Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Millard during CMS and state inspections, most recent first.
Failure to monitor bowel movements and blood glucose. A resident with Alzheimer’s disease and severe cognitive impairment had repeated days with no bowel movement charting and did not receive the ordered bowel protocol medications despite standing bowel orders. Another resident with diabetes had ordered BID blood sugar checks, but evening glucose readings were not documented for several days, and the DON confirmed the missing documentation and that the MAR had no place to record the reading.
Failure to implement pressure relieving boots for a resident with pressure ulcers. A resident with TBI, hemiplegia, limited ROM, and memory problems had a stage 3 pressure ulcer to the right foot and later developed a new DTI to the right foot near the toe. The care plan called for a pressure relieving/reducing device, but the TAR initially had no boot order, and later documentation showed no use of the Prevalon boots; when observed in bed, the boots were in the wheelchair. The DON confirmed the boots were not initiated until after the stage 3 ulcer developed.
The facility failed to secure treatment carts on the 200 and 500 halls, leaving them unlocked and unattended with insulin stored inside. Observations confirmed the carts were not locked, and interviews with RNs acknowledged the oversight. Facility policy requires medications to be stored in locked areas, accessible only to authorized personnel.
The facility failed to perform required neurological checks after falls for two residents. One resident had an unwitnessed fall, with incomplete neurological evaluations recorded in the EHR. Another resident also experienced an unwitnessed fall, with only vital signs logged and insufficient Neuro Check entries. The facility's policy mandates regular neurological evaluations after such incidents, but these were not conducted as required.
The facility failed to implement fall interventions for two residents, both of whom had experienced falls. Despite care plans requiring call lights to be secured with Velcro, observations revealed that this intervention was not followed. Staff confirmed the oversight, highlighting a deficiency in maintaining a safe environment.
Facility staff failed to maintain safe water temperatures in resident handwashing sinks, with temperatures recorded significantly above the recommended range, posing a risk of hot water burns. The Maintenance Director and Administrator confirmed the use of an incorrect thermometer, leading to inaccurate readings and non-compliance with the facility's water management policy.
A resident was transferred to the hospital after a fall, but the facility staff failed to provide a Transfer Discharge notification as required by policy. The oversight was confirmed by the Facility Administrator, and the facility's policy mandates written notification to the resident and their representative, even in emergency transfers.
Facility staff failed to ensure a resident's drug regimen was free from unnecessary duplicate medication orders. The resident, moderately cognitively impaired, had multiple orders for Acetaminophen, including 500 mg every 6 hours as needed, 500 mg four times a day, and 650 mg every 4 hours as needed, all with a maximum daily limit of 3,000 mg. The DON confirmed these orders were duplicate therapy.
Failure to Monitor Bowel Movements and Blood Glucose
Penalty
Summary
The facility failed to monitor bowel movements and follow the ordered bowel protocol for Resident 2. Resident 2 had a diagnosis of Alzheimer’s disease, a BIMS score of 5 indicating severe cognitive impairment, and required assistance with hygiene, bed mobility, transfers, toileting, bathing, and dressing. The bowel movement log showed multiple days with no charting and repeated entries of no bowel movement, with only one small bowel movement documented before a later medium bowel movement. Resident 2 had standing bowel-related orders for Miralax, Senna, and a bowel protocol that included prune juice on day 2 without a bowel movement, Milk of Magnesia on day 3, a bisacodyl suppository on day 4, and a fleet enema with provider notification on day 5, but the record showed the prn bowel protocol medications were not given from 05-01-2026 through 05-13-2026. The DON confirmed the resident had not had a bowel movement other than the small one and that the prn bowel protocol medications should have been given. The facility also failed to document blood glucose readings for Resident 87 as ordered. Resident 87 was admitted with a diagnosis of diabetes mellitus and had an order for Tresiba insulin with a morning blood sugar reading area on the medication record, along with an order for blood sugar checks twice daily for morning and evening medication passes. The blood sugar summary showed no evening blood sugar documentation for three consecutive days, and progress notes for that period did not include those blood sugar levels. The DON confirmed the lack of documentation for the evening readings and stated there was no place on the medication record to document the reading.
Failure to Implement Pressure Relieving Boots for a Resident with Foot Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for Resident 26. The resident’s MDS dated 04-28-2026 documented short-term and long-term memory problems, limited assistance needs for bed mobility and transfers, extensive assistance needs for toileting, bathing, and upper body dressing, total assistance for lower body dressing, a traumatic brain injury, hemiplegia, limited ROM on one side, risk for pressure ulcer development, and a stage 3 pressure ulcer. The care plan revised on 03-19-2026 identified skin integrity impairment related to localized edema and protein-calorie malnutrition and included a pressure ulcer to the right side of the right foot and the right heel, with interventions to monitor the wound, refer to restorative nursing, and provide a pressure relieving/reducing device and/or skin protective device, but it did not specify what device to use, for what area, or how often. Record review showed a new stage 3 pressure ulcer to the right foot on 01-13-2026, and the TARs for November and December 2025 had no order for pressure relieving boots. A TAR entry dated 01-14-2026 later ordered Prevalon boots to both lower extremities, to be worn at all times in bed as the resident allowed. Despite this, the EMR task record from 04-27-2026 through 05-26-2026 showed no documentation of Prevalon boot use, and on 05-26-2026 the resident was observed in bed without the boots, which were found in the wheelchair. The resident also developed a new pressure ulcer to the right foot near the toe, documented as a DTI on 03-04-2026. The DON confirmed on 05-26-2026 that the facility had not initiated pressure relieving boots until after the resident developed the stage 3 pressure ulcer to the right foot.
Unsecured Treatment Carts with Insulin
Penalty
Summary
The facility failed to ensure the security of treatment carts on the 200 and 500 halls, which were left unlocked and unattended. During an observation, it was noted that the treatment cart on the 200 Hall was unlocked, and an interview with a Registered Nurse (RN) confirmed that insulin, a medication used to treat diabetes, was stored in the cart and that it should have been locked when unattended. Similarly, another observation revealed an unlocked treatment cart on the 500 Hall, and an interview with another RN confirmed the presence of insulin in the cart and acknowledged that it should have been secured. The facility's policy on medication storage, dated March 29, 2024, mandates that medications be stored in a locked cart, drawer, or cupboard, with access limited to the person passing medications and the director of nursing services or their designee.
Failure to Perform Neurological Checks After Falls
Penalty
Summary
The facility failed to perform neurological checks after falls for two residents, as required by their policy. Resident 1 experienced an unwitnessed fall, and the Neuro Vital Sign Sheet Report indicated that neurological evaluations should be conducted every 30 minutes for four sets, then every 8 hours for the next three days. However, the records showed only vital signs were logged, and the Neuro Check assessments in the Electronic Health Record (EHR) had only two entries on the day of the fall and one the following day. Similarly, Resident 3 had an unwitnessed fall, and the NVSSR also showed only vital signs logged, with only two Neuro Check entries recorded on the day of the fall. The facility's policy on Neurological Evaluation-Rehab/Skilled requires establishing a baseline neurological status for comparison and monitoring changes, especially after unwitnessed falls or suspected head injuries. An interview with the Director of Nursing confirmed that the Neuro Check entries in the EHR should match the vital signs on the NVSSR and acknowledged that the evaluations were not completed at the appropriate intervals for both residents. This failure to adhere to the policy resulted in incomplete neurological assessments following the falls.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident 3, who has severe cognitive impairment as indicated by a BIMS score of 4, required moderate assistance with toileting, bathing, and lower body dressing, and supervision with transfers. Despite a fall on December 25, 2024, the intervention to secure the call light to the bed with Velcro was not implemented, as observed on February 20, 2025, during two separate observations. This was confirmed by RN D, who acknowledged that the call light was not secured. Similarly, Resident 4, with moderate cognitive impairment and requiring maximum assistance with bathing and moderate assistance with personal hygiene and bed mobility, also experienced a fall on December 25, 2024. The care plan intervention to secure the call light with Velcro was not followed, as observed on February 20, 2025, when the call light was found lying on the bed instead of being secured. This was confirmed by Nurse Aid E. The facility's policy on fall reduction emphasizes the importance of communicating fall risk factors and implementing interventions, which was not adhered to in these cases.
Unsafe Water Temperatures in Resident Sinks
Penalty
Summary
The facility staff failed to maintain safe water temperatures in resident handwashing sinks, leading to the potential risk of hot water burns for six residents out of a total census of 62. Observations conducted on November 18, 2024, revealed that the water temperatures in the sinks of several residents were significantly above the recommended safe range of 110-115 degrees Fahrenheit. Specifically, the water temperature for one resident was recorded at 128 degrees Fahrenheit, while others had temperatures ranging from 122.3 to 130.7 degrees Fahrenheit. During an interview, the Maintenance Director, Administrator, and Maintenance Technician Assistant confirmed that the thermometer used for measuring water temperatures was incorrect, leading to inaccurate readings. The facility's policy on plumbing systems and water management emphasizes the importance of maintaining water temperatures within a safe range to ensure resident safety and comfort. However, the failure to use a properly calibrated thermometer and adhere to the recommended procedures resulted in the deficiency observed by the surveyors.
Failure to Provide Transfer Discharge Notification
Penalty
Summary
The facility staff failed to provide a Transfer Discharge notification for a resident who was sent to the hospital following a fall. The resident, identified as Resident 18, was transferred to the hospital on July 5, 2024, but there was no evidence in the medical records, including progress notes, faxes, demographic sheets, and practitioner orders, that a Transfer Discharge notice was provided to the resident or their responsible party. This oversight was confirmed during an interview with the Facility Administrator on November 20, 2024. The facility's Discharge and Transfer Policy, reviewed and revised on January 3, 2024, outlines the requirement to notify the resident and their representative of the transfer or discharge in writing, in a language and manner they understand. The policy specifies that even in cases of emergency transfers to an acute care center, a notice of transfer must be provided as soon as practicable. The responsibility for completing the Notification of Transfer or Discharge falls to the social worker or designated individual, or the charge nurse if the transfer occurs when social services are not present.
Duplicate Medication Orders for a Resident
Penalty
Summary
Facility staff failed to ensure that a resident's drug regimen was free from unnecessary duplicate medication orders. A review of the electronic health record (EHR) for a resident, who was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12, revealed multiple orders for Acetaminophen. The resident had diagnoses including adult failure to thrive, bipolar disorder, anxiety disorder, history of falling, chronic kidney disease stage 3, and legal blindness. The EHR showed three separate orders for Acetaminophen: 500 mg every 6 hours as needed, 500 mg four times a day, and 650 mg every 4 hours as needed, all with a maximum daily limit of 3,000 mg. An interview with the Director of Nursing confirmed these orders constituted duplicate therapy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Brookestone Village | 1.5 mi | ★★★★★ | 10 | 0 |
| Hillcrest Millard Llc | 1.7 mi | ★★★★★ | 10 | 0 |
| Newport House | 2.1 mi | ★★★★★ | 8 | 0 |
| The Banyan At Montclair | 2.3 mi | — | 19 | 0 |
| Rose Blumkin Jewish Home | 3.7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.