Sam Swope Care Center

In the surveyor’s words

From the most serious findings on record at Sam Swope Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF578Aug 16, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure a residents' right to formulate an advance directive were honored for one of four residents reviewed for advance directives out of 35 sampled residents (Resident (R) 85). R85 who was his own decision maker, requested and signed to be a full code status (life saving measures) upon admission to the facility; however, the facility inadvertently entered a Do Not Resuscitate (DNR) order which contradicted the resident's decision. Additionally, the facility allowed the resident's Power of Attorney (POA) to sign DNR documents instead of the resident signing his own code status forms. […]

• Immediate jeopardy, isolatedF656Aug 16, 2024

  Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for four of 35 sampled residents (Resident (R) 85, R90, R59, and R117). Upon admission to the facility, R85 chose his code status to be a full code; however, the resident's Care Plan contradicted his code status by having conflicting information when his care plan indicated he was a full code and had a do not resuscitate (DNR) code status. This placed the resident at risk for death in the event of cardiac and/or respiratory failure episode. An Immediate Jeopardy was identified at on [DATE] and was determined to exist on [DATE] at S483.21(b)(1) F656-Develop/Implement Comprehensive Care Plan. […]

• Immediate jeopardy, isolatedF656Dec 22, 2022

  Based on interview, record review, review of the facility's camera footage, and review of the facility's policy, it was determined the facility failed to develop a Comprehensive Care Plan (CCP) to ensure one (1) of seventy-six (76) sampled residents (Resident #1) was provided adequate supervision to prevent elopement from the facility on [DATE]. Staff found Resident #1, outside, at the back of the facility on [DATE] at 10:26 PM, approximately five-hundred fifty-eight (558) feet from his/her room. The resident was found on the sidewalk face down and unresponsive behind the facility. Resident #1 was taken to a local Emergency Department (ED) by Emergency Medical Services (EMS). Resident #1 expired, on [DATE] at 11:23 PM. […]

• Immediate jeopardy, isolatedF689Dec 22, 2022

  Based on observation, interview, record review, review of the facility's investigation, review of the facility's camera footage, https://www.wunderground.com and review of the facility's policies, it was determined the facility failed to ensure a safe environment and failed to ensure each resident received adequate supervision and monitoring to prevent an elopement from the facility for one (1) of seventy-six (76) sampled residents (Resident #1). Resident #1 eloped from the facility, on [DATE] at 9:50 PM, and was not found by staff until 10:24 PM. When found, the resident was unresponsive, face down, with blood coming from his/her head. The resident expired at the hospital on [DATE] at 11:23 PM. […]

• No harm, potential for more than minimal, patternF761Aug 16, 2024

  Based on observation, record review, interview, and review of the facility's policy, the facility failed to ensure all supplies in the medication room and crash carts were not expired for three out of the six medication rooms and three out of the six crash carts. This had the potential for the facility to use expired medications and supplies that could potentially not be effective. The findings include: Review of the facility's policy dated 05/2023, titled Crash Cart Stocking Protocol revealed the Director of Nursing or Nursing leadership provided Central supply a list of supplies needed for crash cart . Crash Carts are stocked by Central Supply and are covered until opened and used . […]