Good Samaritan Ambassador

In the surveyor’s words

From the most serious findings on record at Good Samaritan Ambassador, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 1, 2022

  Based on interview and document review, the facility failed to comprehensively assess and implement individualized interventions to reduce the risk of falls for 2 of 3 residents (R1, R2) reviewed for accidents. This resulted in actual harm for R1 and R2 who both fell multiple times and obtained fractures which required emergency medical care. Findings include: A hospital Discharge Summary for R1 dated 6/30/22, identified the resident had sustained fractures of both hands and right foot due to trauma and [CONDITION(S)]. On 7/23/22, at 5:43 a.m. a progress note identified R1 was admitted to the hospital with intercranial hemorrhage and r (right) femoral neck fracture following a fall 7/22/22 at the facility. […]

• No harm, potential for more than minimal, isolatedF582Jan 9, 2025

  Based on interview and document review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice-Centers for Medicare and Medicaid-10055 (SNFABN-CMS-10055) was provided for 1 of 3 residents (R126) reviewed for beneficiary notices. Findings include: R126's Part A discharge Minimum Data Set (MDS) dated [DATE], indicated R126 was admitted [DATE]. R126's was cognitively intact. R126's Notice of Medicare non-coverage form CMS-10123 (NOMNC-CMS-10123), signed and dated 7/29/24, indicated R126's services would end 7/31/24 although Medicare coverage days remaining. R126 remained in the facility. […]

• No harm, potential for more than minimal, isolatedF880Jan 9, 2025

  Based on observation, interview and document review, the facility failed to use proper personal protective equipment (PPE) for 1 of 1 residents (R17) reviewed for droplet precautions. Findings include: R17's annual Minimum Data Set (MDS) dated [DATE], included R17 was severely cognitively impaired and required substantial assistance for toilet hygiene, dressing, and transfers. R17's electronic medical record (EMR) included a facility form titled Good Samaritan Society - Ambassador COVID - 19 Test dated 12/30/24, indicated a positive test result for COVID-19. R17's EMR entry dated 12/30/24, included R17 tested positive for COVID-19 and droplet precautions were initiated. On 1/7/25 at 8:43 a.m., nursing assistant (NA)-A was observed entering R17's room with a food tray. […]

• No harm, potential for more than minimal, isolatedF554Mar 16, 2023

  Based on observation, interview and document review, the facility failed to assess the ability of 2 of 2 residents (R38 and R32) to self-administer medications observed to be left at bedside, or without a nurse present during administration. Findings include: R38's quarterly Minimum Data Set (MDS) dated [DATE], identified R38 was cognitively intact, and able to express needs. R38 was identified as receiving limited assistance to complete activities of daily living (ADLs). R38's diagnoses included, dementia, anxiety, depression, chronic obstructive pulmonary disease (COPD) and coronary artery disease. During interview on 3/13/23, at 2:28 p.m. it was noted R38 had the following medications on her bedside stand: 1. a 30 milliliter bottle of artificial tears 2. […]

• No harm, potential for more than minimal, isolatedF676Mar 16, 2023

  Based on interview, observation, and document review the facility failed to ensure 1 of 1 resident (R327) who had a significant weight loss received assistance with eating. Findings include: R327's admission Minimum Data Set (MDS) dated [DATE], indicated severe cognitive impairment and required extensive physical assistance of one person for eating. R327's care plan dated 2/21/23, indicated resident required supervision and eating assistance as needed. R327's Mini-Nutritional assessment dated [DATE], indicated no weight loss or decrease in food intake in the prior 3 months, but scored at risk of malnutrition. R327's Food and Nutrition Data Collection dated 2/20/23, indicated R327's hospital admission weight was 180#. […]