Good Samaritan Society - Millard

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J)(i)(1) and 12-006.09(J)(iii). Based on observation, interview and record review the facility failed to identify a significant weight loss, implement interventions to prevent further weight loss and failed to obtain weights for 4 (Resident 1,26, 40 and 62) of 7 residents. The facility census was 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.01(A)Based on observations, record reviews, and interviews, the facility management failed to utilize its resources to attain or maintain the highest practicable physical and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.07(C) Based on record review and interview, the facility failed to ensure the Quality Assurance Performance Improvement Program (QAPI - a facility process that identifies problems in the facility and works to correct the concerns) identified and addressed concerns related to deficient practice identified on the annual survey 2026 ( F550, F605, F641, F677, F684, F686, F688, F692, F695, F712, F756, F761, F835, F838, F843, F880, and F865 ) This had the potential to affect 74 residents who resided in the facility. [...]

Inspectors wroteBased on record review and interview, the facility failed to review and update the facility assessment with input from the Medical Director and Director of Nursing. This has the potential to affect all residents in the facility. The facility staff identified a census of 74.

Inspectors wroteBased on record review and interview; the facility staff failed to have a transfer agreement between the facility and hospital. This had the potential to effect all residents in the facility. The facility staff identified a census of 74.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were seen by a physician for the initial comprehensive visit for 4 (Resident 6, Resident 8, Resident 42, and Resident 95) of 4 sampled residents. Facility staff identified a census of 74.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(D,E &F), 12-006.19, 12-006.18(B). Based on observation, interview and record review the facility failed to store Nebulizer equipment, clean CPAP mask and tubing and failed to utilize handwashing and gloving techniques to prevent potential cross contamination for 4 (Resident 4, 10, 15 and 45). The total sample size was 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S)Based on record review and interview, the facility failed to timely notify the selected funeral home of needed services for 1 (Resident 88) of 1 sampled resident. The facility staff identified a census of 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to perform an abnormal involuntary movement score (AIMS, an evaluation used to look for involuntary muscle movements usually in the face, lips, tongue, hands, and feet) evaluation for the use of antipsychotic medications for 1 (Resident 3) of 5 sampled residents. The facility staff identified a census of 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility staff failed to accurately code the mood score on the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 1 (Resident 1) of 5 sampled residents. The facility staff identified a census of 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(i)(1)Based on observation, record review and interview, the facility failed to ensure that 1 resident (Resident 95) received dining assistance in a timely manner. The facility had a census of 74. A record review of Resident 95's admission Record revealed resident was admitted to the facility on [DATE] with a diagnosis of an unstable burst fracture (an injury which could develop more damage) of T7-T8 vertebra (the 7th and 8th bone in the upper middle back). A record review of Resident 95's Brief Cognitive Assessment Tool - short form (BCAT - a clinical test used by healthcare professionals to evaluate a patient's cognitive functioning and practical judgement) result revealed Resident 95 had a score of 12 which indicated Resident 95 had severe cognitive impairment. [...]

Inspectors wroteLicensure 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.

Inspectors wroteBased 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.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(v). Based on record review and interview the facility failed to implement an ambulation program as recommended by therapy and per resident wishes for 1 (Resident 42) of 2 sampled residents. The facility census was 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g) Based on observation, interview and record review the facility failed to ensure Continuous Positive Airway Pressure (CPAP: a machine that delivers a steady stream of pressurized air through a mask to keep the throat open when asleep) orders were obtained and followed for 1 (Resident 4) of 1 resident sampled. The facility census was 74.

Inspectors wroteBased on record review and interview, the facility failed to perform follow up on the consultant pharmacist's monthly recommendations for 2 (Resident 3 and Resident 62) of 5 sampled residents. Facility staff identified a census of 74.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)(i)Based on observation and interview, the facility failed to ensure that medication were secured for 1 (Resident 10) during medication administration. The facility had a census of 74. An observation on 5/19/2026 at 8:10AM of medication administration by Medication Aide (MA) Q to Resident 10 revealed the following: MA Q had prepared the medications for administration to Resident 10 and locked the medication cart. MA Q had left the medication cards, which still contained medications, on the top of the cart. MA Q walked down the hall away from the cart with the prepared medications and had reached Resident 10's door before they looked back to the cart and saw the medication cards unsecured on the cart. [...]

Inspectors wroteLicensure 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. [...]

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.

Inspectors wroteLicensure 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.