LIBERAL, KS - Federal inspectors documented widespread systemic failures at Good Samaritan Society - Liberal during a July 2024 inspection, identifying deficiencies across multiple areas of care including failure to properly respond to a sexual assault allegation, inadequate fall prevention measures, and breakdowns in medication administration and food safety protocols.
Serious Lapse in Response to Sexual Assault Allegation
The most severe violation documented during the inspection involved the facility's handling of a sexual assault allegation reported by a resident identified as R17. Inspectors determined the facility failed to acknowledge and respond appropriately to the resident's allegations and her subsequent behavioral changes that aligned with trauma response patterns.
According to the inspection report, R17 expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while residing at the facility. Federal surveyors determined this failure placed the resident in Immediate Jeopardy - the most serious designation used by inspectors - putting her at risk for untreated trauma and negative impacts to her mental, physical, and psychosocial well-being.
The inspection revealed multiple failures in the facility's abuse reporting and investigation protocols. Staff did not identify and respond appropriately to R17's allegations according to established procedures. Additionally, the facility failed to report the alleged abuse to the State Agency or local law enforcement within required timeframes as mandated by federal regulations.
Sexual assault in nursing homes represents a particularly vulnerable situation given residents' potential cognitive impairments, physical limitations, and dependence on facility staff for protection. When facilities fail to respond appropriately to such allegations, residents may experience ongoing trauma, loss of trust in caregivers, and deterioration in mental health. Proper protocol requires immediate investigation, ensuring the alleged victim's safety, reporting to authorities, and providing appropriate psychological support.
The inspection also documented that the facility failed to investigate all allegations of resident-to-resident abuse and did not implement adequate measures to protect residents from further incidents. This pattern suggested systemic problems in the facility's abuse prevention and response systems rather than isolated incidents.
Fundamental Failures in Quality Oversight Programs
Inspectors identified critical deficiencies in the facility's Quality Assessment and Performance Improvement (QAPI) program, which serves as the foundation for identifying and correcting care problems. The inspection report stated that the facility failed to ensure an effective QAPI program, as evidenced by the number of deficient practices, elevated scope and severity ratings, and substandard quality of care found during the survey.
A functioning QAPI program represents the primary mechanism through which nursing homes identify care problems, analyze their root causes, and implement corrective actions. Federal regulations require facilities to maintain these programs specifically to prevent the types of widespread deficiencies documented at Good Samaritan Society - Liberal.
The inspection revealed that facility administrators failed to identify and develop corrective action plans for quality deficiencies. This administrative failure placed residents at risk for decreased quality of care, quality of treatment, and overall well-being. Inspectors noted that the deficient QAPI program affected all 43 residents in the facility.
Compounding these concerns, surveyors documented that the facility had been cited for similar violations during previous inspections. The current survey found deficient practices in three of the same areas identified previously, demonstrating that the facility had not maintained corrective measures in known problem areas. This pattern of recurring deficiencies indicates fundamental problems in the facility's ability to sustain quality improvement initiatives.
Assessment and Care Planning Breakdowns
The inspection documented multiple failures in the facility's assessment and care planning processes, which form the basis for individualized resident care. Surveyors found that staff failed to recognize a significant change in one resident's physical condition and did not perform a required Comprehensive Minimum Data Set (MDS) assessment within the mandated 14-day timeframe following the condition change.
The MDS serves as the primary assessment tool in nursing homes, capturing comprehensive information about each resident's functional abilities, medical conditions, and care needs. Federal regulations require facilities to complete MDS assessments within specific timeframes, particularly when residents experience significant changes in condition. Delays in completing these assessments can result in uncommunicated care needs and place residents at risk for further physical, mental, and psychosocial deterioration.
Inspectors also identified inaccuracies in MDS completion for five sampled residents, representing nearly 30 percent of the residents reviewed during the survey. Inaccurate MDS information can lead to inappropriate care planning, inadequate staffing allocations, and incorrect reimbursement calculations.
The facility failed to develop a comprehensive person-centered care plan for one resident and did not revise fall care plans with appropriate interventions for three residents. Care plans translate assessment information into specific interventions tailored to each resident's needs and preferences. When facilities fail to maintain current, comprehensive care plans, staff lack clear guidance on how to address residents' evolving needs.
Medication Administration and Monitoring Failures
The inspection revealed serious gaps in medication management practices. Staff failed to provide scheduled pain medication for R8 as ordered by the physician, directly impacting the resident's comfort and quality of life. Inadequate pain management can lead to decreased mobility, reduced participation in therapies, sleep disturbances, and diminished overall well-being.
Additionally, the facility did not respond to a pharmacist's recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for R21 to evaluate the effects of psychotropic medications. The AIMS assessment serves as a critical monitoring tool for detecting tardive dyskinesia and other movement disorders that can develop as side effects of certain psychiatric medications. These conditions may become permanent if not identified early, making regular monitoring essential for residents receiving these medications.
Psychotropic medications require particularly careful monitoring in nursing home populations due to residents' advanced age, multiple medical conditions, and increased vulnerability to adverse effects. Failure to conduct recommended monitoring assessments places residents at risk for undetected complications that could significantly impact their physical functioning and quality of life.
Safety Hazards and Fall Prevention Deficiencies
Inspectors documented that the facility failed to ensure an environment as free from accident hazards as possible. Staff did not thoroughly document fall mat placement for R21 as directed in the care plan, creating potential for falls and injuries.
The inspection also revealed unsafe transfer practices when staff utilized a full body mechanical lift for R36 without a second staff member present. Mechanical lift transfers require two staff members to ensure resident safety - one to operate the lift controls and monitor the resident's position, and another to guide and support the resident during movement. Single-person mechanical lift transfers significantly increase the risk of falls, improper positioning, and injuries to both residents and staff.
Falls represent the leading cause of injury among nursing home residents, frequently resulting in fractures, head trauma, and functional decline. Proper fall prevention requires consistent implementation of individualized interventions based on each resident's specific risk factors.
The facility also failed to provide necessary care and services related to the Restorative Nursing Program for five of 17 sampled residents. Restorative nursing programs help residents maintain or improve functional abilities through consistent practice of activities such as walking, transferring, and performing activities of daily living. When facilities fail to provide these services consistently, residents may experience preventable functional decline.
Food Service and Sanitation Concerns
The inspection identified deficiencies in food service operations affecting both quality and safety. Inspectors found that the facility failed to serve food that was palatable, attractive, and at appropriate temperatures. Meal quality directly impacts residents' nutritional intake, with unappetizing or improperly temperature food leading to reduced consumption and potential malnutrition.
More seriously, surveyors documented that the facility failed to prepare and serve food under sanitary conditions, creating potential for foodborne illness. Nursing home residents face heightened vulnerability to foodborne pathogens due to age-related changes in immune function, underlying medical conditions, and medications that may suppress immune response. Foodborne illness in this population can result in serious complications including dehydration, hospitalization, and increased mortality risk.
Staffing Reporting Inaccuracies
The inspection revealed that the facility failed to accurately submit direct staffing information to the Centers for Medicare and Medicaid Services through the Payroll Based Journal (PBJ) reporting system. Specifically, the facility inaccurately reported Registered Nurse coverage on 29 dates between January 1, 2023, and September 30, 2023.
The PBJ system provides transparency about nursing home staffing levels, allowing consumers, regulators, and researchers to evaluate whether facilities maintain adequate nurse staffing. Inaccurate reporting undermines this transparency and may misrepresent the actual care resources available to residents. Research consistently demonstrates that adequate RN staffing correlates with better resident outcomes, including fewer hospitalizations, pressure ulcers, and complications.
Additional Issues Identified
The inspection documented several other violations requiring correction:
Assessment and Documentation: Staff failed to accurately complete Minimum Data Set assessments for multiple residents, potentially leading to inappropriate care planning and resource allocation.
Individualized Care Planning: The facility did not maintain comprehensive, current care plans addressing residents' evolving needs and preferences.
Quality Improvement Systems: Administrators did not implement effective processes to identify quality concerns, analyze root causes, and sustain corrective actions over time.
Regulatory Compliance: The facility demonstrated patterns of recurring deficiencies in previously cited areas, indicating inadequate follow-through on correction plans.
The July 2024 inspection findings at Good Samaritan Society - Liberal revealed systemic problems affecting multiple aspects of resident care and facility operations. The combination of immediate jeopardy related to sexual assault response, widespread assessment and care planning failures, medication management gaps, safety hazards, and ineffective quality oversight programs indicated fundamental breakdowns in the facility's ability to provide appropriate care and maintain regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Liberal from 2024-07-24 including all violations, facility responses, and corrective action plans.
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