Good Samaritan Society - Grand Island Village

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D)Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview the facility failed to ensure that consent was obtained prior to the administration of psychoactive medications (any medication that affects behavior, mood, thoughts, or perception) for 2 of 3 sampled residents (Residents 3 and 4). The facility census was 57.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (F)(i)Based on record review and interview the facility failed to ensure that a baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed by staff to provide initial effective and person-centered quality care for a resident) was developed and reviewed with the resident/resident representative and ensure that a written summary was offered to the resident/resident representative for 3 of 3 residents reviewed (Residents 7, 2, and 9). The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on record review, observations and interviews, the facility failed to ensure that the medication error rate was not 5% or higher. This affected 4 of 8 residents (Residents 21, 26, 40, and 58). The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05 (D)Licensure Reference Number 175 NAC 12-006.05 (E)Based on record review and interview the facility failed to be inform the resident/resident representative of the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to choose the alternative or option they prefer prior to administering psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) for 2 (Resident 3 and Resident 4) of 5 residents. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02 (H)State Statute 28-372Based on record review and interview, the facility failed to report all allegations of mistreatment and abuse within the regulatory reporting parameters. This affected 1 (Resident 4) of 1 sampled resident. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 (G)(i)Based on record review and interviews, the facility failed to provide evidence that the required information was conveyed to the hospital at the time of transfer and failed to notify the resident or responsible party of the facility bed hold policy at the time of transfer for 1 Resident (Resident 5) of 1 sample resident. Facility census was 46Findings are:A.Review of a facility policy titled Discharge and Transfer dated 12/18/2025 revealed when a transfer or discharge occurs, the location must ensure that the transfer or discharge is documented in the medical record and appropriate information is communicated to the receiving healthcare center or provider. Review of Resident 5's medical record revealed an admission date of 09/30/2025 and a discharge date of 12/19/2025. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) (iii)(2)Based on observation, record review, and interview the facility failed to ensure that pressure ulcer (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) assessments including wound size were documented as required to determine healing or worsening of the pressure ulcers for 1 of 1 residents reviewed (Resident 2). The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)Licensure Reference Number 175 NAC 12-006.12(D)(i)(2) Based on record review, observation, and interview, the facility failed to ensure that medications that are subject to abuse were counted correctly in order to easily account for these medications on individual resident's narcotic count sheets. This had the potential to affect one of one resident sampled (Resident 1) . The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review and interviews, the facility failed to ensure the dishwashing machine achieved the manufacturer designated temperature during the rinse cycle to ensure sanitization of dishes used by the residents and kitchen staff. This had the potential to affect all the residents' receiving food from the kitchen. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 1-005.06(F)Licensure Reference Number 175 NAC 12-006.18Based on observation, record review, and interview the facility failed to ensure that staff performed disinfection of mechanical lifts between resident use to prevent cross-contamination, failed to ensure that staff performed hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) before putting on gloves and after removing gloves, and failed to perform hand washing to prevent the potential for cross contamination for 1 resident (Resident 22) during resident transfers and cares. The facility census was 46.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(F)(i) Based on record reviews and interview, the facility failed to ensure the licensed nurse had the knowledge and training to provide care for a Pleurex catheter for Resident 9. This affected 1 of 3 residents reviewed for use of a Pleurex catheter. The facility's census was 55.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.17 The facility failed to ensure that staff perform hand washing between glove changes and to wear EBP for Resident #5 while performing wound cares to prevent the potential for cross contamination. The facility census was 55. Record review of Resident 5's admission record dated 5/5/25 revealed admission to the facility was 3/31/22. Record Review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 4/2/25 revealed: Section C - BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15 indicating the resident was cognitively intact. -Section GG - dependent assist with footwear and maximum assist with repositioning. Physicians Orders dated 5/5/25 revealed: [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent accidents for 1 (Resident 1) of 3 sampled residents. The facility census was 44.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review; the facility failed to use the correct sling size to transfer a resident, and failed to asses and monitor a resident after a fall for 1 (Resident 6) of 3 sampled residents. The facility census was 41.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.18 Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review; the facility failed to ensure the required isolation sign was posted and staff donned (put on) and doffed (took off) the required Personal Protective Equipment (PPE) for 1 (Resident 146) of 1 sampled residents that had been identified as positive for COVID-19, this had the potential to affect all residents in the facility. The facility failed to ensure 3 (Residents 10, 11, and 12) of 3 sampled resident's oxygen tubing was changed and dated weekly and was stored in a bag when not in use, and failed to clean and store 1 (Resident 40) of 1 sampled resident's nebulizer kit (neb)(a kit used to deliver liquid medication to the lungs) daily to prevent cross-contamination (transfer of bacteria from one surface to another). The facility census was 41. A. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.12(D)(i) Based on observation, interview, and record review; the facility failed to safely store medications by leaving unattended medications at resident's bedside for 1(Resident 3) of 1 sampled residents. The facility census was 41. A record review of Resident 3's admission Record revealed Resident 3 admitted to the facility on [DATE] and was admitted to the hospital on [DATE]. An observation on 09/23/24 at 9:51 AM revealed an unattended medication cup containing 12 medications varying in size and color sitting on a bedside table in Resident 3's room. An interview with Licensed Practical Nurse (LPN)-G on 09/23/2024 at 9:52 AM was conducted. LPN-G revealed that These (the pills in the medication cup) look like Resident 3's morning pills. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to follow infection control guidelines to prevent cross contamination related to peri cares and catheter cares for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 41.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.04B2c Based on observation, interview and record review, the facility failed to ensure the kitchen had a qualified Dietary Manager. This had the potential to affect all 47 residents that consumed food from the kitchen. The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11E Based on observation, interview and record review, the facility failed to ensure open food items in the kitchen were dated and/or labeled and failed to ensure the kitchen equipment was clean to prevent the potential for foodborne illness. This had the potential to affect all 47 residents that consumed food from the kitchen. The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.10D Based on observation, interview and record review, the facility failed to ensure 1 (Resident 100) of 2 sampled residents received an antibiotic (a medication used to treat an infection) as scheduled and failed to ensure food was given after sliding scale Insulin (progressive increase in pre-meal or nighttime insulin doses based on pre-defined blood glucose (sugar) ranges) was administered for 2 (Residents 100 and 107) of 3 sampled residents per manufacturer's specifications. The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review, the facility failed to ensure glove changes and hand hygiene were performed during wound care on 1 (Resident 2) of 4 sampled residents, failed to handle linen in a manner to prevent cross contamination for 2 (Resident's 6 and 99) of 2 sampled residents, and failed to secure catheter drainage bag in a manner to prevent cross contamination for 1 (Resident 13) of 1 sampled resident. The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D6(7) Based on observation, interview and record review, the facility failed to ensure 1 (Resident 100) of 6 sampled residents had a valid order for Oxygen and Positive Airway Pressure device (PAP)(a machine used to treat Obstructive Sleep Apnea (OSA). The total facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09D Based on Observation, Interview and Record Review the facility failed to ensure bowel medications were managed to prevent excessive bowel movements for one resident, (Resident 25). The facility census was 47.