Good Samaritan Society - Millard

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(iv)(5) and 12-006.09 Based on interview and record review the facility failed to monitor bowel movements and implement a bowel protocol for 1(Resident 2) of 1 resident sampled and failed to monitor blood glucose per physician's order for 1 (Resident 87) of 1 resident sampled. The facility census was 74. The findings are: A.Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 04-14-2025 revealed the facility staff assessed the following about the resident: -admitted to the facility on [DATE]. -Brief Interview of Mental Status (BIMS) was scored as a 5. According to the MDS Manual, a score of 0 to 7 indicates severe cognitive impairment. -had a diagnosis of Alzheimer's Disease. -required limited assistance with hygiene, bed mobility and transfers -required extensive assistance with toileting, bathing and dressing. Record review of Resident 2's Bowel Movement (BM) log printed on 05-19-2026 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interview; the facility staff failed to implement interventions to promote pressure ulcer healing for 1 (Resident 26) of 4 sampled residents. The facility census was 74. Findings are:A.Record review of Resident 26's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 04-28-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had short-term and long-term memory problems.-required limited assistance with bed mobility and transfers.-required extensive assistance with toileting, bathing and upper body dressing-required total assistance with lower body dressing.-had a Traumatic Brain Injury (TBI) and hemiplegia (a medical condition that causes severe or complete paralysis on one vertical half of the body).-had limited Range of Motion (ROM) on one side of the body. -was at risk of developing a pressure ulcer.-had a stage 3 pressure ulcer Record review of Resident 26's Comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 12-006.12(D)(i) Based on observation, interview and record review the facility failed to ensure the treatment carts on the 200 and 500 halls were secure while left unattended. The facility census was 59. An observation on 02-20-2025 at 1:20 PM revealed an unlocked treatment cart on the 200 Hall. An interview on 02-20-2025 at 1:25 PM with Registered Nurse (RN) D revealed insulin (a medication used to treat Diabetes) was stored in the treatment cart and confirmed the treatment cart was unlocked and should have been when left unattended. An observation on 02-20-2025 at 1:34 PM revealed an unlocked treatment cart on the 500 Hall. An interview on 02-20-2025 at 1:40 PM with RN F revealed insulin was stored in the treatment cart and confirmed the treatment cart was unlocked and should have been when left unattended. Record review of the facility policy titled Medications: Acquisition Receiving Dispensing and Storage dated 03-29-2024 revealed under section 5 the following: Medications will be stored in a locked medication cart, drawer or cupboard. Only the person…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(H) Based on interview and record review the facility failed to perform neurological checks after a fall for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 59. The findings are: A. Record review of Resident 1's Electronic Health Record (EHR) revealed Resident 1 had an unwitnessed fall on 02-01-2025. Record review of Resident 1's Neuro Vital Sign Sheet Report (NVSSR) dated 02-01-2025 revealed at the top of the sheet instructions that after the completion of the initial neurological evaluation with vital signs, continue with evaluations every 30 minutes for 4 sets, then every 8 hours for the next 3 days. Furthermore, the NVSSR only had vital signs logged on the form. An interview with Registered Nurse (RN) H on 02-24-2025 at 7:50 AM revealed when performing neurological checks, the first check is completed when the fall occurred and then every 30 minutes for 4 sets, then every 8 hours for 3 days. Additionally, the vital signs are charted on the NVSSR and the remainder of the assessment is to be charted into the EHR.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 12-006.09 (I)(i)(3). Based on observation, interview and record review the facility failed to implement fall interventions for 2 (Resident 3 and 4) of 4 residents sampled. The facility census was 59. The findings are: A. Record review of Resident 3's Minimum Data Set (MDS; a federally mandated assessment tool used for care planning) dated 12-18-2024 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS), a brief screen that aids in detecting cognitive impairment, was scored as a 4. According to the MDS Manual a score of 0-7 indicates severe cognitive impairment. -required moderate assistance with toileting, bathing and lower body dressing -required supervision assistance with transfers. Record review of Resident 3's care plan printed on 02-20-2025 revealed Resident 3 had a fall on 12-25-2024 and the intervention put into place to prevent further falls was to have the call light secured to the bed with Velcro. An observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 1-009.04(i) Based on record review, observation, and interview, the facility staff failed to maintain water temperatures in resident handwashing sinks to prevent the potential for hot water burns. This effected 6 of 62 residents (Resident 2, 13, 33, 36, 41 and 42). The facility identified a census of 62. Findings are: Observations on 11/18/2024 at 9:38 AM-10:30 AM revealed the following water temperature in residents hand washing sink: -Resident 36's water temperature was 128 degrees Fahrenheit. -Resident 41,42,13, and 33's water temperature was 122.3 degrees Fahrenheit. Observation with the Maintenance Director ( MD), Administrator, and Maintenance Technician Assistant (MTA)-C on 11/18/2024 between 12:52-1:26 PM revealed the following water temperatures in resident hand washing sinks: -Resident 36's water temperature was 130.1 degrees Fahrenheit. -Resident 41's water temperature was 130.0 degrees Fahrenheit. -Resident 13 and 33's water temperature was 129.0 degrees Fahrenheit. -Resident 2's water temperature was 130.7 degrees Fahrenheit. Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(G)(ii) Based on record review and interview; the facility staff failed to provide a Transfer Discharge notification for 1 (Resident 18) of 1 resident. The facility had a census of 62. Findings are: A record review of Resident 18's progress notes revealed the resident had been sent to hospital on 7/5/2024 following a fall. Record review of Resident 18's medical record that included progress notes, faxes, demographic sheets and practitioner ordered revealed the was no evidence the facility staff had provided a Transfer Discharge notice to the resident or their responsible part. An interview on 11/20/2024 at 2:11 PM with the Facility Administrator confirmed a transfer discharge notification was not completed for Resident 18 Record review of the facility Discharge and Transfer Policy reviewed/revised 01/03/24 revealed the following information: -Policy -Before a location transfers or discharges a resident, the location must: 1. Notify the resident and the residents' representative of the transfer or discharge and the reason for the move in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.10 Based on record review and interview; facility staff failed to ensure 1 (Resident 18) of 5 residents was free of duplicate medication orders (orders for two or more identical medications or same therapeutic class). The facility had a census of 62. Findings are: A record review of Resident 18's Minimum Data Set (MDS -a federally mandated process for assessing the health needs and functional capabilities of residents in nursing homes) revealed Resident 18 had a Brief Interview for Mental Status (BIMS - a mandatory tool used to identify the cognitive function of a resident in a nursing home) of 12, which indicated Resident 18 is moderately cognitively impaired. A record review of Resident 18's electronic health record (EHR) revealed the following diagnoses: Adult failure to thrive, Bipolar disorder, Anxiety disorder, History of falling, Chronic Kidney Disease, stage 3, legal blindness. A record review of Resident 18's EHR revealed the following medication orders: -Acetaminophen Extra Strength Tablet 500 MG. Give 500 milligrams (mg) by mouth…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.10D Based on observations, interviews and record review; the facility failed to ensure that insulin was administered within recommended time frames for 1 of 1 residents (Resident 46). The facility census was 48. Findings are:A record review of Resident 46's Minimum Data Set (MDS, a federally mandated assessment tools used for care planning) dated 6/30/2023 revealed Resident 46 had a score of 15 on the Brief Interview for Mental Status (BIMS).This indicated Resident 46 had intact cognition. A record review of Resident 46's MDS revealed Resident 46 had a diagnosis of Diabetes Mellitus (a disease in which the body doesn't produce insulin to control the amount of glucose or sugar in the blood). An interview on 9/21/2023 at 7:41 AM was conducted with Resident 46. During the interview Resident 46 reported getting insulin (an animal derived or synthetic form of insulin used to treat diabetes) hours after eating. A record review of a physicians' order dated 7/4/2023 contained the following instructions: Insulin Aspart 100 unit/3 ml Pen 2-10 units SQ…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.17 Based on observation, record review and interview; the facility staff failed to maintain Oxygen tubing and a CPAP (Continuous Positive Airway Pressure) a device used to deliver positive air pressure to a residents airway to prevent closure during sleep) mask to prevent cross contamination for 1 (Resident 42) of 1 sampled resident, failed to perform hand hygiene prior to medication administration for Resident 6, 30 and 31, failed to wear facial masks near Resident 9, 14, 1 and 6 and handle clean linen in a manner to prevent the potential for cross contamination. The facility staff identified a census of 48. The findings are: A. Observation on 08/10/22 at 03:30 PM of the oxygen tubing rolled up and on top of the concentrator without being covered. The CPAP mask was uncovered on top of overbed table. Observation on 08/11/22 at 07:30 AM of the oxygen tubing rolled up and on top of the concentrator without being covered. The CPAP mask was uncovered on top of overbed table. Review of the current physician orders revealed an order dated 08/11/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide a written notice of the reason for transfer for 2 (Residents 38 and 24) of 2 residents reviewed. The facility census was 48. Findings are: A. Record review of Resident 38's Census Record revealed that Resident 38 had been sent to the hospital on 3/29/22, 6/13/22, 6/18/22 and 8/5/22. Record review of Resident 38's Electronic Medical Record revealed no written notice of the reason for the transfers had been provided to the patient or the representative at the time of those transfers. Interview on 08/16/22 at 10:52 AM with the facility Administrator confirmed that no written notice of the reason for the transfers had been provided to the resident or the representative at the time of those transfers. B. Review of Resident 24's medical record revealed Resident 24 was transferred to the hospital on 8/5/2022 for uncontrolled respiratory failure. Review of Resident 24's medical record revealed a bed hold signed for the hospitalization on 8/5/2022, however not letter was sent to Resident 24 or Resident 24's representative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D6 Based on observation, record review and interview; the facility failed to have physician orders for Oxygen therapy and failed to maintain the CPAP (a device used to deliver positive air pressure to a residents airway to prevent closure during sleep) in a working manner for 1 (Resident 42) of 1 sampled resident. The facility staff identified a census of 48. The findings are: Interview conducted with Resident 42 on 08/10/22 at 11:04 AM revealed the CPAP leaks water all over and Resident 42 hasn't worn the CPAP for two or three weeks or more. Resident 42 stated that (gender) has been using the Oxygen concentrator and the nasal cannula at night since the CPAP leaks. Observation on 08/10/22 at 11:15 AM of ResMed air curve 10 CPAP machine on the night stand revealed the CPAP tubing and mask lying on top of table. Observation of Oxygen Concentrator with nasal cannula and tubing rolled up and laid on top of the Oxygen Concentrator. Review of Resident 42's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.