Good Samaritan Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to utilize Enhanced Barrier Precautions for 2 (R1 and R3) of 3 residents reviewed for wound care in a total sample of 5. Findings Include:The facility's undated Enhanced Barrier Precautions policy documents: It is the policy of the facility to use Enhanced Barrier Precautions in addition to standard precautions as a method of infection control, requiring the use of gown and gloves in situations of high-contact resident care. Definition: Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms. EBP requires gown and glove use during high-contact resident care activities and prevents the spread of infection to and among residents and staff. EBP will also be initiated for all residents with indwelling medical devices such as, but not limited to central lines, urinary catheters, feeding tubes and tracheostomies. A peripheral intravenous line (not peripherally…

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 and interview, the facility failed to provide documentation by a physician regarding the basis of a resident's involuntary discharge with indications for why a resident should not return to the facility following hospitalization, what resident needs could not be met at the facility, what the facility's efforts were to meet those needs, and the specific services the receiving facility could provide to meet the needs of the resident which could not be met at the facility for one of three residents (R1) reviewed for involuntary discharge in the sample of four. Findings include: R1's Progress Notes, dated 8-31-24 at 4:00 PM, document R1 was sent to the emergency room by ambulance due to R1 having combative behaviors, threatening staff and (V10/R1's Family Member), hallucinating, and having increased paranoia. R1's Progress Notes, dated 9-1-24 at 2:16 AM, document R1 was being admitted to the hospital for treatment of a urinary tract infection and chronic kidney disease. R1's Progress Notes, dated 9-12-24 at 3:00 PM and signed by V4/Admission's Coordinator,…

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 and interview, the facility failed to notify the resident, resident's representative, and the Ombudsman in writing of the reasons for discharge for one of three residents (R1) reviewed for involuntary discharge notice in the sample of four. Findings include: The Ombudsman's Residents' 'Rights for People in Long-Term Care Facilities policy, dated 11/2018, documents, You have the right to keep living in your facility. You must be given written notice if your facility wants you to move from the facility. The notice must: tell you why your facility wants you to move; tell you how to appeal the decision to the Illinois Department of Public Health; and provide a stamped and addressed envelope for you to mail your appeal in. R1's Progress Notes, dated 8-31-24 at 4:00 PM, document R1 was sent to the emergency room by ambulance due to R1 having combative behaviors, threatening staff and (V10/R1's Family Member), hallucinating, and having increased paranoia. R1's Progress Notes, dated 9-1-24 at 2:16 AM, document R1 was being admitted to the hospital for treatment of 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 and interview, the facility failed to provide a bed hold notice to a resident and a resident's representative upon transfer to the hospital for one of three residents (R1) reviewed for bed hold notice in the sample of four. Findings include: The facility's Bed Hold and readmission Policy, dated 10-26-18, documents, Purpose: The primary purpose of the policy for bed hold and readmission to (the facility) is to establish uniform guidelines for the resident, family member, or legal representative in the event a resident is transferred to a hospital, to another level of care, or takes a leave of absence from the home. A written copy of the bed-hold policy will be provided to the resident at the time of transfer for hospitalization or therapeutic leave. R1's Progress Notes, dated 8-31-24, document R1 was sent to the emergency room and admitted to the hospital. R1's Medical Record does not include documentation of a bed hold noticed being given to R1 nor (V10/R1's Family Member) after R1 was sent to the hospital on 8-31-24. On 10-25-24 at 11:28 AM, V10 (R1's Family…

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, interview, and record review, the facility failed to use the Heat Stickers to ensure dishes reach the correct/required surface temperature when in the rinse cycle in the dish machine and failed to have staff wash hands with soap and water as required between handling dirty dishes and clean dishes in the dish room. This has the potential to affect all 101 residents living in the facility. Findings: 1. The document, Dish Machine Temperature Recording for Food Service Staff Policy, 4/2024, states, It is the policy of the Food Service Department that the acceptable wash temperature (should be) 150 - 165 degrees Fahrenheit (F) and the acceptable rinse temperature is 180 degrees F or above. Any temperature reading below 150 degrees F wash, or 180 degrees F rinse should be noted, and a department supervisor or designee notified. On 8/12/24 at 10:55 AM, V5, Assistant Dietary Manager, stated, We do not use the Surface Temperature Stickers for the dish machine. You (Illinois Department of Public Health (IDPH) Surveyor) had me get the (surface temperature stickers) last…

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 and interview, the facility failed to report bruises of unknown origin to the State Agency for two of two residents (R35 and R81) reviewed for abuse in the sample of 34. Findings include: Abuse Prevention Program Facility Policy, dated 6/19/2021, documents, Internal Reporting Requirements and identification of Allegations: Any reasonable suspicion of a crime against a resident or individual receiving care from the facility, including but not limited to, alleged violations of abuse, neglect, exploitation of mistreatment including injuries of unknown source and misappropriation of resident property must be reported to the state survey agency (IDPH/Illinois Department of Public Health) under the following time frames: Alleged Abuse or Serious Bodily Injury - Immediately but no later than 2 (two) hours after forming the suspicion. Allegation of neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury -not later than 24 hours…

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 and interview, the facility failed to initiate abuse investigations for bruises of unknown origin for two of two residents (R35 and R81) reviewed for abuse in the sample of 34. Findings include: Abuse Prevention Program Facility Policy, dated 6/19/2021, documents, Internal Reporting Requirements and identification of Allegations, The nursing staff is responsible for reporting on a facility incident report the appearance of bruises, lacerations, or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation, and reporting to the administrator. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instructions. Internal Investigation of Abuse, Neglect or Misappropriation Allegations and Response. 1. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. 2. Any incident or…

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 interview and record review, the facility failed to ensure a resident was transferred safely during a shower to avoid falling for one of five residents (R45) reviewed for falls in the sample of 34. Findings include: The facility's Program for Reduction of Fall Risk, dated 7/23/15, documents, As part of the program for the prevention of falls, all newly admitted residents and those residents experiencing a change in function will be assessed for the risk of falls. Interventions to prevent falls will be implemented on the basis of the risk assessment. Purpose: To prevent falls and enable staff to recognize those residents who have been found to be at increased risk for falls. R45's current Care Plan, dated 5/28/24, documents, I (R45) have had a decline in my strength/independence during transfers. I use a (mechanical lift) lift for transfers. This same Care Plan documents, I am at increased risk for falls related to impaired cognition, poor safety awareness, diuretic use and weakness. I use a mechanical lift. R45's Safety Event Fall report, dated 7/19/24, documents R45…

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 interview and record review, the facility failed to immediately report an allegation of potential verbal abuse to the administrator and the State Agency for one of three residents (R2) reviewed for abuse in the sample of three. Findings include: The Facility's Abuse Prevention Program, dated 7/24/19, states, Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect or misappropriation of property they observe, hear about, or suspect to the administrator or the person in charge of the facility acting on behalf of the administrator, or an immediate supervisor who must then immediately notify the administrator. A Final Incident Investigation Report, dated 11/6/23, documents an employee, V5/Dietary staff, reported R2 was attempting to get up from her chair after lunch, and V7/Licensed Practical Nurse was heard raising her voice at R2 and trying to get R2 to sit back down. This same investigation documents the incident occurred on 11/5/23, but was not reported to the Administrator or the State Agency until 11/6/23. On 11/14/23 at 2:10…

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 observation, interview, and record review, the facility failed to assess a resident for an underlying condition prior to increasing an anti-psychotic medication, and failed to attempt gradual dose reductions of an anti-psychotic medication for one of four residents (R8) reviewed for anti-psychotic use with the diagnosis of Dementia in the sample of 41. Findings include: The facility's Medication Monitoring Psychotropic Drug Management Program Policy, dated 3-11-19, documents, There will be an attempt at dose reduction of psychotropic medications and/or attempts of alternative behavioral interventions in two separate quarters at least one month apart and then annually thereafter. R8's admission Physician's Order Sheets (POS's), dated 5-5-20, document Risperidone one mg (milligram) at bedtime daily for the diagnosis of Unspecified Dementia without behavioral disturbance. R8's POSs, dated 4-29-21, document R8's Risperidone was increased to one mg at bedtime daily and 0.5 mg daily at 8:00 AM daily, 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 record review and interview, the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) action plan to address symptomatic staff to resident COVID-19 outbreaks within the facility. This failure had the potential to affect all 114 residents residing within the facility. Findings include: The CMS (Centers for Medicare & Medicaid Services) Form 672 (Resident Census and Conditions of Residents), dated 8-31-22 and signed by V2 (Director of Nursing), documents 114 residents reside within the facility. The facility's Quality Assurance Performance Improvement policy, dated 2-11-21, documents, The long term care facility will develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of outcomes of care and quality of life. Based on resident interviews, observations, family interviews, or record reviews any issues that are identified as potentially causing harm to the resident will be immediately brought to the attention of the administrator, addressed, and resolved. Performance…

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 and interview, the facility failed to offer and administer all required boosters for the Pfizer-BioNTech and Moderna COVID-19 (Coronavirus Disease 2019) vaccinations to maintain these residents up to date for 24 of 26 residents (R3, R7, R11, R20, R26, R35, R41, R45, R50, R51, R63, R64, R75, R78, R79, R80, R81, R88, R89, R90, R91, R93, R96, R104) reviewed for COVID-19 immunizations in the sample of 60. Findings include: The facility's COVID-19 Infection Prevention and Control Program policy, dated March 22, 2022, documents, Description: (The facility) has developed a COVID-19 infection prevention and control program to decrease the risk of residents and staff becoming infected with SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), the virus that causes COVID-19. Vaccinations and Vaccine Boosters: COVID-19 vaccinations and vaccine boosters will be offered to all consenting and eligible employees and residents onsite at scheduled dates and times through the (local health department). Additional vaccination locations will be used as they become…

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, interview, and record review, the facility failed to provide a Physician ordered diet to one of three residents (R72) reviewed for nutrition in a sample of 60. Findings include: The facility's Using the Diet Order Communication Form Policy, dated 2022, documents, In health care communities, nutritional care and selection of diet therapy is accomplished through an organized process of assessment and communication. In licensed long term care communities, this occurs after admission, with diet order being written by the attending Physician or authorized designee (such as Registered and /or Licensed Dietitian when allowed by state regulator and licensing authorities). The Diet Order Form is a suggested tool to assist with the communication between nursing and dining services to ensure proper and accurate implementation of the Physician's order. It is suggested that the Dining Services Manager periodically review the written Physician's diet orders against the meal cards to ensure accuracy of meal delivery/service. R72's Nutritional Status plan of care, dated…

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.