The Good Samaritan Society-Kissimmee Village

In the surveyor’s words

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

• Immediate jeopardy, patternF689Sep 6, 2021

  Based on observation, interview and record review, the facility failed to prevent a physically and cognitively impaired resident from exiting the facility; failed to conduct accurate elopement assessments and implement appropriate interventions to address elopement risk; failed to ensure an alarm system functioned effectively to maintain a secure environment; and failed to ensure staff were knowledgeable of elopement protocols to promote safety for 29 of a total sample of 33 residents reviewed for elopement, (#1, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32 and #33). […]

• Immediate jeopardy, patternF835Sep 6, 2021

  Based on observation, interview and record review, the facility failed to effectively utilize its resources to provide oversight of assessments and staff assignments to ensure appropriate levels of supervision; failed to maintain a secure environment with an effective door alarm system; and failed to ensure staff received education and demonstrated proficiency in elopement prevention procedures before and after an elopement incident, for 29 of a total sample of 33 residents reviewed for elopement, (#1, #4, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #30, #31, #32 and #33). […]

• Immediate jeopardy, isolatedF600Aug 10, 2023

  Based on record review, and interview, the facility failed to protect the resident's right to be free from neglect by not ensuring the correct procedure was followed when using a full body mechanical lift to transfer residents, failed to provide nursing care and services to ensure proper post-fall nursing evaluation was conducted and failed to complete a thorough investigation for possible neglect for a fall with major injury for 1 of 7 residents sampled for falls, (#1). This failure resulted in resident #1' transfer to the hospital for treatment of a fractured clavicle and laceration to the head requiring staples. Clavicle fracture (collarbone), is diagnosed through physical examination and x-rays. […]

• Immediate jeopardy, isolatedF609Aug 10, 2023

  Based on interview, and record review, the facility failed to thoroughly investigate an incident involving neglect and failed to report the results of the investigation to the State Survey Agency related to an avoidable fall with major injury for 1 of 7 residents sampled for falls, (#1). On 7/10/23 at approximately 9:30 AM, the facility failed to prevent an avoidable fall for a physically and cognitively impaired resident. The fall occurred during a transfer from a bed to a wheelchair with a full body mechanical lift. Resident #1 fell feet first from the sling while she was suspended above the floor when one of six loops that secured the sling was not attached to the lift. […]

• Immediate jeopardy, isolatedF689Aug 10, 2023

  Based on interview, and record review, the facility failed to prevent an avoidable fall with major injury for a vulnerable, physically, and cognitively impaired resident, and failed to ensure the correct procedure was followed when using a full body mechanical lift to transfer residents for 1 of 7 residents sampled for accidents, of a total of 45 residents requiring mechanical lifts for transfers, (#1). This failure resulted in the resident sustaining a fractured left clavicle and laceration to the head requiring staples. Clavicle fracture (collarbone), is diagnosed through physical examination and x-rays. Resident #1 likely experienced severe pain and swelling at the collarbone fracture and with possible visible deformity. […]