Inspection Reports for
The Evangelical Lutheran Good Samaritan Society

The plan addresses deficiencies related to resident care plans, oxygen tubing management, and dementia education. Corrective actions include root cause analyses, staff education, updated procedures, and ongoing audits to ensure compliance.

The visit was complaint-related, triggered by allegations concerning bathing care, infection control, and staff training deficiencies. The complaints were substantiated as evidenced by the cited deficiencies.

The facility failed to ensure residents received baths according to their schedules, failed to implement proper infection control practices related to oxygen tubing, and failed to provide required annual dementia care training to most nurse aides.

The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm without 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 plan addresses root cause analyses and updates to policies and procedures regarding workplace investigations and abuse and neglect. Staff education and ongoing audits are planned to ensure compliance and prevent recurrence.

The complaint investigation involved allegations of staff mistreatment of resident #3. The resident reported rough and rude peri care by a nurse but could not recall details. The facility investigated but did not report the allegation to the State agency and did not fully document or interview other residents or staff.

The facility failed to develop adequate written policies for abuse, neglect, and exploitation investigations, failed to report one alleged staff mistreatment to the State agency, and failed to thoroughly investigate the allegation including interviewing other residents or staff.

The facility was found to be in substandard care for deficiency F607, with a severity level initially at 'F' but later reduced to 'C'. Due to repeated noncompliance, the facility will not be given an opportunity to correct deficiencies before enforcement remedies are imposed.

The plan addresses multiple deficiencies related to infection control, fall prevention, pressure ulcer prevention, lab result management, and care plan accuracy. The facility outlines corrective actions, staff education, monitoring protocols, and timelines to achieve substantial compliance by October 12, 2017.

The survey found a single 'D' level deficiency that was isolated and constituted no actual harm but had potential for more than minimal harm without 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 failed to accurately code resident assessments for UTIs and falls, failed to revise care plans after falls, failed to provide timely treatment for a UTI with an appropriate antibiotic, failed to reposition residents as care planned to prevent pressure ulcers, and failed to determine the root cause of a fall and implement appropriate fall prevention strategies. Additionally, the facility failed to ensure staff transferred a resident as care planned.

The facility identified multiple deficiencies related to resident care including pressure ulcer prevention, restorative nursing documentation, blood sugar monitoring, medication storage, food safety, and wound documentation. Corrective actions and audits were planned to ensure substantial compliance by August 9, 2017.

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

The facility had multiple deficiencies 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 store food and maintain kitchen equipment in a sanitary manner, failure to maintain infection control practices, failure to discard outdated medications, and failure to maintain complete and organized clinical records.

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 effective August 9, 2017.

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

The report confirms that all cited deficiencies identified by regulation numbers 483.45(d)(e)(1)-(2), 483.45(a)(b)(1), and 483.45(c)(1)(3)-(5) were corrected as of 06/15/2017.

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 resident #1, who had a history of sexually motivated behaviors and cognitive impairment, resulting in unintentional touching of another resident's chest. The facility determined the touch was not intentional or sexual in nature.

The facility failed to adequately monitor one resident with cognitive impairment who unintentionally touched another resident's chest area. The care plan did not address supervision in all common areas, and staff observations confirmed the resident self-propelled in the facility with insufficient monitoring.

The visit was complaint-related involving allegations of sexually inappropriate behavior by Resident #1. The plan of correction includes actions taken in response to the complaint.

Resident #1 exhibited sexually inappropriate behavior requiring emergency evaluation and admission to a behavioral unit. The facility implemented monitoring, staff education, and care plan updates to manage the risk and prevent recurrence.

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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

This Plan of Correction is related to a complaint investigation identified as 'Gd Sam Hutchinson complaint 05252017'.

The plan addresses deficiencies involving failure to follow medication parameters, missed medication doses, and inadequate monitoring and auditing of medication administration. Corrective actions include staff education, audits, and quality assurance reviews.

Complaint investigation KS00116036 focused on medication administration errors and pharmaceutical service deficiencies.

The facility failed to ensure one resident did not receive unnecessary drugs by administering Metoprolol despite heart rate below physician parameters. Additionally, the facility failed to have a system to ensure medications were dispensed and administered as ordered for 5 sampled residents. The consultant pharmacist failed to identify and report irregularities related to medication administration and availability during the monthly drug regimen review.

The facility failed to ensure one resident received accurate medication administration of Coumadin, with doses given incorrectly contrary to physician orders. Interviews and record reviews confirmed the medication was not administered as prescribed.

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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.

A medication error involving Coumadin for resident #10 was identified and corrected. The facility implemented staff education, order review processes, and ongoing audits to prevent recurrence and ensure compliance.

This Plan of Correction is in response to deficiencies cited during the Good Sam Hutch complaint investigation dated 03/30/2017.

The plan addresses deficiencies related to change in condition assessments, lab monitoring for residents on Coumadin, and pharmacy recommendation follow-up. Root cause analyses were completed and corrective actions including staff education, audits, and monitoring were implemented to ensure compliance.

Complaint investigation #KS00112259 focused on inadequate assessment and monitoring of a resident on anticoagulant therapy who experienced a change in condition, was hospitalized, and died. The complaint was substantiated with findings of failure to monitor vital signs, failure to obtain ordered labs, and failure to act on pharmacy recommendations.

The facility failed to ensure adequate assessment and monitoring of a resident receiving anticoagulant therapy, resulting in delayed vital signs monitoring, failure to obtain ordered PT/INR labs for over two months, and failure to report signs of anticoagulant complications. The resident was transferred to the hospital with septic shock and elevated INR and subsequently died.

The facility was found not in substantial compliance, with conditions constituting 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 admissions were imposed.

The facility failed to ensure policies and procedures related to resident services were posted in an accessible location, did not conduct resident council meetings quarterly between October 2015 and April 2016, failed to review at least one resident's Negotiated Service Agreement annually, and did not conduct annual fire drills including resident evacuation as required.

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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

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

The survey was complaint-driven under survey #107240. The complaint was substantiated by findings that the facility did not adequately train staff on ANE policies related to unauthorized photographs and social media.

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

The survey found the most serious deficiency to be F226, a 'C' level deficiency indicating no actual harm but 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 and the plan.

This plan of correction is related to a complaint investigation identified as Good Sam Hutch complaint 10272016.

The facility had deficiencies related to policies and procedures on abuse and social media/photographs/videos, which had the potential to affect all residents. The plan outlines corrective actions including policy review, staff re-education, and ongoing audits to ensure compliance.

The revisit confirmed that the previously cited deficiency under regulation 483.25(h) was corrected as of 08/09/2016. No uncorrected deficiencies were noted at the time of this revisit.

The findings represent the results of complaint investigations KS00101976, KS00102742, and KS00101286.

The facility failed to provide adequate supervision and fall prevention interventions for residents, particularly residents #1 and #2, who experienced multiple falls resulting in injuries including fractures and head trauma. The facility consistently failed to complete root cause analyses and implement appropriate interventions after each fall.

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

The plan addresses the need for bowel and bladder assessments for residents, staff education on fall prevention policies and interventions, and the establishment of a falls committee to review and prevent falls. The facility aims to achieve substantial compliance by August 9, 2016.

The plan addresses multiple deficiencies related to resident care plans, pain management, bathing preferences, medication monitoring, staffing, admission orders, and pharmacy oversight. The facility outlines corrective actions, education plans, audits, and root cause analyses to achieve substantial compliance by December 7, 2015.

The facility failed to review and revise care plans for residents related to falls and pain management, failed to provide adequate pain management and bathing care, failed to implement fall prevention interventions, failed to store hazardous items securely, failed to monitor medication regimens adequately, 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, 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.

The survey found the most serious deficiencies to be an "F" level deficiency, widespread, with no harm but potential for more than minimal harm, not constituting 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.

All previously reported deficiencies identified by regulation numbers and prefix codes were corrected by 08/14/2014 as documented in this report.

The plan details multiple corrective actions including staff education, audits, care plan updates, and environmental safety improvements. The facility aims to achieve substantial compliance by August 14, 2014.

The survey found deficiencies at a level of actual harm that is not immediate jeopardy. Due to prior noncompliance and current deficiencies, 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 was triggered by multiple complaint investigations identified by numbers KS00076805, KS00075573, KS00075623, and KS00075867.

The facility was found deficient in multiple areas including dignity and respect, reasonable accommodation of needs, comprehensive care plans, pain management, pressure ulcer care, fall prevention, medication management, food service, dental care, and sanitary food handling.

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 facility implemented new staffing procedures including pager availability and call light response improvements. Medication administration policies were reinforced with staff education and audits. Quality assurance teams continue to monitor and address quality of care and staffing concerns.

The visit was a complaint investigation triggered by allegations of delayed staff response to call lights and medication administration failures. The investigation substantiated these issues.

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

The facility implemented multiple corrective actions including staff education on resident-specific care needs, privacy, dignity, pain management, nutrition, dialysis coordination, infection control, medication management, environmental maintenance, and quality assurance processes. The plan includes ongoing audits, resident interviews, and quality assurance monitoring to ensure compliance and improvement.

Complaint investigation into multiple complaints including resident privacy violations, abuse and neglect allegations, inadequate care and staffing, and infection control issues.

The facility failed to ensure resident rights, privacy, and dignity; failed to conduct proper background checks and abuse investigations; failed to maintain sanitary conditions; failed to develop and implement effective care plans for pain, skin integrity, nutrition, and medication management; failed to provide sufficient staffing; and failed to maintain proper infection control and medication storage.

The Plan of Correction outlines corrective actions for deficiencies related to policy availability, Resident Council meetings, Negotiated Service Agreements, and emergency evacuation fire drills. The facility describes steps taken to educate residents and staff, conduct audits, and monitor compliance through QAPI.