Good Samaritan Society Miller Pointe a Prospera Co

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 5 of 19 sampled residents (Resident #3, #37, #65, #73, and #121) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), personal protective equipment (PPE), dressing changes, glove changes, and hand hygiene has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 1 sampled resident (Resident #100) observed with medications at bedside. Failure to ensure residents take all prescribed medications and document medication administration may result in errors and/or adverse effects for the resident.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure safe and secure medication storage for 1 of 6 unlocked and unattended medications cars (Driftwood Lane). Failure to securely store medications may result in unauthorized access to medications by residents, visitors, and staff.

Inspectors wroteBased on observation, record review, review of menus, review of facility policy, and staff interview, the facility failed to serve food according to prepared menus for 3 of 3 sampled residents (Resident #10, #11, and #74) observed during tray line. Failure to serve food according to the portion sizes listed on the resident's menu/tray card may result in inadequate nutrition and weight loss or weight gain.

Inspectors wroteBased on observation, record review, review of the facility reported incident (FRI), review of facility training records, review of facility policy, review of manufacturer's guide, and staff interview, the facility failed to utilize devices necessary to prevent accidents and/or injury for 2 of 2 sampled residents (Resident #1 and #2) observed while in a spa chair. Failure to utilize the spa chair safety belt resulted in Resident #1 experiencing a fall and fracture and placed all residents at risk for falls and/or injury. During the on-site FRI investigation, the surveyor consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 02/23/25. The IJ resulted from the facility's failure to utilize the spa safety belt and the resident sustained a fracture. * 02/27/25 at 9:47 a.m. [...]

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 3 sampled residents with an indwelling catheter (Resident #163) and 2 of 3 residents (Residents #34 and #89) on transmission-based precautions (TBP). Failure to practice infection control standards related to enhanced barrier precautions (EBP) and TBP has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, policy review, review of staff education, review of facility reported incident, and resident interview, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury for Resident #1. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident.

Inspectors wroteBased on review of the facility reported incident, review of facility policy, and record review, the facility failed to report an incident of potential neglect to the State Survey Agency (SA) for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to report an event of potential neglect in the required time frame does not comply with regulations established to protect residents.

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to follow professional standards of practice regarding medication administration for 19 of 20 unidentified residents on the 100 unit. Failure to follow professional standards for safe medication preparation and administration placed the residents at risk of receiving the wrong medication.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow infection control practices on 2 of 2 units with Covid positive residents (Unit 500 and 600). Failure to follow infection control practices related to Personal Protective Equipment (PPE) has the potential to transmit infections to other residents, staff, and visitors.

Inspectors wroteBased on observation and staff interview, the facility failed to promote privacy and confidentiality of the medication administration records (MAR) on 2 of 6 units (300 and 400 unit) observed. Failure to promote resident privacy and lock computer screens may result in unauthorized viewing of resident records by other residents, visitors, or unlicensed staff.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or their representative and/or the State Long Term Care Ombudsman written notice of transfer for 3 of 5 sampled residents (Resident #30, #47, and #68) with a hospital transfer. Failure to provide a written copy of the transfer notice does not allow the resident and/or their representative to make an informed decision regarding their rights or inform the Ombudsman of the transfer.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a bed-hold notice to 1 of 5 sampled residents (Resident #30) with a transfer to the hospital. Failure to provide the facility's bed-hold notice does not allow residents or their legal representatives to make informed choices regarding their readmission rights.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 2 of 25 sampled residents (Resident #39 and #81). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care and safety.

Inspectors wroteBased on observation, record review, review of facility policy, and family and staff interview, the facility failed to provide assistance with activities of daily living (ADL) for 1 of 17 sampled residents (Resident #81) requiring substantial assistance with dressing or transfers. Failure to dress and assist the resident out of bed may result in decreased self-esteem and quality of life.

Inspectors wroteBased on observation, record review, review of facility policy, manufacturer resources, and staff interviews, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 4 sampled residents (Resident #3) who required a full body mechanical lift with sling for transfers. Failure to ensure staff utilize the proper size sling for each resident placed all residents who transfer with a mechanical lift at risk for accident and/or injury.