Marion and Bernard L Samson Nursing Center

In the surveyor’s words

From the most serious findings on record at Marion and Bernard L Samson Nursing Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF645Mar 21, 2024

  Based on record review, staff interview, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Reviews (PASARR) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnosis for five (Residents #64, #16, #61, #103 and #98) out of seven residents sampled for PASARRs. Findings included: Review of the electronic medical record (EMR) revealed Resident #64 was admitted to the facility on [DATE]. An admission record for the resident revealed a primary diagnosis of Alzheimer's and a secondary diagnosis of Dementia. […]

• No harm, potential for more than minimal, widespreadF732Mar 21, 2024

  Based on observations and interviews, the facility failed to ensure Nurse Staffing Information was posted accurately for four of four days. Findings included: An observation was conducted on 3/18/2024, 3/19/2024, 3/20/2024, and 3/21/2024 at various times throughout the days, at the front entrance of the facility, and each facility nurse station (total of 4 floors). A Staff Posting Report, which reports the number of nursing staff assigned in the facility for the day, was not observed. An interview was conducted with the Staffing Coordinator on 3/21/2024 at 12:20 PM. The Staffing Coordinator stated the total numbers were posted by the receptionist at the front desk. The Night Nursing Supervisor placed the posting at the reception desk, in a plastic frame. […]

• No harm, potential for more than minimal, widespreadF881Mar 21, 2024

  Based on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed. Findings included: Review of the facility's infection prevention documentation showed no documentation related to an ongoing surveillance of resident infections and antibiotic orders for the months of February and March of 2024. On 3/20/24 at 1:50 p.m., an interview was conducted with the current Infection Control Preventionist (IPC), who was also the Assistant Director of Nursing as well as assistant manager to the unit managers on the second and third floor. The IPC transitioned to this role in January 2024. […]

• No harm, potential for more than minimal, patternF695Mar 21, 2024

  Based on observations, staff interviews, and medical record reviews, the facility failed to ensure that seven (#555, #28, #43, #87,#37, #58, and #96) seven randomly observed residents who received respiratory care, had their respiratory equipment (e.g., oxygen tubing, nebulizers) properly stored while not in use, and dates on the residents' oxygen tubing. The findings included: 1. On 03/18/24 at 12:25 p.m., Resident #555, who had pneumonia, was receiving oxygen via nasal cannula at 1.5 liters/minute according to the flow meter on the standard oxygen concentrator (a machine that uses room air to make oxygen for people who need supplemental oxygen). There was no date on oxygen tubing, so that the staff would know how long the tubing has been in use. […]

• No harm, potential for more than minimal, patternF761Mar 21, 2024

  Based on observation, interview, and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for six (Residents #56 #107, #54, #43, #133, and #407) on three of three floors (2nd, 3rd and 4th floors) and did not ensure medication and treatment carts were secured on two of three floors (2nd and 3rd floors). Photographic evidence was obtained. Findings included: On 3/19/24 at 9:15 a.m. Staff B, Licensed Practical Nurse (LPN) left a brown glass medication bottle on top of the medication cart when she went to administer medications to a resident. The cart was not positioned where it was always visualized by Staff B. On 3/20/24 at 12:50 p.m. […]