GOOD SAMARITAN SOCIETY -LOVELAND VILLAGE

An administrative relicensure survey was completed on 6/30/26. No deficiencies were cited.

A revisit survey was completed on 5/7/25 for all previous deficiencies cited on 11/13/24. The facility is in compliance with all deficiencies that were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 11/13/24. Deficiencies were cited.

Chapter 2, Part 12.2.2 B (4) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: Ensuring the facility complies with Department reporting requirements related to infectious diseasesBased on observation, record review and interview, the residence failed to report the outbreak of an infectious disease according to the department's reporting requirements, affecting 47 current residents. Findings include:1. ObservationOn 11/13/24 at 7:45 a.m., a set of personal protective equipment (PPE) including gowns, gloves, shoe covers and cleaning supplies was observed hanging by the side of the medication cabinet in the medication room. 2. Record reviewThe residence emergency response document on infectious disease outbreak read in part: "A sudden rise in the number of cases of a disease, sometimes a single case of a highly infectious disease is considered an outbreak. The residence must notify the infection prevention or designee, also the residence must notify the state department of health if required to do so."A hospital discharge note dated 11/12/24 revealed Resident #1 was hospitalized for pneumonia from 11/10/24 to 11/12/24. The hospital discharge note for Resident #1 also revealed methicillin-resistant staphylococcus aureus (MRSA) was detected on the resident. The note instructed the residence to implement contact isolation precautions until Resident #1 met the clearance criteria for MRSA.3. Interview On 11/13/24 at 7:45 a.m., Staff #1 confirmed Resident #1 was hospitalized from 11/10/24 to 11/12/24 for pneumonia and MRSA which led to the implementation of contact isolation precautions after her return to the residence. On 11/13/24 at 2:00 p.m., the administration confirmed the MRSA outbreak was not reported to the department. She said the residence implemented all contact isolation precautions but failed to report to the department because she did not think it was a health emergency at the time.

Based on record review and interview, the residence failed to evaluate a resident transferred to another healthcar entity prior to readmission, affecting 47 current residentsFindings include. 1. Record reviewA hospital discharge note dated 11/12/24 revealed Resident #1 was hospitalized from 11/10/24 to 11/12/24. The hospital discharge note further read that Resident #1 required contact isolation precautions due to a diagnosis of methicillin-resistant staphylococcus aureus (MRSA). On 11/13/24, further review of Resident #1 ' s records revealed no documented evidence that an assessment was completed by the residence prior to her re-admission into the residence on 11/12/24, though a progress note dated 11/12/24 indicated Resident #1 was not at her baseline after she returned from the hospital and that she continued to manifest symptoms of a potential infection. 2. InterviewOn 11/13/24 at 2:00 p.m., the administrator stated that the hospital contacted a staff member at the residence and informed them that Resident #1 was ready to be discharged. She stated the resident was picked up from from the hospital and brought back to the residence, however the residence failed to complete an assessment prior to re-admitting Resident #1. She also said the residence failed to read the discharge note from the hospital therefore was unaware that Resident #1 was diagnosed with MRSA.

THIS SECTION IS FOR INFORMATIONAL PURPOSENo response is required. The residence was advised to review and maintain regulations found in 6 CCR 1011-1 Chapter 714.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposalrecords. Any irregularities shall be investigated and resolved. The results of the audits shall be documented androutinely included as part of the assisted living residence's Quality Management Program assessment and review.