Good Samaritan Home Care LLC

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents. Findings include: 1. Upon arrival, the Compliance Officer observed E2 and E3 were the only employees at the facility. 2. In a documentation request, the Compliance Officer asked to review the current employee schedule. E2 presented an "Employee Work Schedule" for review. 3. A review of the current employee schedule revealed E3 was not listed on the schedule at all, even though present at the facility on the day of the inspection. The Compliance Officer also observed the schedule was not current, with the last date recorded as July 18, 2024. 4. In an interview, E2 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day.

Based on documentation review, record review, and interview, the manager failed to ensure an entry in a resident's medical record was not changed to make the initial entry illegible, for two of two residents sampled. The deficient practice posed a risk to the residents' health and safety if the documentation in the medical records was not accurate and legible. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Resident's Medical Records (including electronic records) and Documentation." Under the title, "Procedures," the policy stated, "2. Documentation will be dated, legible, authenticated and only use abbreviations approved for this facility...6. Errors in documentation will be corrected as follows: a. Mistakes will be corrected by drawing a single line through the error and with the initials of the person making the correction next to it. No individual is allowed to correct another person's documentation...c. Use of erasers, white out, scratches is not allowed." 2. A review of R1's medical record revealed white correction fluid was used on a document titled, "Insulin and SQ Treatments Doctor Approval," which rendered the initial entry illegible. 3. A review of R2's medical record revealed an "Activities of Daily Living Chart" with the month of "April" written over a previous entry, which rendered the initial entry illegible. 4. A review of R2's medical record revealed white correction fluid was used on a document titled, "Activities of Daily Living Chart, June 2024," which rendered the initial entry illegible. 5. Further review of resident/facility documentation revealed white correction fluid or a solid white label was used on the following documents, which rendered the initial entry illegible: -"Phone Numbers You Need to Know:" on an unidentifiable residency agreement document dated February 15, 2018; -"Acceptance Signatures" on an unidentifiable residency agreement dated February 15, 2018; and -House rules documentation on an unidentifiable residency agreement dated March 2, 2022 and February 16, 2018. 6. In an interview, E2 acknowledged several entries in R1's, R2's, and one unidentifiable resident's medical records contained correction fluid, solid white labels, or handwriting that rendered the initial entries illegible.

Based on documentation review, record review, and interview, the manager failed to ensure a medication administered to a resident was administered by an individual under direction of a medical practitioner. The deficient practice posed a risk as medication administration was being completed by an individual who had not been approved by a qualified individual to provide medication administration services. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Medications Including Opioids and Narcotics." The policy stated, "...d. The "Initial Medication Order" form signed by the physician or medical practitioner will contain a statement identifying an individual or individuals authorized to administer medication...These authorized individuals will be certified caregivers and must have completed the orientation and the "verification of Skills and Knowledge" which will be documented in their personnel record." 2. A review of R1's medical record revealed R1 received medication administration. 3. A review of R1's medical record revealed documentation titled, "Medication administration authorization" which stated, "Trained caregivers as named below may administer medications or assist in the self-medication administration from the medication organizers, or medication containers as per facility policy and procedure." 4. A review of the aforementioned documentation revealed E3 was not named as a caregiver authorized to administer medication. 5. A review of E3's personnel record revealed E3 received a certified caregiver certificate on July 20, 2024. 6. A review of R1's medication administration record (MAR) revealed E3 administered medications to R1 (prior to E3 receiving E3's caregiver certificate) on the following days, as evidenced by E3's initials on the MAR: -June 29, 2024-June 30, 2024; -July 3, 2024-July 8, 2024; and -July 11, 2024-July 26, 2024. 7. A review of R2's MAR revealed E3 administered medications to R2 (prior to E3 receiving E3's caregiver certificate) on the following days, as evidenced by E3's initials on the MAR: -June 28, 2024-June 30, 2024; -July 3, 2024-July 8, 2024; and -July 11, 2024-July 26, 2024. 8. In an interview, E2 acknowledged E3 provided medication administration services without the direction of a medical practitioner.

Based on observation, documentation review, and interview, the governing authority failed to ensure a food menu met the requirements of this rule. The deficient practice posed a risk if the source of a potential food borne illness could not be identified and the Department was unable to determine substantial compliance. Findings include: 1. During a tour of the facility, the Compliance Officer asked R1 if there were any issues R1 was concerned about. R1 reported the meals were not balanced appropriately for a diabetic resident. R1 reported the facility rarely served fresh fruits and vegetables and reported the meals were too high in carbohydrates and regularly consisted of pasta, rice, french fries, and hot dogs. R1 reported E1 had been gone for a couple of weeks and E1 was the only personnel member that would make meals. 2. During a tour of the facility conducted on July 26, 2024, the Compliance Officer observed a food menu in a plastic sleeve posted near the kitchen. However, the food menu was dated for July 14, 2024-July 20, 2024. The Compliance Officer observed a current menu placed under the posted menu dated July 21, 2024-July 27, 2024. 3. The Compliance Officer observed the posted menu reported fish of the day, rice, tartar sauce, cauliflower, creme broule, and milk was to be served for dinner the day of the survey. The current menu reported shrimp scampi, spaghetti, green salad, cake or cookies, milk, water or juice was to be served. 4. In an interview, the Compliance Officer asked E2 what was going to be served for dinner that evening. E2 reported beef, potatoes, and green beans were planned. The Compliance Officer asked to see the ingredients for the dinner that was to be prepared that evening. E3 reported the residents had already been served dinner and the boxes to the frozen dinners served had already been thrown away. 5. In an interview, E2 acknowledged the posted menu was not current and accurate and did not include the foods to be served or include any substitutions made no later than the morning of the day of the meal service.