Inspection Reports for
Good Samaritan Society -Loveland Village

The investigation was triggered by complaints about inadequate supervision and fall prevention for Resident #1. The complaint was substantiated as the facility failed to prevent multiple falls and implement timely interventions.

The facility failed to ensure adequate supervision and timely implementation of fall prevention interventions for Resident #1, who fell seven times between 12/8/24 and 2/1/25, resulting in a hip fracture and placement on hospice. Staff inconsistently implemented care planned fall interventions, and the resident's cognitive impairments and impulsivity contributed to repeated falls.

The complaint investigation substantiated sexual abuse by CNA #1 against Resident #2 on 7/27/24 and Resident #3 before CNA #1's suspension. The facility and police conducted extensive interviews and investigations. Resident #2 was cognitively impaired and physically dependent; Resident #3 was cognitively intact but visually impaired. CNA #1 was suspended immediately and terminated on 8/13/24. The facility implemented staff education and reported to appropriate agencies.

The facility failed to prevent sexual abuse of two residents by CNA #1. The abuse incidents occurred on 7/27/24 and were reported and investigated, leading to the immediate suspension and later termination of CNA #1. The facility conducted staff education on abuse and neglect following the incidents and expanded interviews and investigations after new information emerged.

The complaint investigation found that Resident #58, a known fall risk, sustained a fall due to staff failing to reset the floor alarm properly. The fall resulted in a fracture. The facility's investigation and corrective actions were verified during the onsite survey.

The facility failed to ensure that the floor alarm, a care planned fall intervention for Resident #58, was properly reset to the on position after being triggered, resulting in a fall and fracture. The facility conducted an investigation, implemented corrective actions, re-educated staff, and initiated audits to prevent recurrence.

The investigation was triggered by a complaint regarding Resident #58's fall on 4/20/24 and medication errors involving Residents #49 and #62. The fall was substantiated as the alarm was off, and medication errors were confirmed with a 7.7% error rate.

The facility failed to ensure proper fall prevention interventions for Resident #58, resulting in a fall with a fracture due to a floor alarm being off. Additionally, the facility failed to maintain medication error rates below 5%, with errors including crushing extended-release medication and failure to check vital signs prior to medication administration.

The complaint investigation focused on resident falls and medication storage practices. The facility was found to have multiple residents with repeated falls, inadequate fall prevention measures, and poor communication with hospice providers. Medication storage rooms contained expired medications that were not removed, posing risks to resident safety.

The facility failed to provide adequate supervision and fall prevention interventions for residents with repeated falls, resulting in actual harm. Additionally, the facility failed to properly label and discard expired medications in medication storage rooms, posing potential risks to residents.

The facility was found deficient in multiple areas including failure to provide adequate activities for residents, improper pressure ulcer care, lack of proper wander guard assessments and consents, missing orders and care plans for respiratory devices, inappropriate use and documentation of psychotropic medications, medication errors including insulin pen priming and medication storage issues, and inadequate infection control practices during wound care.