Inspection Reports for Good Samaritan Society – Millard

The complaint investigation focused on allegations that the facility failed to resolve grievances, notify responsible parties of condition changes, provide appropriate discharge notices, have appropriate reasons for involuntary discharge, and have appropriate bed hold policies. The facility was found compliant except for failure to ensure appropriate antibiotic therapy for one resident.

The facility was found to be in compliance with most allegations except for failure to ensure one resident met criteria for continued antibiotic therapy. Additional deficiencies were cited related to bowel/bladder incontinence, tube feeding management, ventilation, fire safety, and life safety code compliance.

The complaint alleged the facility failed to use appropriate interventions to prevent injuries. The investigation substantiated this allegation with findings of deficient practices related to fall prevention and safe use of equipment.

The facility failed to implement appropriate interventions to prevent injuries for 3 of 4 sampled residents, including improper use of a shower table and failure to apply fall prevention measures such as hip protectors and scoop mattresses.

The complaint alleged the facility failed to give correct emergency information regarding residents' condition and failed to monitor a resident's change of condition. The first allegation was not substantiated; the second was substantiated with findings of failure to monitor antibiotic use for adverse reactions in two residents.

The facility was found not to be in violation regarding providing correct emergency information. However, the facility failed to monitor residents' changes in condition related to antibiotic use for 2 of 3 sampled residents, which was a violation of regulatory requirements.

The complaint investigation included allegations of inadequate housekeeping, failure to complete timely investigations, failure to ensure personal hygiene, insufficient staffing, equipment operation, elopement safety, service provision, and resident dignity. The facility was found in violation for failure to timely report and investigate neglect and verbal abuse, failure to ensure personal hygiene, and other cited deficiencies.

The facility was found to be in compliance with housekeeping, staffing, equipment operation, elopement prevention, resident respect, and service provision. Deficiencies were found related to failure to timely report and investigate allegations of neglect and verbal abuse, failure to develop a pain management care plan, failure to provide toileting as per care plan, failure to identify and treat skin breakdown, failure to evaluate clinical justification for indwelling catheter use and catheter care, failure to evaluate a toileting program, failure to maintain safe hot water temperatures, failure to prevent falls, failure to provide adequate dental services, corridor obstruction, hazardous area door latching, sprinkler system testing, fire extinguisher inspection, smoking area safety, and improper use of extension cords.

The complaint alleged failure to notify healthcare practitioner of change in condition, failure to put preventive measures in place to protect residents from accidents, failure to ensure sufficient staff, failure to provide care and treatment to prevent skin breakdown and pressure sores, failure to maintain an ongoing activities program, and failure to provide care to maintain range of motion. The investigation substantiated failures related to notification and pressure ulcer care.

The facility failed to notify the healthcare practitioner of a change in condition for one resident and failed to provide care and treatment to prevent skin breakdown and pressure sores for another resident. The facility ensured sufficient staff, maintained an ongoing activities program, and provided care to maintain range of motion. Several violations related to failure to implement interventions for pressure ulcer treatment and prevention were identified.

The complaint investigation included allegations of failure to promptly answer call lights, insufficient staffing, failure to change fall interventions, failure to follow plan of care, failure to notify healthcare practitioners of condition changes, failure to protect residents from neglect, failure to supervise residents to prevent injuries, and failure to ensure prompt response to calls for assistance. Several of these allegations were substantiated with violations cited.

The facility failed to promptly answer call lights, have sufficient staff, follow the plan of care, notify healthcare practitioners of condition changes, supervise residents to prevent injuries, and ensure prompt response to calls for assistance. Several deficiencies related to pressure ulcer care, dental status coding, ADL care, pressure ulcer treatment, bowel and bladder function, fall prevention, hydration, and medication cart security were identified. Life safety code deficiencies were also noted.

The complaint investigation was triggered by allegations including failure to protect residents from misappropriation, insufficient staffing, failure to notify family of changes, failure to provide care for skin breakdown, failure to provide medications per physician orders, and failure to provide care for bladder elimination. Some allegations were substantiated with violations found, including failure to protect from aggressive behaviors, failure to notify family, medication errors, and failure to provide bladder care. The facility failed to report an allegation of abuse to APS timely.

The facility was found not to be in violation for misappropriation, staffing sufficiency, and staffing schedule accuracy. However, violations were found for failure to protect residents from physically aggressive behaviors, failure to notify family or responsible party of change in condition, failure to provide medications per physician orders, failure to provide care and treatment for bladder elimination, and failure to manage aggressive behaviors. Medication errors were observed with an error rate of 7.14%, and a significant medication error involving failure to administer an antibiotic led to hospitalization of a resident.

The complaint investigation included allegations that the facility failed to protect residents from retaliation, failed to have sufficient staff to meet residents' needs, failed to provide necessary services, failed to notify family or responsible party of change in condition, failed to provide care according to practitioner's orders, and failed to provide adequate intake to prevent dehydration. The facility was found compliant with all except failure to notify physician of significant weight gain and low blood sugar results for Resident 64.

The facility was found to be in compliance with allegations related to retaliation, staffing sufficiency, provision of necessary services, care according to practitioner's orders, and prevention of dehydration. However, a deficiency was cited for failure to notify a resident's physician of a significant weight gain and low blood sugar results. Additional deficiencies were found related to resident bathing choices, failure to provide cueing during meals, failure to evaluate clinical indications for indwelling catheter use, presence of outdated laboratory vials, infection control lapses including failure to sanitize glucometers and hand hygiene, and incomplete or inaccurate clinical documentation.

The complaint investigation included allegations that the facility failed to protect residents from loss/theft of personal items, abuse, injuries of unknown origin, failure to provide care to prevent and promote healing of skin breakdown, failure to identify change of condition, failure to resolve grievances, failure to report injuries and allegations of abuse, failure to protect from misappropriation, and failure to evaluate causal factors for falls. The investigation included resident record reviews, observations, and interviews with residents, family, and staff.

The facility was found compliant with protecting residents from theft, abuse, injuries of unknown origin, reporting abuse, and evaluating causal factors for falls. Deficiencies were found related to failure to resolve grievances for one resident, failure to investigate potential neglect for one resident who fell and was lifted without nurse notification, and failure to complete comprehensive pressure ulcer assessments and evaluate causal factors for pressure ulcers for one resident.

The complaint alleged failure to administer medications according to practitioner's orders and failure to identify a change in condition. The investigation confirmed these allegations with specific findings related to medication errors and failure to notify physician of a suicidal statement.

The facility failed to administer medications according to physician orders, failed to notify the physician of a resident's suicidal statement, and failed to evaluate and intervene after suicidal statements. Medication error rate was 9.09% with errors in insulin dosing and medication administration timing. A significant medication error occurred when an antibiotic was not administered, resulting in resident hospitalization.

The facility failed to properly assess and document a burn injury for Resident 2 and did not ensure follow-up lab testing for Resident 1's Coumadin therapy. Additionally, the facility failed to investigate accident causes and implement preventive interventions for two residents, including a coffee spill burn and an injury during transfer.

The facility was found deficient in multiple areas including failure to submit timely investigative reports, inadequate housekeeping, failure to follow bowel management protocols, inadequate supervision to prevent falls, life safety code violations including corridor wall penetrations, door deficiencies, fire safety system issues, and improper storage of oxygen and chemicals. Several fire safety and emergency preparedness deficiencies were also noted.

The complaint was substantiated as the facility did not provide the required 30-day discharge notice to Resident 1. The discharge was due to the facility's inability to meet the resident's needs related to communication issues and lack of Spanish-speaking staff.

The facility failed to provide the required 30-day written notice of discharge to Resident 1 and their family before discharge due to inability to meet the resident's communication needs related to language barriers.

The survey identified multiple deficiencies including failure to maintain proper resident notification of rights and Medicaid non-coverage notices, inadequate resident knowledge of survey results and ombudsman contact information, delayed reporting of abuse allegations, incomplete care plans for certain residents, inadequate monitoring of dialysis catheter sites, failure to maintain sanitary food temperatures and sanitizing solutions, improper cleaning of mechanical lifts, and multiple life safety code violations including obstructed doors, fire safety system deficiencies, and improper storage of oxygen cylinders.

The complaint investigation revealed failures in timely reporting of abuse allegations to Adult Protective Services and the state licensure agency, incomplete investigations, failure to suspend staff during investigations, and inadequate protection of residents during investigations.

The facility failed to report allegations of potential abuse to the appropriate state agency within required timeframes for 6 of 13 sampled residents. The facility also failed to implement policies to protect residents during investigations, failed to develop comprehensive care plans addressing elopement risks for 2 residents, and failed to properly place and monitor Secure Guard bracelets and pressure alarms for residents at risk of elopement or falls.

The facility was found deficient in multiple areas including failure to assess residents' ability to self-administer medication, improper use of physical restraints, failure to report allegations of abuse timely, inadequate provision of reasonable accommodations, failure to evaluate psychosocial needs, housekeeping deficiencies, infection control lapses, and failure to ensure drug regimens were free from unnecessary drugs. The facility submitted plans of correction and committed to ongoing monitoring and staff education.