Good Samaritan - Hays

Inspectors wroteThe facility failed to ensure Resident (R) 1 remained free from a significant medication error. On 05/05/2026, the Infectious Disease doctor, who was consulting on R1's Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcers on his gluteus (buttocks) and coccyx (area at the base of the spine), ordered fluconazole 400 milligrams (mg) twice a day for a bone biopsy culture, which revealed C. Albicans (a microscopic yeast and fungus which can cause fungal infections). The facility failed to initiate the medication until 05/23/2026.

Inspectors wroteThe facility had a census of 44 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary for one Resident (R) 44 reviewed for discharge that included a completed recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay. This deficient practice placed the resident at risk of receiving inadequate care.

Inspectors wroteThe facility had a census of 44 residents. The sample included 12 residents, with two reviewed for urinary catheter or Urinary Tract Infection (UTI - Infection of any part of the urinary system). Based on observation, record review, and interview, the facility failed to provide appropriate care when staff failed to provide completed incontinent and catheter care for Resident (R) 3 after a bowel movement, before a dressing change, and who had a history of urinary tract infections. This deficient practice placed the resident at increased risk for UTI.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 34's blood pressure medication was administered outside the physician-ordered parameters and the parameters were transcribed incorrectly. This placed the resident at risk for physical decline, related complications, and at risk for unnecessary drugs.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to hold and notify the physician of blood pressure medications per the physician-ordered parameters for one resident, Resident (R) 34. The facility also failed to transcribe physician-ordered parameters correctly. This deficient practice placed the resident at risk for physical decline, other related complications, and at risk for unnecessary drugs.

Inspectors wroteThe facility had a census of 44 residents. The sample included 12 residents, with two reviewed for hospice services. Based on observation, record review, and interview, the facility failed to include a hospice plan of care with a description of the services provided which included contact information, visit frequency, medications, and medical equipment for Resident (R) 8. This deficient practice placed the resident at risk of not receiving needed care.

Inspectors wroteThe facility had a census of 41 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)16, and R28's insulin (hormone which allows cells throughout the body to uptake glucose) flex pen with the date opened and expiration date, failed to discard R6's and R38's expired insulin vial and failed to discard expired stock medications on two medication carts. This placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 41. The sample included 13 residents. Based on record review, interview and observation the facility failed to treat residents with respect, dignity, and privacy during blood glucose testing. This placed the resident at risk for impaired psychosocial wellbeing.

Inspectors wroteThe facility had a census of 41 residents. The sample included 13 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing fluid restriction implementation for Resident (R) 16, who received dialysis treatment. This placed the resident at risk for complications and health decline.

Inspectors wroteThe facility had a census of 41 residents. The sample included 13, with six reviewed for unnecessary medications. Based on record review and interview the facility failed to provide appropriate and adequate narcotic drug reconciliation, when staff failed to accurately record controlled substance doses on the narcotic count record and further failed to immediately report a discrepancy in Resident (R) 142's liquid Ativan (drug used to treat anxiety) count. This placed R142 at risk for missed, doses, misappropriation and/or diversion.

Inspectors wroteThe facility had a census of 41 residents. The sample included 13 residents. Based on observation, record review, and interview the facility failed to ensure one of three residents, reviewed during medication administration pass, remained free of medication errors. This placed the resident at risk for adverse reaction from the medication.

Inspectors wroteThe facility had a census of 41 residents. The sample included 13 residents. Based on record review and interview the facility failed to consistently deliver the 41 residents mail on Saturdays.

Inspectors wroteThe facility had a census of 43 residents. Based on observation, interview, and record review the facility failed to store, prepare, and serve foods in a sanitary kitchen for the 43 residents of the facility.

Inspectors wrote- On 10/20/21 at 08:48 AM, Housekeeper U prepared to enter R38's room. She stated R38 had Methicillin-resistant Staphylococcus aureus (MRSA- a type of bacteria resistant to many antibiotics) in the urine. Housekeeper U prepared to enter R38's room by gathering cleaning supplies of broom, mop, dustpan, and cleaning cloths. She then donned (put on) a gown, gloves, and mask. She used appropriate cleaning products to sanitize MRSA. The rooms' hand washing sink, overbed table and cleansing cloths sprayed with Ecolab Peroxide Surface Cleaner and Disinfectant. Housekeeper U then wiped down the overbed table, handrail to the bed, oxygen concentrator, counter and sink, doorknobs, and light switches. Housekeeper U had not sprayed or wiped R38's wheelchair or vinyl recliner. Next the toilet was cleaned. [...]

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to promote care in a manner to maintain and enhance dignity and respect, when staff applied a patch to Resident (R) 7's right shoulder at the dining room table, with five residents in full view.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents, with two reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide staff assistance with eating to Resident (R) 22, who required assistance of one staff for eating and who had a recent weight loss .

Inspectors wroteThe facility had a census 43 residents. The sample included 12 residents with one reviewed for a decrease in activities of daily living (ADL) and mobility, Resident (R) 10. Based on record review, observation, and interviews, the facility failed to prevent a decline in functional ability for R10 when the facility failed to implement a restorative program.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement effective nutritional interventions to prevent weight loss for one of five sampled residents, Resident (R) 22, who had a weight loss.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide the physician ordered medications for one of five sampled residents, Resident (R) 13.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure the facility's consulting pharmacist (CP) identified and reported irregularities to the Director of Nursing, physician and medical director when the facility failed to obtain a physician ordered lab for Resident (R) 33. This placed R33 at increased risk of medication complications and side effects.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to obtain an ordered lab test for Resident (R) 33. This placed R33 at increased risk of medication complications and side effects.

Inspectors wroteThe facility had a census of 43 residents. The sample included 12 residents. Based on observation and interview, the facility failed to label and dispense medication appropriately for Resident (R) 2, R14, and R21.