Good Samaritan - West Union

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record (EHR), clinical records, facility records, facility policy review, and staff interview the facility failed to timely report an allegation of abuse for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 35 residents. Findings Include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated moderate cognitive impairment. The MDS documented Resident #2 had no hallucinations or delusions. The MDS identified Resident #2 had been occasionally incontinent of urine. The MDS listed diagnoses of renal insufficiency, over-active bladder, non-Alzheimer's dementia, and post-traumatic stress disorder (PTSD).The Care Plan Report revised on 4/20/26 identified Resident #2 had a psychosocial well-being deficit related to Post Traumatic Stress Disorder (PTSD). The Care Plan Intervention dated 4/20/26 directed staff to explain all care procedures prior to completing, and the Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on electronic health record (EHR) review, clinical records, facility records, facility policy review, and staff interviews the facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) before the PASRR short term approval end date for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 35 residents.Findings Include:Resident #2's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 2/25/26. The MDS identified Resident #2 was currently considered by the state level II PASRR process to have a serious mental illness. The MDS included a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderate cognitive impairment. The MDS documented Resident #2 had no hallucinations or delusions. The MDS listed diagnoses of depression, bipolar disorder, and post-traumatic stress disorder.The Notice of PASRR Level II Outcome dated 2/16/26 documented a short-term approval end date of 4/17/26. The PASRR Outcome Explanation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, policy review and staff interview the facility failed to provide education and obtain informed consent prior to starting psychotropic medication that have black box warnings (the most serious safety warning used by the Food and Drug Administration (FDA) and requires the healthcare provider to have a comprehensive discussion with the resident about the risks, benefits and alternatives for use) for 1 of 5 resident sampled (Resident #7). The facility identified a census of 38 residents.Findings include: Resident #7's 2/19/26 Minimum Data Set (MDS) Assessment documented the resident utilized a hearing aid and was able to hear with minimal difficulty. Resident #7 had unclear speech but was usually able to understand others. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition. The MDS documented Resident #7 had little interest/pleasure in doing things 2-6 days; felt down, depressed or hopeless 7-11 days; had little energy 2-6 days; felt bad, or a failure of letting herself or family down…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, document review, policy review and staff interview, the facility failed to serve the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) as required; failed to outline the specific Medicare services that would be ending and failed to document the estimated charges to continue skilled services for 2 of 3 residents sampled (Resident #1 and #13). The SNF ABN Form communicates to a resident and/or legal representative when Medicare services will no longer be covered and they may be liable for payment of services. The facility identified a census of 38 residents.Findings include: 1.Resident #1's Electronic Healthcare Record (EHR) Census showed he admitted into Medicare skilled services on 1/22/26. A 1/22/26 10:10 PM Health Status Progress Note documented Resident #1 admitted to the facility and would be receiving physical therapy (PT) and occupational (OT) therapy services. A Center for Medicare and Medicaid (CMS) SNF Beneficiary Protection Notification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review, Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Version 1.20.1, dated October 2025 (RAI) review and staff interview the facility failed to correctly code insulin on the Minimum Data Set (MDS) for 1 of 3 residents (Resident #12) reviewed for insulin use. The facility reported a census of 38 residents.Findings include:The admission Record for resident #12 documented an admission date of 10/10/22.The MDS dated [DATE] documented the resident received insulin 1 time during the assessment period of 12/19/25- 12/25/25.The Order Summary Report dated 12/25/25 lacked an order for insulin.The Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of insulin being given.Facility policy titled MDS 3.0 (Minimum Data Set) RAI (Resident Assessment Instrument)- Rehab/Skilled & Therapy and Rehab last reviewed on 10/27/25 directs staff to determine if there is accurate documentation to support coding for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, policy review, and staff interview the facility failed to implement a revised Restorative Nursing Program (RNP) and failed to provide active assist range of motion (AAROM) per the RNP for 1 of 1 residents sampled (Resident #2). The facility identified a census of 38 residents. Findings include:Resident #2's 1/1/26 Minimum Data Set (MDS) Assessment showed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. The Resident exhibited impaired functional mobility on one side of the upper and lower body; utilized a walker and wheelchair. The MDS listed diagnoses of stroke, hip fracture, and multiple sclerosis (a disabling autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves) that causes disruption of communication between the brain and body, leading to symptoms like fatigue, mobility challenges, vision problems, and numbness). The MDS documented Resident #2 participated in 1 day of restorative nursing active range of motion in the last 7 days.A 2/25/26 Therapy and Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, and observations the facility failed to provide a sufficient number of staff to ensure each resident's call light is answered timely for 5 of 6 residents reviewed (Resident #2, #3, #4, #5, #6). The facility reported a census of 45 residents. Findings include: 1. According to the Minimum Data Set, dated [DATE], Resident #2 had diagnoses which included diabetes and dementia. The resident had a brief interview for mental status score (BIMS) of 9 which indicated moderate cognitive ability. The MDS revealed the resident required substantial assistance from staff for toileting and activities of daily living. The resident utilized a walker with one staff to ambulate to the rest room. During an interview with Resident #2 on 10/29/24 at 11:10 am, the resident indicated when he presses his call light it takes a while for the staff to assist him to the restroom. He admitted that he sometimes has to go to the bathroom and does not wait for the staff to assist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, staff and resident interviews, and observations the facility failed to provide tuberculosis screening for 2 of 3 new employees reviewed (Staff H and Staff I). The facility reported a census of 45 residents. Findings include: Review of employee file documents revealed Staff H-Certified Nurses Aide had a hire date of 6/25/24 and worked full time. During an interview with Staff H-CNA on 10/29/24 at 11:10 am, Staff H stated when she began her employment at the facility the former Director of Nurses only did 1 tuberculosis screening test and failed to give her the second step as required. Staff H began her Step 2 Tuberculosis screening on this day. Review of employee file documents revealed former Staff I-Certified Nurses Aide had a hire date of 12/19/23. The facility received her archived employee file from the Corporate office but failed to find the aide ever had any tuberculosis screening completed as per facility policy. Review of the Tuberculosis Control Plan and Screening for Employees policy dated 12/7/2023 indicated new employees will have a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and policy review the facility failed to ensure 4 of 5 residents were educated about immunizations and offered the Influenza and Pneumococcal vaccination annually (Resident #20, #39, #15, and #34). The facility reported a census of 38 residents. Findings include: 1. Record review of Resident #20 Electronic Health Record (EHR) Immunizations on 5/9/24 revealed she had not received the following: a. Pneumococcal Polysaccharide (PPSV23) b. Pneumococcal Conjugated (PCV20) Record review of Resident #20 Progress Notes 2/28/2020 to 5/9/24 lacked documentation that education was provided or that she was given or refused PPSV23 and PCV20 vaccinations (for Pneumonia). 2. Record review of Resident #39 EHR Immunizations on 5/9/24 revealed he was not up to date with Pneumococcal vaccinations. Record review of Resident #39 Progress Notes 11/30/2023 to 5/9/24 lacked documentation that education was provided or that he was given or refused Pneumococcal vaccines. 3. Record review of Resident #15 EHR Immunizations on 5/9/24 revealed he was not up to date with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to send appropriate records for a transfer to the local emergency room (ER) for 1 of 1 residents reviewed (Resident #42). The facility reported a census of 38 residents. Findings include: Record review of Resident #42 Minimum Data Set (MDS) dated [DATE] documented he was discharged on 4/5/24 to the local hospital. The MDS informed his cognitive skill for daily decision making was severely impaired. Record review of Resident #42 Assessments in his Electronic Health Record (EHR) lacked documentation a discharge Assessment was completed on 4/5/24. Record review of Resident #42 Progress Notes on 4/5/24 lacked documentation of what paperwork was sent with the resident to the local hospital. During an interview on 5/9/24 at 10:40 AM the facilities Administrator revealed when Resident #42 went to the hospital on 4/5/24 they did not update the hospital or send documents regarding ADL's, his Care Plan, or what personal belongings were being…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff and pharmacist interview, the facility inaccurately coded 2 of 2 residents Minimum Data Set (MDS) by documenting the residents received insulin during the look back period when they did not (Resident #4 and #10). The facility reported a census of 38 residents. Findings include: 1. The MDS for Resident #4 dated 2/15/24 documented she received one insulin injection between 2/9/24 to 2/15/24. Record review of Resident #4 Treatment Administration Record (TAR) for February 2024 revealed she did not receive insulin medications. 2. The MDS for Resident #10 dated 2/22/24 documented she received one insulin injection between 2/16/24 to 2/22/24. Record review of Resident #10 TAR for February 2024 revealed she did not receive insulin medications. During an interview on 5/8/24 at 11:16 AM with the facilities Nurse Consultant revealed Trulicity is an insulin and provided TAR for Resident #4 and #10 showing they received the Trulicity injection during their MDS look back period. During an interview on 5/8/24 at 11:18 AM with one of the facilities Pharmacists revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and policy review the facility failed to provide documentation of what interventions were attempted prior to giving as needed (PRN) anti-anxiety medications for 1 of 3 residents reviewed for anti-anxiety medications (Resident #22). The facility reported a census of 38 residents. Findings include: Record review of Resident #22's March 2024 Medication Administration Record (MAR) documented he received his once a day PRN anti-anxiety medication on the following dates: a. 3/2/24 b. 3/3/24 c. 3/4/24 d. 3/5/24 e. 3/7/24 f. 3/8/24 g. 3/9/24 h. 3/10/24 i. 3/11/24 j. 3/12/24 k. 3/13/24 l. 3/16/24 m. 3/18/24 Record review of Resident #22's Progress Notes from 3/4/24 to 3/18/24 lacked documentation of non-pharmacological interventions attempted prior to giving his PRN anti-anxiety medication. Record review of Resident #22's Progress Notes by the Pharmacy Consultant from 2/4/24 to 5/3/24 lacked direction to staff that they needed to document interventions attempted prior to giving PRN anti-anxiety medications. During an interview on 5/9/24 at 10:42 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.