Inspection Reports for
The Evangelical Lutheran Good Samaritan Society

The plan addresses deficiencies including resident bathing preferences, oxygen tubing management, and dementia education for staff. Root cause analyses were completed, and corrective actions such as staff education, audits, and procedural updates are planned to ensure substantial compliance by 02/28/2019.

The survey found a most serious deficiency at a '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 reviewed and accepted, resulting in a finding of substantial compliance effective 02/28/2019.

The visit was triggered by complaint investigations identified by case numbers KS00128367, KS00125309, KS00125262, and KS00122003.

The facility failed to ensure residents received baths according to their schedules and failed to implement proper infection control practices related to respiratory care. Additionally, the facility did not provide required annual dementia care in-service training for most nurse aides sampled.

The plan details root cause analyses and corrective actions including updates to guidelines and policies, staff education, and ongoing audits to ensure compliance with abuse and neglect reporting and investigation procedures.

The survey found the facility was in substandard care for deficiency F607, with a severity level initially 'F' but later reduced to 'C'. Due to the history of noncompliance, the facility was not given an opportunity to correct deficiencies before enforcement remedies were imposed, including denial of payment for new Medicare and Medicaid admissions effective January 23, 2018.

The complaint investigation involved allegations of staff mistreatment of resident #3, who reported rough and rude peri care by a nurse. The resident could not recall specific details about the incident. The facility investigated but did not report the allegation to the State agency, concluding no proof of mistreatment. The investigation lacked thoroughness, missing interviews with other residents or staff and documentation.

The facility failed to develop adequate written policies regarding abuse, neglect, and exploitation, specifically lacking guidance on handling evidence, investigation procedures, and protective measures. Additionally, the facility failed to report one alleged staff mistreatment to the State agency and did not thoroughly investigate the allegation, lacking documentation and interviews with other residents or staff.

The plan addresses multiple deficiencies including inaccurate MDS documentation, fall risk and care plan updates, pressure ulcer prevention and repositioning protocols, antibiotic treatment follow-up, lab result communication, and proper resident transfers. The facility outlines corrective actions, staff education, monitoring, and quality assurance processes to achieve substantial compliance by October 12, 2017.

The survey found the most serious deficiency to be a 'D' level deficiency, isolated, 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 effective 10/12/2017.

The facility was found deficient in accurately coding resident assessments, revising care plans after falls, providing timely and appropriate treatment for pressure ulcers and urinary tract infections, repositioning residents as care planned, and ensuring safe transfer practices. Specific failures included inaccurate MDS coding for UTIs and falls, failure to revise care plans after a fall, failure to provide timely antibiotic treatment for a UTI resistant to initial medication, failure to reposition residents leading to worsening pressure ulcers, and failure to implement appropriate fall prevention strategies and transfer assistance.

All previously cited deficiencies listed with their regulation numbers were marked as corrected and completed as of the revisit date.

The survey found the most serious deficiency 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, resulting in a finding of substantial compliance effective August 9, 2017.

The plan addresses multiple deficiencies related to resident care including pressure ulcer prevention, restorative nursing documentation, blood sugar monitoring, medication storage, food safety, and wound documentation. The facility outlines corrective actions, staff education, audits, and quality assurance measures to achieve substantial compliance by August 9, 2017.

The inspection included complaint investigations #110148, #109143, #100925, and #99452.

The facility was found deficient in multiple areas including failure to implement pressure ulcer prevention interventions, failure to provide restorative range of motion as planned, failure to ensure drug regimens were free from unnecessary drugs, failure to maintain sanitary food storage and kitchen cleanliness, failure to maintain infection control practices, and failure to maintain complete and organized clinical records.

The revisit confirmed that the previously cited deficiencies, including those under regulation 483.25(d)(1)(2)(n)(1)-(3), were corrected by 06/27/2017 as documented in the report.

The revisit confirmed that all previously cited deficiencies were corrected as of 06/15/2017, with no uncorrected deficiencies remaining.

The survey found a 'D' level deficiency indicating 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 effective June 27, 2017.

The complaint investigation #6466 found that the facility failed to adequately monitor a resident with dementia and Alzheimer's disease who unintentionally touched another resident's chest. The facility determined the touch was unintentional and related to the resident's cognitive impairment.

The facility failed to adequately monitor one resident with advanced cognitive impairment who unintentionally touched another resident's chest area. The resident had a history of inappropriate sexual behaviors, and the care plan did not fully address monitoring in all common areas. Staff monitored the resident one-on-one after the incident, but the facility did not prevent unintentional touching in all common areas.

Complaint related to sexually inappropriate behavior by Resident #1; substantiation status not explicitly stated.

Resident #1 was taken to the Emergency Room and admitted to Kinsley Behavior Unit for evaluation and treatment of sexually inappropriate behavior. The facility implemented multiple corrective actions including private room placement, monitoring, staff education, and ongoing resident and staff interviews to ensure safety and compliance.

The survey found the most serious deficiency to be an 'E' level deficiency indicating 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 June 15, 2017.

The complaint investigation KS00116036 focused on medication administration errors, including failure to hold medications per physician parameters and failure to administer medications due to unavailability or resident sleeping.

The facility failed to ensure that medications were administered according to physician orders, including holding Metoprolol when the resident's pulse was below ordered parameters, and failed to have a system to ensure medications were available and administered as ordered. The consultant pharmacist did not identify or report irregularities related to medication administration failures during the monthly drug regimen review for all sampled residents.

This Plan of Correction is linked to the Gd Sam Hutchinson complaint dated 05/25/2017.

The plan addresses multiple deficiencies including failure to follow medication parameters, missed medication doses, and inadequate monitoring. Corrective actions include education, audits, root cause analysis, and ongoing quality assurance reviews.

The revisit confirmed that the previously cited deficiency related to regulation 483.45(a)(b)(1) was corrected as of 05/02/2017. No other deficiencies were noted in this report.

The revisit confirmed that all cited deficiencies related to regulations 483.24, 483.25(k)(l), 483.45(d)(e)(1)-(2), and 483.45(c)(1)(3)-(5) were corrected as of 04/28/2017.

The facility failed to ensure one resident received accurate doses of Coumadin as ordered, with doses given incorrectly on consecutive days. Interviews with nursing staff confirmed the medication was not administered according to the physician's alternating dose order.

The survey found the most serious deficiency to be a 'D' level deficiency indicating 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 effective May 2, 2017.

The Director of Nursing notified the physician of a medication error involving resident #10, conducted a root cause analysis, reviewed all residents with Coumadin orders, and provided education and training to licensed nurses to prevent recurrence. The facility implemented systemic changes including daily audits and competency checks to ensure compliance.

Complaint investigation #KS00112259 focused on inadequate care and monitoring of resident #1 who was on anticoagulant therapy and experienced a change in condition leading to hospitalization and death.

The facility failed to ensure adequate assessment and monitoring of resident #1 who was on anticoagulant therapy, resulting in delayed lab monitoring and failure to detect signs of bleeding. The resident was transferred to the emergency room with septic shock and elevated INR and subsequently died. The facility also failed to act on pharmacy consultant recommendations regarding lab monitoring.

This Plan of Correction is in response to a complaint investigation at Good Sam Hutch dated 03/30/2017.

The plan outlines corrective actions including root cause analyses, staff education, audits, and monitoring to address deficiencies related to change in condition assessments, lab monitoring for residents on Coumadin, and pharmacy recommendation follow-up. The facility aims to achieve substantial compliance by 04/11/2017.

The survey found that the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety related to F329, "J", CFR 483.45(d)(e)(1)-(2). Enforcement remedies including denial of payment for new Medicare and Medicaid admissions effective April 25, 2017, were imposed.

The revisit inspection found that all previously cited deficiencies were corrected as of 01/24/2017, with no outstanding deficiencies noted.

The facility was found deficient in multiple areas including failure to post policies and procedures related to resident services in an accessible location, failure to conduct resident council meetings quarterly, failure to review negotiated service agreements at least annually, and failure to conduct annual fire drills including resident evacuation.

The survey found the most serious deficiencies at an '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.

The report confirms that the previously reported deficiencies have been corrected as of the revisit date.

The survey found the most serious deficiency to be F226, a 'C' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance.

The complaint survey (#107240) found the facility did not meet requirements for ANE policies and training, specifically regarding unauthorized photographs/videos and social media. The training provided was incomplete and not mandatory, with some staff not attending.

The facility failed to develop and implement a policy including training for current and new staff regarding abuse, neglect, and exploitation (ANE) related to unauthorized photographs or video recordings of residents and social media networks. Approximately one-third of staff did not attend the ANE training meeting, and the existing training was not specific to recent CMS regulatory changes.

This Plan of Correction is related to a complaint investigation identified as Good Sam Hutch complaint 10272016.

The facility identified deficiencies related to abuse and social media/photographs/video policies that had the potential to affect all residents. The facility updated policies, re-educated staff, and implemented ongoing education and audits to ensure compliance.

The revisit confirmed that the previously reported deficiencies, including the one identified under regulation 483.25(h), were corrected by 08/09/2016.

The survey found the most serious deficiency in the facility to be at 'G' level, resulting in enforcement remedies including a denial of payment for new Medicare and Medicaid admissions effective October 15, 2016, until substantial compliance is achieved.

The visit was complaint-related, investigating allegations regarding inadequate supervision and fall prevention for residents who experienced multiple falls with injuries.

The facility failed to provide adequate supervision and fall prevention interventions for two sampled residents who experienced multiple falls, including serious injuries such as fractured ribs and closed head injury. Root cause analyses were consistently incomplete or missing, and appropriate interventions were not developed or implemented after falls.

This plan of correction is related to the Good Sam Hutchinson complaint dated 07/15/2016.

The plan addresses deficiencies related to fall prevention, bowel and bladder assessments, staff education, and implementation of a falls performance improvement plan. The facility aims to achieve substantial compliance by 08/09/2016.

The Plan of Correction details multiple corrective actions including care plan reviews and updates, pain management improvements, bathing preference adherence, bowel and bladder monitoring, medication monitoring, staffing improvements, and order entry accuracy. Root Cause Analyses were completed for each deficiency, and education and audits are planned to ensure compliance.

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, resulting in a finding of substantial compliance effective December 7, 2015.

The facility failed to review and revise care plans for two residents regarding falls and pain management, failed to provide adequate pain management, failed to ensure dependent residents received baths as care planned, failed to implement fall prevention interventions, failed to secure hazardous items, failed to monitor medications adequately, failed to transcribe physician orders correctly, and failed to maintain sufficient nursing staff to meet resident needs.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was not in substantial compliance with Life Safety Code requirements.

The plan details multiple corrective actions including staff education, audits, care plan updates, and monitoring related to dignity, call light accessibility, bowel and bladder assessments, pain management, oral care, skin assessments, medication orders, food service, and dental care. The facility aims to achieve substantial compliance by August 14, 2014.

The survey found the most serious deficiency at a level of actual harm that is not immediate jeopardy, requiring corrections. Due to the deficiencies and prior noncompliance, the facility was not given an opportunity to correct before enforcement remedies were imposed, including denial of payment for all new Medicare admissions effective August 4, 2014.

The inspection included complaint investigations for complaint numbers KS00076805, KS00075573, KS00075623, and KS00075867.

The facility was cited for multiple deficiencies including failure to promote dignity and respect, failure to accommodate resident needs, failure to develop comprehensive care plans especially related to urinary incontinence, inadequate pain management, failure to provide appropriate denture care, failure to prevent and treat pressure ulcers, failure to implement appropriate toileting schedules, failure to maintain a safe environment, failure to avoid unnecessary medications, failure to ensure food temperature and substitutions, failure to handle food hygienically, and failure to provide routine and emergency dental services.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The revisit confirmed that the deficiencies previously cited under regulations 483.30(a), 483.60(a),(b), and 483.75(o)(1) were corrected by 09/04/2013.

The plan addresses issues related to staffing levels and timely response to resident call lights, medication administration errors, and quality assurance processes. The facility implemented new procedures, staff education, and monitoring to ensure compliance and improvement in these areas.

The complaint investigation was related to staff not responding timely to resident call lights and failure to initiate and administer new medication orders properly. The investigation included observations, interviews, and record reviews confirming these issues.

The facility failed to ensure timely response to resident call lights, resulting in delayed assistance. Additionally, the facility failed to properly initiate and administer new physician medication orders for sampled residents, and lacked an effective Quality Assessment and Assurance program to address these deficiencies.

The plan details multiple corrective actions including staff education on resident-specific care needs, pain management, privacy, dignity, nutrition, infection control, medication management, and environmental safety. It also describes implementation of monitoring, audits, and quality assurance activities to ensure compliance and ongoing improvement.

The inspection was triggered by complaints regarding resident privacy, abuse, neglect, staffing shortages, and quality of care issues including pain management and infection control.

The facility failed to ensure resident privacy, conduct proper background checks on staff, investigate abuse allegations, provide adequate care including pain management, nutrition, grooming, and pressure ulcer prevention, maintain a safe environment, and ensure sufficient staffing. Multiple deficiencies were cited related to resident rights, care planning, medication management, infection control, and facility maintenance.

The plan outlines corrective actions for deficiencies related to policy availability, resident council meetings, negotiated service agreements, and emergency evacuation fire drills, with monitoring and audits scheduled to ensure compliance.