Good Samaritan - Atwood

In the surveyor’s words

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

• Immediate jeopardy, patternF610Jul 31, 2024

  The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to investigate an allegation of sexual abuse and initiate protective measures until an investigation was completed. On 07/24/24 at 09:37 PM Resident (R)1 told her daughter that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). LN G told R1's representative there were no male staff working that night and said she had been down R1's hallway passing medications and had not seen anyone walking in the hall. […]

• Immediate jeopardy, isolatedF609Jul 31, 2024

  The facility identified a census of 24 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported Resident (R)1's allegation of sexual abuse to the Licensed Nursing Home Administrator (LNHA) and further failed to report the sexual abuse allegation to the required state agencies including law enforcement. On 07/24/24 at 09:37 PM, R1 told her representative that a dirty old man came into her room and tried to get into her pants. At 10:00 PM R1's representative called the facility and reported the allegation to Licensed Nurse (LN). […]

• Immediate jeopardy, isolatedF686May 9, 2024

  The facility identified a census of 27. The sample included three residents reviewed for pressure injuries/ulcers. Based on record review and interview, the facility failed to ensure adequate treatment to prevent the worsening of a facility acquired pressure ulcer and failed to promote healing. On 12/15/23, Resident (R) 1, who required assistance from two staff for bed mobility, developed a facility acquired unstageable (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) pressure ulcer to her left heel. The facility applied heel protectors but did not involve the provider until seven days later. The provider ordered a dressing to the wound, changed every seven days. […]

• Immediate jeopardy, isolatedF700Oct 12, 2022

  The facility had a census of 31 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to assess and identify risks for Resident (R)1, who was severely cognitively impaired, regarding the use of side rails and further failed to place bolsters (a long thick pillow that is placed under other pillows for support) as required to prevent entrapment when side rails and an air mattress were used concurrently. On [DATE] facility staff placed side rails on R1's bed, already equipped with an air mattress, to assist R1 with bed mobility. The facility did not place a bolster per policy to protect R1 from entrapment. On [DATE] R1 experienced a significant change and was placed on hospice services. […]

• Actual harm, isolatedF689Jan 3, 2024

  The facility identified a census of 34 residents with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to prevent a fall with major injury to Resident (R) 1. On 12/11/23 at approximately 07:45 AM, Certified Nurse's Aide (CNA) M failed to apply the safety belt in the bath chair. As a result of this failure, R1 sustained a displaced intertrochanteric (area between the greater and lesser hip bone) fracture (broken bone) of the right femur (the bone of the thigh). […]