Good Samaritan Health Care Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma informed care complete with identified experiences and preferences regarding potential triggers (a stimulus that could prompt a recall of a previous traumatic event even if the stimulus itself is not traumatic or frightening) that may cause re-traumatization (a reliving of the traumatic experience) for 1 of 3 residents (Resident 47) reviewed for trauma informed care. This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Review of the facility's policy titled, Trauma Informed Care, revised October 2022, showed the purpose was to .ensure that residents who are trauma survivors receive culturally competent, trauma-informed care .in order to eliminate or mitigate (to make less severe or painful) triggers that may cause re-traumatization of the resident. The policy showed the facility promoted an environment of…

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 interview and record review the facility failed to ensure that 1 of 5 residents (Resident 1) reviewed for unnecessary medications, had an acceptable indication for use for a psychoactive medication (a class of medication that affects brain activity of mental functioning and behavior). Resident 1 was prescribed an antipsychotic medication (a psychoactive medication primarily used to treat psychosis with a high risk for adverse side effects [ASE's]) with no acceptable mental health diagnosis or identified individualized target behaviors to justify the use of an antipsychotic. This failure placed Resident 1 at increased risk for deterioration in their mental and physical health status. Findings included . Record review of a facility policy titled, Behavior Management/Psychotropic Medication Overview, dated 10/2022 showed, .When psychotropic medications are ordered, an appropriate diagnosis must have been obtained .Behavior monitoring will be documented when an antipsychotic medication is ordered…

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 interview and record review, the facility failed to provide copies of personal and medical records, as required, to 1 of 3 residents (Resident 1), reviewed for resident rights. This deficient practice placed residents at risk of not having access to their complete medical history, potentially affecting their ability to make informed decisions, and violated their resident rights. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses of muscle wasting, contusion (bruise) of the scalp, and repeated falls. Review of the comprehensive assessment completed on day of discharge, dated 12/04/2023, showed Resident 1 had intact cognition and required set up and supervision assistance with personal cares. Review of record requests received by the facility showed a written request, dated 07/29/2024, was submitted to the facility on behalf of Resident 1 by a local attorney's office. The records request included a Consent for…

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 maintain their Respiratory Protection Program (RPP) for N95 respirator masks (a respiratory protective device designed to filtrate airborne particles by achieving a very close facial fit) initial and annual fit testing for 4 of 5 staff (Staff D, E, F, and G) reviewed for infection control practices during a COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing, that could result in severe impairment or death) outbreak. This deficient practice placed residents and staff at continued risk of exposure and spread of COVID-19 during an active outbreak. Findings included . Review of guidance from the Washington State Department of Health titled Respiratory Protection Program for Long-term Care Facilities, showed the N95 respirator protected the user when the seal around the person's nose and mouth was tight enough to prevent the respiratory…

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 interview and record review, the facility failed to prevent an avoidable accident when COVID 19 reagent solution (a chemical used in a test to determine if a person has COVID 19 [infectious disease by a virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death]) was used as an eye drop for 1 of 1 resident (Resident 2) reviewed for accidents and hazards. This deficient practice placed residents at risk for unnecessary exposure to chemicals and potentially harmful outcomes. Findings included . <Resident 2> Review of the medical record showed Resident 2 admitted to the facility on [DATE] with diagnoses of pelvic fracture, head contusion (a deep bruise caused by a direct blow to the body), and bladder infection. Review of the comprehensive assessment, dated 03/24/2024, showed Resident 2 was…

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 interview and record review, the facility failed to ensure residents were free from significant medication errors when physician's orders were not implemented timely for 1 of 2 residents (Resident 1) reviewed for medication administration. This deficient practice placed residents at risk for adverse side effects and an overall decline in medical condition. Findings included . <Resident 1> Review of the medical record showed Resident 1 readmitted to the facility on [DATE] with diagnoses of osteomyelitis (infection in the bone) to the left foot, diabetes mellitus (a disease that a disease that impairs the body's ability to process sugar in the blood), and peripheral vascular disease ([PVD] circulation disorder caused by narrowing, blockage or spasms in the blood vessels of the legs and feet). Review of the comprehensive assessment dated [DATE] showed Resident 1 had moderately impaired cognition, required the assistance of one person for personal cares, hygiene, dressing, and the assistance of two people…

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 residents who had personal fund accounts established, received accrued interest on those accounts or accurate statements for 11 of 18 residents (Residents 1, 4, 5, 12, 21, 29, 32, 33, 50, 51, and 183) reviewed for personal funds. This failed practice caused residents not to receive or have access to monies owed to them. Findings included . Review of the facility's policy Resident Trust Account, dated 01/2023, showed the facility would provide a secure bank account that earns interest for residents. The policy further showed the trust accounts would be reconciled within two days of receiving the monthly bank statement and at that time interest would be posted to the resident's accounts. Review of the resident's printed statements and lists of trust accounts, provided by Staff D, Business Office Manager, who had personal funds accounts established, showed 11 current residents and one discharged resident with balances greater than $50.00 and no interest income had been earned or applied to the accounts. Review of a 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Four medication errors were identified for 3 of 14 residents (Residents 6, 27 and 52) observed during 25 medication administration opportunities that resulted in an error rate of 16%. Errors in medication administration had the potential to place residents at risk for not receiving the full therapeutic effect of the medication and possible adverse side effects. Findings included . <Resident 6> Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses including lung disease and muscle weakness. The 07/14/2023 comprehensive assessment showed the resident required limited assistance of one staff for activities of daily living (ADLs). The assessment also showed the resident had an intact cognition. Review of the physician's orders, dated 12/08/2021, showed that the resident's Methadone (a [narcotic-a medication that has a numbing, calming…

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 ensure resident's personal refrigerators; 1. were free of expired foods, 2. temperatures were being monitored and maintained within acceptable standards of practice, and 3. cleaning schedules were followed for 4 of 4 residents (Resident 4, 5, 51, and 31) reviewed for safe food handling practices. This failed practice put residents at risk for being exposed to a food-borne illness (Illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and decreased quality of life. Findings included . Review of the facility's policy, titled Resident Room Refrigerators/Resident Food, dated November 2019, showed temperatures of the refrigerators were to be checked and documented on the temperature log twice weekly by the housekeeping staff. The housekeeping staff were also responsible for the disposing of expired food. The policy further showed, food items that required refrigeration should have been kept in air-sealed tight…

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 implement effective infection control practices for 2 of 4 dining rooms (West and Rehab Dining Rooms), reviewed for appropriate infection control practices during meal serve out. This failure placed residents at risk for infectious diseases and a diminished quality of life. Findings included . <West Dining Room> During an observation on 08/07/2023 at 11:50 AM , Staff W, Nursing Assistant, (NA), entered the [NAME] dining room and poured beverages for residents. Staff W did not wash their hands prior to serving beverages. Staff W also cleaned up a coffee spill and without performing hand hygiene continued to make drinks and serve them to the residents (Residents 9, 28, 36 and 78). Staff W assisted residents entering the dining room to their places at the tables. Staff W helped the residents with their clothing protectors and adjusted residents sitting in their wheelchairs for more upright positioning. Staff W did not perform hand hygiene after touching the residents and their equipment. Observation on 08/07/2023…

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 provide a safe and sanitary environment for unlocked and opened doors to soiled utility rooms and storage rooms that contained an electrical power source, cable hookups, exposed electrical wires, metal bars, shelves with loose miscellaneous metal parts and a basket of metal oxygen connectors on 4 of 6 hallways (Hallways main, 2, 4, and 5), reviewed for safe and sanitary environment. This failure placed residents at risk of injury, potential illness related to unclean conditions, and a diminished quality of life. Findings included . Observation on 08/11/2023 from 10:40 AM through 11:02 AM showed the storage room's door in the 500 hall near the nurse's station was partially open. This room had three round utility bins that contained soiled briefs and linens. Observation on 08/11/2023 from 11:04 AM to 11:12 AM showed the storage room's door in the 500 hall near the nurse's station was partially open. Observation on 08/14/2023 from 9:29 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide care and services in a dignified manner when 1) tally marks (a form of numeral used for counting ongoing results) were placed on a whiteboard every time the call light button was turned on, and 2) the resident did not receive assistance with their care needs while out of the facility at an appointment (appt) for 1 of 3 sampled residents (Resident 71) reviewed for dignity. This failure resulted in Resident 71 feeling like they were part of undignifed interactions with the facility staff, they could not ask for help when they needed it, and embarrassed. Findings included . Review of the facility's policy Resident Rights, dated as revised 11/2016, showed residents had the right to .a dignified existence .inside and outside the facility . and dignity and respect when they received care and treatment. <Resident 71> Review of the resident's electronic health record (EHR) showed the resident admitted to the facility on [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 observation, interview, and record review, the facility failed to maintain private medical information in a manner that ensured privacy, securtiy, and confidentiality for 2 of 2 residents (Residents 39 and 53) reviewed for confidentiality of medical records during medication pass.This failure placed residents at risk for loss of personal privacy and confidentiality of medical information. Findings included . Review of the facility's policy titled, Resident Rights, revised 11/2016, showed the facility will honor the resident's rights to include their right to privacy and confidentiality. The policy also showed the facility must give the resident a list of their rights which included each resident having the right to confidential treatment of their personal and medical records. These records may not be shown to any other person without permission from the resident, unless required by law for care. <Resident 39> Review of the medical record showed the resident was readmitted to the facility on [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 observation, interview, and record review, the facility failed to ensure a homelike environment for 2 of 2 residents (Resident 55 and 23), reviewed for comfortable room temperatures. This failure placed the resident in an uncomfortable room environment and a diminished quality of life. Findings included . Review of the facility's 11/2016 policy titled, Resident Rights, showed that the facility would honor resident rights including the right to receive treatment and care in a safe, clean and homelike environment that promotes maintenance or enhancement of their quality of life and individuality. <Resident 55> Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including weakness, depression, and aphasia ( a brain disorder that causes trouble speaking). The 06/23/2023 comprehensive assessment showed the resident required extensive assistance of one staff member for activities of daily living (ADLs). The assessment also showed the resident has a severely…

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 recognize a resident's grievance as an allegation of abuse for 1 of 2 sampled residents (Resident 58), reviewed for abuse. This failure resulted in Resident 58 feeling bad and placed them at risk for unidentified abuse and psychosocial harm due to unrecognized allegations of abuse. Findings included . Review of the facility's policy Abuse/Neglect/Misappropriation/Exploitation, dated as revised 10/2022, showed the facility was to implement procedures designed to identify potential instances of abuse. During an interview on 08/07/2023 at 3:48 PM, Resident 58 said the other day a nurse came into their room while the Nursing Assistants (NAs) were using a mechanical lift (a type of equipment used to assist a person to be lifted and transferred) to help them get out of bed. Resident 58 said the nurse seemed pushy and asked the NAs why they were using the mechanical lift, stating Resident 58 needed to try, and if they did not get up they were going to be bedridden. Resident 58 stated that during a prior conversation,…

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 conduct thorough investigations for 2 of 2 residents (Residents 58 and 71) reviewed for allegations of abuse. This failed practice placed residents at risk for unmet care needs and decreased quality of life related to unrecognized abuse/neglect. Findings included . Review of the facility's policy, titled, Incident Documentation and Investigation,, dated October 2022, showed the facility would complete an incident investigation as soon as an .allegation of abuse, neglect . was identified. The policy further showed the incident should include .protect the resident; a description of the incident, including resident description and the immediate action that was taken; physician and family notification was documented; the licensed nurse (LN) obtains witness statements from the assigned nursing assistant, nursing assistants in the immediate area, nursing assistants from the shift prior, roommates, and the alleged perpetrator; the resident is placed on alert charting to monitor for adverse effects to the incident;…

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 consistently follow feeding guidelines for 2 of 2 residents (Residents 78 and 28), reviewed for safe swallowing guidelines. This failure placed the residents at risk for choking, aspiration (a condition where food or liquids are breathed into the lungs), and an overall decline in their health status. Findings included . <Resident 78> Review of the resident's Electronic Health Record (EHR) showed the resident was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty in swallowing foods or liquids) and dementia. Review of the resident's most recent comprehensive assessment, dated 06/27/2023, showed the resident had impaired cognition and required an extensive assist of one for eating. Further record review showed the resident was admitted to the hospital on [DATE] related to shortness of breath and possible aspiration pneumonia (an infection that affects one or both lungs). Review of a hospital speech therapy…

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 ensure that residents who required dialysis (a process that uses a machine to filter waste and fluids from the blood when the kidneys no longer function) received care and services consistent with professional standards of practice for 2 of 3 residents (Residents 333 and 26), reviewed for dialysis services. The facility did not ensure that communication forms were completed, and pre/post dialysis treatment weights were consistently available for facility staff to monitor for changes in the resident's condition. This failure placed the residents at risk for unidentified complications. Findings included . The facility policy titled Dialysis, revised 11/2015, showed . Send the Dialysis Communication Form to the dialysis center The dialysis center documents weights for pre and post dialysis treatment. The licensed nurse on duty when the resident returns from dialysis will ensure the Dialysis Communication Form was completed . Completed…

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 ensure culturally competent, trauma-informed care related to assessing for trauma, and identifying triggers for residents with a history of sexual assault for 2 of 2 residents (Residents 4 and 57), reviewed for mood and behavior. This failed practice put residents at risk for re-traumatization, unidentified triggers, and a decreased quality of life. Findings included . Review of the facility's policy, titled Trauma Informed Care, dated 10/2022, showed the facility would .identify triggers; utilization of family/friends, responsible parties for history, triggers and interventions; will offer/provide community resources including mental health services; the plan of care will be reviewed routinely . <Resident 4> Review of the resident's electronic health record (EHR) showed the resident re-admitted to the facility on [DATE] with diagnoses to include depression (a mood disorder that causes a persistent feeling of sadness and loss of interest…

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 interview, and record review, the facility failed to ensure as-needed (PRN) psychotropic medications (medications capable of affecting the mind, emotions, and behavior) were limited to 14 days without providing a physician-documented rationale or duration for 1of 5 residents (Resident 51) reviewed for unnecessary medication use. This failure placed the resident at risk of being over medicated, medical complications related to the side effects, and a diminished quality of life. Findings included . Review of the facility's policy's, titled Behavior Monitoring/Psychotropic Medication Policy, dated October 2022, and Behavior Management/Psychotropic Medication Overview, dated October 2023, showed no process for the use of PRN psychotropic medication use. <Resident 51> Review of Resident 51's electronic health record (EHR) showed the resident admitted to the facility on [DATE] with diagnoses to include a lung disease and anxiety (Intense, excessive, and persistent worry and fear about everyday situations).…

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.