard and elevator sensor findings |
| Social Service Staff H | Social Service Staff | Named in dental care findings for Resident #22 |
| Dietary Manager G | Dietary Manager | Named in dental care findings for Resident #22 |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 11, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the plan of correction. |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Aug 15, 2014
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the survey completed on 2014-07-16.
Findings
The report confirms that the previously cited deficiencies under regulations 483.20(d)(3), 483.10(k)(2), and 483.25(h) were corrected as of 2014-08-15.
Deficiencies (2)
Regulation 483.20(d)(3), 483.10(k)(2): Previously cited deficiency corrected as of 08/15/2014.
Regulation 483.25(h): Previously cited deficiency corrected as of 08/15/2014.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 23, 2014
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified during a complaint investigation at the facility.
Findings
The plan addresses fall prevention interventions, updating care plans for residents with falls, and implementing a neuro check checklist for falls with potential head injury. Training and auditing procedures are outlined to ensure compliance and monitoring.
Deficiencies (2)
F280-D: The care plan for the resident was updated with new fall prevention interventions including white noise, incontinence product changes, enhanced rest periods, and contacting family if restless. Training for charge nurses and case managers on care plan updates will be provided and falls will be audited for compliance.
F323-D: A neuro check checklist will be initiated for falls with potential head injury to ensure timely assessments. Nurses will initial and date the checklist until completion, with coaching provided to charge nurses and audits conducted to ensure compliance.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: Jul 16, 2014
Visit Reason
The inspection was conducted as a complaint investigation (#76342) regarding the facility's failure to revise the care plan and implement interventions for a resident with falls.
Complaint Details
Complaint investigation #76342 focused on Resident #3's care plan and fall prevention measures. The complaint was substantiated as the facility failed to revise care plans and implement required neurological checks after falls.
Findings
The facility failed to revise the plan of care and implement individualized interventions to prevent further falls for Resident #3. Neurological assessments were not completed as required after the resident's falls, and the facility did not consistently update care plans following falls.
Deficiencies (2)
F 280: The facility failed to revise the plan of care for Resident #3 after multiple falls, despite changes in the resident's condition and fall risk.
F 323: The facility failed to implement interventions to prevent further falls and did not complete neurological assessments per policy after Resident #3's falls.
Report Facts
Resident census: 36
Sample residents reviewed: 3
Falls neurological check delay: 14
Falls neurological check delay: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Stated nurses do not implement new interventions after every fall and explained neurological assessment practices | |
| Administrative Nurse B | Confirmed neurological checks are required after falls with head injury and verified some assessments were not completed timely |
Inspection Report
Plan of Correction
Deficiencies: 10
Date: Jun 27, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including reference checks for new hires, cleaning and maintenance of resident rooms, updating care plans for residents at risk of skin breakdown and falls, wound care documentation, chemical safety, food safety, medication storage and monitoring, infection control, and securing handrails.
Deficiencies (10)
F226-D: Reference checks will be obtained on new hires and staff in hiring positions will be trained to complete at least two reference checks prior to job offers.
F253-E: Sinks and toilet bowls will be cleaned of stains, hard water residue removed, and chipped paint repaired in resident rooms and bathrooms.
F279-D: Resident #42's care plan was updated to include potential skin breakdown and pressure ulcer prevention interventions.
F280-D: Care plans for residents #33 and #42 were reviewed and updated to include fall prevention and pressure ulcer care interventions.
F314-D: Residents with pressure ulcers will have wounds properly documented and receive necessary treatment and monitoring to promote healing and prevent infection.
F323-E: All chemicals labeled 'Keep out of reach of children' have been placed behind locked doors and staff will be trained on chemical safety procedures.
F371-F: Expired milk and cheese were disposed of; dietary staff will be trained on food safety and temperature monitoring procedures.
F431-E: Controlled substance medications are stored in double locked compartments and monitored for expiration; staff training and audits will ensure compliance.
F441-D: An infection control program will be maintained to prevent disease transmission, including proper handling of contaminated items during resident treatment.
F468-E: Handrails cited were secured and all handrails will be inspected regularly with repairs completed as needed.
Report Facts
Audit frequency: 3
Audit frequency: 2
Training completion date: Jun 27, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice Shobe | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 27, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates confirming compliance.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 10
Date: May 28, 2014
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to implement abuse/neglect policies, maintain sanitary conditions, develop comprehensive care plans, provide adequate treatment for pressure ulcers, ensure safe environment free of hazards, maintain sanitary food handling, properly store medications, and maintain infection control practices.
Deficiencies (10)
F226: Facility failed to implement abuse/neglect policies by not obtaining reference checks for 1 of 3 newly hired staff.
F253: Facility failed to maintain sanitary environment in 8 resident bathrooms on one hallway with stains and chipped paint.
F279: Facility failed to develop comprehensive care plans for 2 of 14 residents related to pressure ulcers and falls.
F280: Facility failed to revise care plans with new interventions after multiple falls and pressure ulcer risks for 2 residents.
F314: Facility failed to provide necessary treatment and documentation for pressure ulcers in 3 residents, including failure to document daily wound condition and weekly measurements.
F323: Facility failed to store chemicals in locked areas inaccessible to 8 cognitively impaired residents, creating accident hazards.
F371: Facility failed to remove expired milk and failed to hold cheese at proper cold temperature on salad bar.
F431: Facility failed to store controlled substances in double locked compartments, failed to monitor medication refrigerator temperatures, and failed to remove expired medications.
F441: Facility failed infection control by staff not removing contaminated gloves after administering eye drops to infected resident.
F468: Facility failed to have firmly secured handrails on one of four hallways.
Report Facts
Resident census: 35
Number of bathrooms with sanitation issues: 8
Number of residents sampled for care plan review: 14
Number of falls for resident #33: 17
Temperature of medication refrigerators: 38
Temperature of cheese on salad bar: 44.2
Inspection Report
Re-Inspection
Deficiencies: 1
Date: May 28, 2014
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at an 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 4
Date: Mar 4, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.20(d), 483.20(k)(1), 483.25(l), 483.60(c), and 483.65 were corrected as of the revisit date.
Deficiencies (4)
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.25(l): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.60(c): Previously cited deficiencies were corrected by the revisit date.
Regulation 483.65: Previously cited deficiencies were corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 6, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection related to resident care plans, medication management, and infection control.
Findings
The facility identified issues with updating care plans for residents with MRSA wounds, ensuring drug regimens are free from unnecessary medications, and maintaining an effective infection control program. Corrective actions include staff re-education, monitoring, and audits to ensure compliance.
Deficiencies (4)
F279-D: The facility failed to update resident care plans to include history of MRSA in wounds and ensure staff follow MRSA precautions. Monitoring and audits will verify compliance.
F329-D: The facility did not ensure residents' drug regimens were free from unnecessary drugs, including monitoring bowel movement reports and reviewing medications like Prilosec and Depakote. Processes for medication review and monitoring were implemented.
F428-D: The licensed pharmacist did not consistently review drug regimens monthly or report irregularities. Procedures were established for pharmacist review and reporting.
F441-E: The facility failed to establish and monitor an infection control program adequately, including communication of MRSA wound cultures and proper nebulizer cleaning. Staff education and audits were planned.
Report Facts
Audit frequency: 3
Depakote level result: 43.2
Plan completion date: Mar 4, 2013
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 4
Date: Feb 4, 2013
Visit Reason
Health resurvey to assess compliance with previously cited deficiencies and regulatory requirements.
Findings
The facility failed to develop comprehensive care plans for infection control, failed to monitor drug regimens adequately, failed to implement infection control interventions for MRSA, and failed to maintain sanitary conditions for nebulizer equipment. Several residents had issues with infection control, medication monitoring, and bowel management.
Deficiencies (4)
F279: The facility failed to develop a comprehensive care plan addressing infection control interventions for a wound infected with MRSA for Resident #15.
F329: The facility failed to adequately monitor the efficacy of residents' medications to ensure the drug regimen was free of unnecessary drugs for Residents #18, #13, and #8.
F428: The facility's pharmacist consultant failed to report irregularities such as lack of bowel elimination monitoring and prolonged use of Prilosec without risk-benefit education for Residents #18, #13, and #8.
F441: The facility failed to implement infection control interventions for MRSA infected wounds, maintain accurate infection records, and properly store nebulizer equipment for Residents #15, #49, #21, and #42.
Report Facts
Resident census: 37
Sample size: 14
Residents reviewed for unnecessary drugs: 10
Residents with drug regimen issues: 3
Depakote blood level: 43.2
Days without bowel movement: 6
Days without bowel movement: 6
Days without bowel movement: 7
Days without bowel movement: 4
Milk of Magnesia administration: 3
Milk of Magnesia administration: 2
Milk of Magnesia administration: 1
Milk of Magnesia administration: 1
Depakote dosage: 250
Wound size: 4
Wound size: 2.5
Wound size: 2.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Observed wound care and dressing changes for Resident #15; stated infection control practices. | |
| Nurse C | Administrative Nurse | Stated lack of care plan for MRSA infection control and lack of education on Prilosec risk-benefit. |
| Nurse D | Described bowel management protocols and medication administration for Resident #18. | |
| Nurse A | Provided wound care for Resident #49 and described infection control notification procedures. | |
| Nurse B | Described bowel management interventions and documentation. | |
| Nurse G | Observed nebulizer mask on floor for Resident #21. | |
| Nurse E | Described nebulizer mask cleaning and storage procedures. | |
| Aide H | Stated infection control practices regarding MRSA linens and resident showering. | |
| Laundry Staff J | Stated linens were not placed in red or individualized bags for MRSA residents. | |
| Pharmacist Consultant F | Failed to notify Director of Nursing of medication irregularities and lack of bowel monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N020001 POC ZQWM11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility with State ID N020001.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N020001 POC
Visit Reason
This document is a plan of correction related to a facility inspection event.
Findings
No deficiency report or findings are included in this document. It only references the plan of correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N020001 POC 1D72F5
Visit Reason
This document is a Plan of Correction submitted by Good Samaritan Society - Decature County in response to previously identified deficiencies during a regulatory inspection.
Findings
The Plan of Correction addresses multiple deficiencies including discharge summary completion, notification to the Ombudsman, use of visual assistive devices, nursing coverage verification, Ekit medication security, blood pressure parameter documentation, insulin pen labeling, and dietary manager certification progress.
Deficiencies (7)
F628-D: Discharge summaries for residents 20 and 22 were completed on 10/2/2025. The facility will conduct daily reviews of admissions, discharges, and transfers to ensure compliance with discharge summary and notification policies.
F676-D: Resident 18's DPOA was contacted and new glasses were provided on 9/24/25. The facility will audit use of visual assistive devices and provide staff education on related policies.
F725-F: PBJ reports from multiple dates were reviewed to confirm nursing coverage was adequate. Ongoing audits and education on PBJ reporting will be conducted to ensure accuracy.
F755-F: The Ekit was secured and new procedures were developed with pharmacy consultation. Nursing staff will be educated and audits conducted to ensure compliance with Ekit procedures.
F757-D: PCP for Resident 1 was contacted to provide blood pressure parameters. The facility will review all residents on blood pressure medications and audit compliance with physician orders.
F761-D: An unlabeled insulin pen for resident 6 was discarded and replaced. Staff will be educated on insulin administration policies and audits conducted on insulin pen dating.
F801-F: The Dietary Manager is enrolled in a certification course and will complete the exam by 12/15/2025. Audits will monitor compliance with dietary management requirements.
Report Facts
Deficiencies cited: 7
Dates of PBJ reports reviewed: 5
Inspection Report
Plan of Correction
Deficiencies: 9
Date: N020001 POC 6ZON11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care plans, privacy in sharing medical information, skin integrity interventions, medication management, and staff education. The facility commits to audits, education, and monitoring to ensure compliance.
Deficiencies (9)
F557-E: Residents' preferences regarding sharing vital signs, accu-checks, oxygen saturation, and insulin in non-private areas were not respected. The facility plans interviews and staff education to address privacy concerns.
F656-D: Care plans for residents on anticoagulants, antidepressants, or with low Braden scores were not consistently updated. The facility will review and audit care plans and educate staff accordingly.
F679-D: A resident was admitted with a compromised area requiring offloading; care plans and activities were updated to support resident needs. Staff education on activities encouragement is planned.
F684-D: Care plans for residents at risk for skin integrity issues were updated and will be reviewed regularly. Licensed staff will receive education on skin observation documentation.
F689-D: Investigation of a hematoma on a resident included caregiver interviews and safety reviews. Skin Observation UDAs will be completed and injuries investigated per policy.
F745-D: Medical records and care plans were updated for residents with discharge plan changes and mental health needs. Staff education on resident profiles is planned.
F756-D: Proper diagnoses for residents on antipsychotics were verified and documented. Pharmacist reviews and staff education on diagnosis expectations will continue.
F757-D: Medication administration records for antianxiety medications were reviewed. Staff education and audits on documentation and medication orders are planned.
F758-D: Diagnoses for residents on antipsychotics were confirmed and documented. Ongoing pharmacist review and staff education on diagnosis requirements will continue.
Report Facts
Audit frequency: 4
Audit frequency: 2
Audit frequency: 2
Completion date: Jun 18, 2019
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