Good Samaritan Society - Liberal

F-F609), for lack of protecting residents from further abuse and lack of investigating all allegations of abuse (See finding at

F-F742 Trauma Informed Care. The IJs further constituted Substandard Quality of Care and changed the recertification survey to an Extended Recertification Survey.

Review of the prior annual recertification survey dated 10/27/2022 revealed areas of care were identified as deficient practice to include Care Plan timing and revision (

F-F756). The Current survey also found deficient practice in three of the same areas, as evidence the facility had not maintained corrective measures in known areas of concern.

The current survey HEJK11found deficient practice with the following failures:

- The facility failed to ensure an effective quality assessment and performance improvement (QAPI) program as evidenced by the number of deficient practices, elevated scope and severity, and substandard quality of care found onsite as followed.

The facility failed to ensure staff identified and responded appropriately to all allegations of abuse, which included Resident 17's allegation of sexual assault.

The facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA - a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required by federal regulations.

The facility failed to investigate all allegations of resident-to-resident abuse, failed to protect residents from further incidents of abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 58 175334 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175334 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Liberal 2160 Zinnia Lane Liberal, KS 67901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility failed to recognize a significant change in a resident's physical condition and perform a Comprehensive Minimum Data Set (MDS) assessment within the required 14-day period of the resident's Level of Harm - Minimal harm or change in condition. This deficient practice had the potential to lead to uncommunicated needs and placed potential for actual harm the resident at risk for further deterioration of his physical, mental, and psychosocial well-being.

Residents Affected - Many The facility failed to accurately complete the Minimum Data Set (MDS) for five sampled residents, as required by the federal regulations.

The facility failed to develop a comprehensive person-centered care plan for one of the 17 residents sampled.

The facility failed to revise fall care plans with interventions for three residents for one of the 17 residents sampled.

The facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of 17 sampled residents related to Restorative Nursing Program to ensure his quality of life.

The facility failed to ensure an environment as free from accident hazards as possible when facility failed to thoroughly document and place fall mat for R 21 as directed in the care plan. The facility failed to ensure a safe transfer for Resident R36, when staff utilized a full body mechanical lift, without a second staff member present.

This deficient practice could potentially result in a mechanical lift transfer accident.

The facility failed to acknowledge and respond appropriately to Resident R17's allegations of sexual assault and her display of behaviors, which align to a trauma response, based on reasonable person concept, when the resident expressed feelings of fear, anger, and aggressiveness associated with her reported allegation of sexual assault while a resident of the facility. This failure placed Resident R17 in Immediate Jeopardy (IJ) and at risk for untreated trauma and the negative impact to her mental, physical, and psychosocial well-being.

The facility failed to provide scheduled pain medication for R 8 as ordered by the physician.

The facility failed to respond to pharmacist's recommendation to complete an Abnormal Involuntary Movement Score to evaluate the effects of the R 21's psychotropic medications.

The facility failed to serve the residents of the facility food, which was palatable, attractive, and served at the appropriate temperature.

The facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne illness.

The facility failed to electronically submit to Centers for Medicare and Medicaid Services (CMS) with complete and accurate direct staffing information, based on payroll and other verifiable and auditable data in

a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report Registered Nurse (RN) coverage on 29 dates between January 1, 2023 and 09/30/23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 58 175334 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 175334 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Liberal 2160 Zinnia Lane Liberal, KS 67901

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility failed to have an effective administration to identify and develop corrective action plans for potential quality deficiencies as found on the current survey. This deficient practice placed the residents at Level of Harm - Minimal harm or risk for decreased quality of care, quality of treatment, and sense of well-being. potential for actual harm

The facility failed to have an effective QAPI program to identify the quality issues in the facility and implement Residents Affected - Many and maintain corrective actions to ensure the highest mental, physical, and psychosocial wellbeing of each resident. This deficient practice affected all 43 residents of the facility and placed them at risk for substandard quality of care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 58 175334