Good Samaritan - Ellsworth

In the surveyor’s words

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

• Actual harm, isolatedF684Aug 25, 2026

  Based on record review, observation, and interview, the facility failed to follow the standards of practice for Resident (R) 1 related to weight monitoring and reporting increasing weight and edema with shortness of breath to ensure physician involvement, resulting in an exacerbation of congestive heart failure (CHF-a condition with low heart output in which the body becomes congested with fluid) requiring hospitalization. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of CHF, hypertension (high blood pressure), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), interstitial pulmonary disease (inflammation and scarring in the tissue around the tiny air sacs in the lungs), chronic obstructive pulmonary disease (COPD- a… […]

• Actual harm, isolatedF684Aug 1, 2023

  The facility reported a census of 32 residents. The sample included five residents reviewed for bowel management. Based on record review and interview, the facility failed to assess bowel function/sounds at onset of abdominal discomfort before staff administered an as needed (PRN) laxative suppository to ensure active bowel sounds to rule out obstruction (a blockage that kept food or liquid from passing through the small or large intestine) for Resident (R) 1, who transferred to the hospital on 07/20/23 and admitted for a bowel obstruction. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. […]

• Actual harm, isolatedF689May 23, 2023

  The facility identified a census of 37 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to ensure staff met Resident (R) 1's safety needs during transport to a doctor's appointment. On 04/12/23, Transportation Driver U drove R1 to an appointment out of town, sixty-two miles away. Transportation Driver U buckled R1's wheelchair into the safety hooks but failed to place the lap belt and shoulder harness across R1's body. On the way to the appointment, Transportation Driver U made an abrupt stop to avoid being hit by another car. In the process of braking suddenly, , R1 slid out of her wheelchair and onto the floor of the transport van with her legs going underneath the front seats of the driver's seat. […]

• Actual harm, isolatedF689Oct 24, 2022

  The facility identified a census of 33 residents with three residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide a safe environment and adequate transfer assistance for Resident (R) 1. On 10/17/22 at approximately 05:30 PM, Certified Nurse Aide (CNA) M assisted R1 out of the whirlpool tub. CNA M opened the whirlpool door, pulled the whirlpool chair out of the whirlpool bath, positioned the whirlpool chair next to R1's wheelchair, which was next to the whirlpool bath, and transferred R1. CNA M transferred R1 on her right side. R1 reached out with her left hand to steady herself and used the open whirlpool door which swung back and hit her right hand. […]

• No harm, potential for more than minimal, widespreadF812Jul 2, 2024

  The facility had a census of 38 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and serve food under sanitary conditions for 38 residents who reside in the facility and receive meals from the facility kitchen, placing the residents at risk for foodborne illness. Findings included: -On [DATE] at 09:19 AM, during initial inspection of the kitchen observation revealed the walk-in refrigerator and freezer had numerous boxes directly stored on the floor. Dietary Staff (DS) BB reported the facility had received supplies the day prior, staff had not unloaded boxes, and the boxes should not have been stored on the floor. The walk-in refrigerator also contained a bag of carrots, opened with use by date of [DATE]. […]