Good Samaritan Society - St James

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 11, 2023

  Based on observation, interview, and document review the facility failed to ensure resident protection when NA-A verbally abused 1 of 2 residents (R1) who complained of abuse. Additionally, the facility failed to protect residents when R4 physically assaulted 1 of 1 resident (R5) who expressed ongoing fear of R4. The facility's failure resulted in an immediate jeopardy for (R1 and R5). The IJ began on 4/19/23, when nursing assistant (NA)-A returned to work without training after calling R1 bitch causing R1 to express ongoing fear of verbal abuse. Additionally, on 4/29/23, R4 wandered into R5's room and choked R5. The DON and Administrator-B were notified of the immediate jeopardy at 5:46 p.m. on 5/9/23. […]

• Immediate jeopardy, isolatedF689Mar 8, 2023

  Based on observation, interview and document review, the facility failed to provide adequate supervision for 1 of 4 residents (R2) with exit seeking behaviors and appropriately secure an unlocked patio door when not in direct supervision of staff. This resulted in an immediate jeopardy (IJ) when R2 eloped from the facility without staff knowledge into the parking lot during freezing weather on 2/23/23. R2 was heard ringing the doorbell to be let back into the facility at 5:41 a.m. Staff were unaware R2 had gone outside. The IJ began on 2/23/23 at 5:36 a.m., when R2 left the facility without staff knowledge through an unsecured door. The facility administrator and interim director of nursing (IDON) were notified of the IJ on 3/7/23 at 5:49 p.m. […]

• Immediate jeopardy, isolatedF686Oct 15, 2021

  Based on interview and document review, the facility failed to notify the provider for care and treatment orders after an unstageable pressure ulcer (PU) developed for 1 of 3 residents (R1) reviewed, which resulted in R1's admission to the hospital due to [CONDITION(S)] (the body ' s extreme response to an infection. It is a life-threatening medical emergency) where she subsequently died . This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when the facility failed to notify the provider, upon discovery, that R1 had develop an unstageable PU, provided care (cleansing and a foam dressing) for three days without provider PU orders and then transferred R1 to the hospital where she died four days later of [CONDITION(S)]. […]

• Actual harm, isolatedF689Aug 31, 2021

  Based on observation, interview and document review, the facility failed to comprehensively assess and develop care planned interventions to prevent falls upon admission for 1 of 3 residents (R1) reviewed who were at risk of falling upon admission. R1 was actually harmed when the facility had not placed fall prevention interventions, R1 fell and fractured her ribs, leg, and wrist, was hospitalized , required surgery, and had declined in ability to perform activities of daily living (ADL's). Findings Include: R1's entry tracking Minimum Data Set (MDS) indicated R1 had been admitted on [DATE]. R1 had a PPS (prospective payment system) MDS (for Medicare payment purposes) dated 8/16/21. […]

• No harm, potential for more than minimal, widespreadF726Aug 31, 2023

  Based on interview and document review, the facility failed to ensure agency nursing assistants (NA's) received appropriate orientation and training prior to starting their first shift caring for residents. This had the potential to affect all 25 residents residing in the facility. Findings include: On 8/29/23 at 2:36 p.m., agency nursing assistant (NA)-A stated the facility used a lot of agency nursing staff including NA's. NA-A stated agency staff came one hour prior to their scheduled shift and received an hour of orientation before caring for residents on their own. NA-A stated one hour was not enough time to show and explain everything. NA-A stated when she arrived one hour prior to her first shift, she was provided sheet of paper that included resident's names and room numbers. […]