Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Miller during CMS and state inspections, most recent first.
Failure to monitor and prevent pressure ulcer progression: A resident with cognitive impairment, diabetes, weakness, dementia, and prior skin breakdown developed a stage II coccyx ulcer while pressure-injury prevention measures were inconsistently documented. The care plan did not include the wheelchair cushion or air mattress, CNA tasks for barrier cream and daily skin checks were not triggered, and there was no documentation that the MD was notified when the wound increased in size or depth or that treatments changed. Staff interviews confirmed gaps in documentation and uncertainty about when key support surfaces were placed.
Baseline care plans were not reviewed with residents or their representatives, and copies were not provided within the required 48-hour timeframe for four newly admitted residents. One resident with moderate cognitive impairment reported not remembering discussion of personal care needs or goals or being offered a copy of the BCP. The administrator and DON stated they were unaware the BCP had to be reviewed with, and a copy offered to, the resident or representative within 48 hours.
Respiratory equipment was not cleaned, dated, or stored properly for multiple residents using O2, nebulizers, and CPAP. Surveyors observed undated nasal cannulas, dusty concentrator filters, a soiled CPAP setup secured with dirty tape, and nebulizer parts left with liquid in the chamber or stored outside of bags. The DON acknowledged several items were not being cleaned or stored as required, and EMR review showed missing documentation for cleaning and replacement.
Controlled medication management was incomplete on the East hall carts, with missing shift-count signatures, inconsistent narcotic record entries, and a controlled medication shortage that could not be located. A resident with a feeding tube and diagnoses including TBI, diabetes, anxiety, and seizures had multiple MAR omissions for scheduled meds, including alprazolam, insulin, seizure meds, and other routine medications, and the narcotic records lacked required details such as dosage, form, pharmacy name, and administration times.
Failure to document a required GDR for psychotropic meds: A resident with dementia with psychotic disturbance and residual schizophrenia was receiving thioridazine and trazodone, but the EMR did not show an attempted GDR or a physician-documented rationale that reduction was clinically contraindicated. The consultant pharmacist and DON both stated that GDRs were to be recommended and addressed, yet the record lacked documentation that this occurred, despite the facility policy requiring GDRs for psychotropic drugs unless contraindicated.
Delayed Significant Change MDS After Hospice Admission: A resident admitted to hospice did not have a significant change MDS completed within the required timeframe. The MDS was completed well after hospice enrollment, and the administrator acknowledged the delay, noting the assessment was missed during the transition from an on-site MDS coordinator to a corporate off-site coordinator. The facility policy stated that a significant change MDS was completed when the resident enrolled in hospice.
Care plans were not reviewed and revised to reflect the current needs of two residents. One resident had severe cognitive impairment, major weight fluctuations, and a non-individualized weight-loss care plan with blank placeholders. Another resident had severe cognitive impairment, anxiety, Alzheimer’s disease, chronic pain, and a Haldol order before bathing, but her care plan did not include her bathing-related behaviors or the need for medication and extra staff support.
The facility failed to accurately document care for a resident with a newly placed suprapubic catheter and failed to correctly transcribe a physician order for another resident’s Haldol. The catheter site care was entered incorrectly and not documented as completed on the TAR for multiple days, and the EMR lacked documentation of the procedure, return to the facility, and post-procedure assessment. A separate resident’s Haldol order for 1 mg before a scheduled shower was entered as a PRN bath order, so the medication was not given as ordered.
Medication labels did not match the MARs for two residents during observed med passes. A CNA/UAP identified that one resident’s eye drop label directed a different frequency than the MAR, and another resident’s eye drop label listed a different product and directions than the MAR. The CNA/UAPs stopped and reported the discrepancies to the nurse and DON, and interviews confirmed the facility had not reconciled the pharmacy labels with the current physician orders.
The facility failed to ensure proper sanitation levels in the kitchen, as staff were unable to verify the chemical sanitation level required for dishwashing due to expired test strips. The dishwasher's chemical sanitation was not functioning, and staff were unaware of procedures to follow in such cases. This deficiency increased the risk of foodborne illnesses for residents.
A blind resident experienced neglect in a LTC facility, including delayed incontinence care, flies on his food, and unmet personal hygiene needs before a funeral. The resident's daughter confirmed these issues, highlighting a failure to uphold the facility's abuse and neglect policy.
A resident with dementia and mobility issues was left on a bedpan overnight, resulting in pressure injuries. Despite being dependent on staff for care, the resident was not on a repositioning program. Staff interviews revealed a lack of comprehensive training on bedpan use, contributing to the deficiency.
The facility lacked an infection prevention and control program. The interim DON had not updated policies, conducted infection surveillance, or established antibiotic stewardship. The administrator confirmed the absence of an active program, and the quality assurance specialist noted the resignation of the former infection preventionist, leaving the facility without a qualified individual.
The facility failed to appoint a qualified infection preventionist (IP) for its infection control program. The interim DON was informed she would be the IP, but her certification had expired, and she was not planning to renew it. The administrator confirmed the absence of a qualified IP, and the previous DON, who was the IP, had resigned, leaving the facility without a qualified infection preventionist.
The facility's QAPI program was found lacking in effectiveness and comprehensiveness, with no current performance improvement plan in place. Issues such as incomplete resident baths, abuse concerns, and outdated dietary test strips were not addressed through the QAPI committee. Additionally, the grievance process was poorly monitored, and customer satisfaction feedback was not reviewed. The QAPI coordinator was unaware of facility-reported incidents, and communication issues were noted within the facility.
The facility failed to maintain effective pest control, with surveyors observing live and dead insects, including flies and crickets, in various areas. Residents experienced flies on personal items and in food, highlighting inadequate pest management. Staff interviews revealed monthly pest control visits and some control measures, but the dining room lacked fly control, and staff were unaware of the issue there.
The facility failed to follow the bathing preferences of three residents, leading to missed baths and unmet care plan requirements. Staffing changes and scheduling issues contributed to the deficiency, with residents not receiving baths on their preferred days or frequency. Interviews and record reviews revealed discrepancies between documented preferences and actual care provided.
The facility failed to update and follow care plans for several residents, leading to unmet care needs. A resident's care plan did not address his use of a neuropathy device, suicidal ideations, or unsafe driving. Another resident's bathing preferences were not met, and her bed was improperly positioned. A third resident did not receive necessary incontinence care. The facility's policy required comprehensive care plans, but these were not accurately maintained.
A resident exhibited suicidal ideation and unsafe driving practices, yet the facility failed to notify the physician. The resident, who had a car at the facility, was observed driving unsafely and made a threat of self-harm, which he later dismissed as a joke. Additionally, the resident engaged in inappropriate behavior with a female. Despite these incidents, the facility did not inform the physician, violating their Notification of Change policy.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfers. The resident was transferred twice, with the POA notified but no documentation of bed hold information provided. The ombudsman did not receive notifications, and the facility's policy required such notices to be sent.
A resident was transferred to the hospital twice without receiving bed-hold notices, as required by the facility's policy. Despite notifying the resident's POA of the transfers, there was no documentation of bed-hold information being provided. Interviews with staff confirmed the absence of these notices, highlighting a failure to adhere to the facility's bed-hold policy.
A resident used an infra-red device for neuropathy pain without a current physician order or safety assessment. The device, observed in the resident's room, was not included in the care plan, and there was no documentation of its use. Interviews revealed a lack of awareness and proper storage of the device, and the facility did not provide a policy on electronic medical equipment.
Failure to Monitor and Prevent Pressure Ulcer Progression
Penalty
Summary
The provider failed to monitor and implement pressure ulcer healing and prevention interventions for a resident who was at risk for skin breakdown and developed a stage II pressure ulcer to the coccyx. The resident had moderate cognitive impairment, diabetes, weakness, dementia, and a history of a stage II sacral pressure ulcer. A Braden Scale assessment identified mild risk for pressure injury, with recommended interventions including frequent turning, pressure-reduction support surfaces, heel protection, moisture management, nutrition management, and friction/shear reduction. The resident was observed with a wheelchair cushion and an air mattress, but he did not know why they were in use and did not know whether he had a skin wound. The resident’s care plan included skin integrity and prior pressure ulcer focus areas, but it did not include the wheelchair cushion or air mattress. The wound assessment on the day the stage II coccyx ulcer was identified documented a pink open area with the first layer of skin gone, and the physician was noted as notified, but there was no documentation of when that notification occurred. Subsequent wound measurements showed changes in size and depth over time, including increases in wound size and depth on multiple assessments. There was no documentation that the physician was notified when the wound increased in size or depth, and there was no documentation that treatments or interventions changed in response to those changes. The record also showed missing documentation related to prevention and daily care. The administrator stated that barrier cream had been entered into the care plan but had not triggered a task in the point-of-care system, and there was no documentation that CNAs applied barrier cream after incontinent episodes or completed daily skin inspections. The DON stated the barrier cream task and daily skin check task were not added to the CNA tasks when the resident was admitted. The DON also acknowledged there was no documentation showing when the wheelchair cushion was placed, that the air mattress was added only after the pressure ulcer developed, and that the physician had not been notified when the ulcer increased in size. Staff interviews confirmed uncertainty about when the cushion was placed and whether the resident had been receiving the documented preventive interventions.
Baseline care plans were not reviewed or provided within required timeframe
Penalty
Summary
The provider failed to ensure that newly admitted residents' baseline care plans were reviewed with the resident and the resident's representative, and that a copy was provided within 48 hours of admission, as required by policy. Four of five sampled newly admitted residents were affected. Resident 19 admitted to the facility and had a baseline care plan initiated, but it was not reviewed with her until four days after admission, and there was no documentation that a copy was provided to her or her representative. Resident 2's baseline care plan was not reviewed and acknowledged by him or his representative until his care conference meeting 20 days after admission. Resident 5's baseline care plan was initiated after admission and emailed to his representative 15 days later, with no documentation that he was provided a copy. Resident 24, who had a BIMS score of 10 indicating moderate cognitive impairment, stated she did not remember anyone talking to her about her personal care needs or goals when she admitted or being offered a copy of her baseline care plan. Her baseline care plan was initiated after admission and provided to her representatives seven days later, with no documentation that she received a copy. The administrator and DON stated the baseline care plan was to be completed within 48 hours, but they were not aware it also had to be reviewed with, and a copy offered to, the resident or resident representative within that timeframe.
Respiratory Equipment Not Cleaned, Dated, or Stored Properly
Penalty
Summary
The provider failed to ensure respiratory equipment was cleaned, stored, and maintained according to professional standards of practice for residents using nebulizers, CPAP, and oxygen. Surveyors observed multiple instances of equipment that was dirty, undated, improperly stored, or missing required parts, and record review showed that documentation of cleaning or replacement was absent for several items. The facility’s own staff and the DON acknowledged that several pieces of equipment were not being handled as expected. For a resident with severe cognitive impairment who was ordered to receive continuous oxygen, surveyors observed an oxygen concentrator beside the bed with the nasal cannula draped over it, later found an undated cannula attached to the concentrator, and also found an undated cannula hanging on the wheelchair attached to a portable oxygen tank. The concentrator filters and filter covers were missing on both sides of the concentrator. The EMR contained no order for the cannula to be replaced and dated and no documentation showing when it had been replaced. For another resident with moderate cognitive impairment who had orders to change oxygen and nebulizer masks weekly and to clean the CPAP daily, surveyors observed the CPAP and nebulizer machines stored on a dresser, the CPAP mask hanging over the dresser, and the CPAP hose and mask secured with clear medical tape that was visibly soiled with fibers, debris, and dust. The concentrator filter contained dust fibers and lint, and the nebulizer mask contained clear liquid in the medicine chamber after a scheduled treatment. The DON acknowledged the CPAP mask did not appear to be removed and cleaned daily, the tape was soiled, the concentrator filter was dirty, and the nebulizer mask had not been cleaned or stored in the black mesh bag after treatment. For two other residents, surveyors observed undated or improperly stored nasal cannulas and nebulizer equipment. One resident’s nebulizer machine was dusty, with an undated tubing and a dated mouthpiece, and the resident stated he did not know how often the equipment should be replaced and did not have a storage bag. Another resident had an undated nasal cannula on the floor and later hanging on the bed rail, and stated she did not have a bag for storage until the day before the interview. Record review and staff interviews showed that staff were responsible for cleaning nebulizer masks after use, replacing nasal cannulas and nebulizer masks weekly, documenting those replacements, and storing unused equipment in bags, but the records did not show the required cleaning or replacement documentation for the sampled residents.
Controlled medication counts and documentation were incomplete and inconsistent
Penalty
Summary
Pharmaceutical services were not maintained to account for controlled medications and to document their receipt, counts, administration details, and destruction process. Review of the East hall treatment cart controlled drug count record showed multiple shift changes with missing signatures, incomplete counts for entire days, and entries that did not include all required nurse sign-offs. Review of the East medication cart inventory sheets also showed repeated missing signatures across several months, and the facility acknowledged that the missing signatures could indicate the counts had not been completed. Resident 3 had diagnoses including depression, anxiety, diabetes, traumatic brain injury, and post traumatic seizures, and was observed with a feeding tube and limited verbalization. Review of his Individual Resident Narcotic Records for alprazolam showed missing required information such as medication form, administration method, dosage, prescription number, pharmacy name, and, on some forms, the resident’s name or sticker. The records also lacked times for removal from locked storage for multiple doses, and some entries were inconsistent or incomplete, including dates where the amount on hand, amount administered, and remaining count did not align. One record also documented tablets returned to the retail pharmacy for repackaging. Review of Resident 3’s MAR showed multiple medications not documented as administered, including DuoNeb, Reglan, Tylenol, alprazolam, simethicone, Topamax, valproic acid, lispro insulin, levetiracetam, guaifenesin, Augmentin, melatonin, mirtazapine, Basaglar insulin, and morphine sulfate. Some alprazolam doses were documented as removed from locked storage but not documented as administered, while other doses were documented as administered on the MAR but not documented as removed from locked storage. The record also showed missing blood sugar documentation for several lispro insulin administrations. In addition, during a controlled medication count in the East medication cart, Resident 1’s Pregabalin bubble pack card was short by one capsule, and the missing capsule could not be located.
Failure to Document Required GDR for Psychotropic Medications
Penalty
Summary
The provider failed to ensure that one sampled resident who was receiving antipsychotic and psychotropic medications had an attempted gradual dose reduction (GDR) or a physician-documented rationale showing that a GDR was clinically contraindicated. The resident was admitted with diagnoses including dementia with psychotic disturbance and residual schizophrenia. His medication regimen included thioridazine hydrochloride 100 mg daily for schizophrenia and trazodone hydrochloride 50 mg daily for insomnia, and his care plan identified psychopharmacological medication use related to schizophrenia and insomnia with an intervention to consider dosage reduction when clinically appropriate. Review of the resident’s electronic medical record showed that consultant pharmacist recommendations from 12/30/23 through 1/29/26 did not include a GDR for trazodone or thioridazine, and there was no documentation that a GDR was clinically contraindicated by the physician since admission. During interview, the consultant pharmacist stated she reviewed residents’ records monthly, documented recommendations when needed, and noted that in April 2025 the resident needed a GDR recommendation but she could not find where it had been made or addressed by the physician. The DON stated that the consultant pharmacist was expected to recommend GDRs and that the physician was to document why a GDR was or was not clinically contraindicated. The facility policy stated that residents who use psychotropic drugs must receive GDRs and behavioral interventions unless clinically contraindicated, and that within the first year after admission or initiation of an antipsychotic, the facility must attempt a GDR in two separate quarters unless contraindicated. The policy also required the reduction committee to review the need for psychotropic medications at least every three months and document the rationale for continuing the medication. In this case, the record did not show the required GDR attempt or physician rationale for continuing the medications without reduction.
Delayed Significant Change MDS After Hospice Admission
Penalty
Summary
The provider failed to ensure that a significant change MDS assessment was completed within 14 days after a resident was admitted to hospice services. Resident 3 was admitted to the facility, had a physician's order for hospice referral and admission if appropriate, and was admitted to hospice on 10/20/25. His significant change MDS assessment was not completed until 11/21/25, 32 days after hospice admission. During interview, the administrator stated he expected the MDS coordinator to initiate significant change assessments and that the clinical team discussed residents who may qualify during daily meetings. He acknowledged that a significant change MDS was needed when a resident was admitted to hospice, but he did not know the required timeframe and confirmed the assessment for Resident 3 was not completed within 14 days. He also stated the facility's MDS coordinator was from the corporate office and not on-site, and believed the assessment was missed during the transition from an on-site to an off-site MDS coordinator. The facility's hospice services policy stated that a significant change MDS was completed when the resident enrolled in a hospice program.
Care plans were not updated to reflect current resident needs
Penalty
Summary
The provider failed to ensure care plans were reviewed and revised to reflect current care needs for two residents. One resident had severe cognitive impairment, diagnoses including dementia, a right hip fracture, insomnia, and heart failure, and his weight fluctuated from 147.0 lbs to 169.0 lbs and then down to 139.5 lbs. His care plan contained a weight-loss focus area with blank placeholders for individualized details, including unspecified causes, goals, and weighing frequency. The DON acknowledged the care plan was not individualized and stated the resident’s weight changes were related to edema and diuretic use. Another resident had severe cognitive impairment, diagnoses including anxiety, Alzheimer’s disease, and chronic pain, and had a physician’s order for Haldol before bathing. CNA interview revealed she did not like baths, needed two staff for bathing, and received medication to help her stay calm. However, her care plan only stated she required assistance with bathing and preferred one whirlpool bath per week, with no indication of bathing-related behaviors. The DON stated she expected the care plan to include interventions for those behaviors, and staff reported care plans were to be updated as residents’ needs changed.
Inaccurate catheter care documentation and medication order transcription
Penalty
Summary
The facility failed to ensure accurate assessment, care, and documentation for a resident with a newly placed suprapubic catheter. The resident had moderate cognitive impairment and had been admitted with a Foley catheter order before later undergoing suprapubic catheter placement at an outside hospital. The record showed a nursing treatment order entered on 1/18/26 to cleanse the suprapubic catheter site with soap and water and apply a slit sponge daily at bedtime, but the treatment was not documented as completed on the TAR for multiple dates in January and February. The EMR also contained no documentation showing when the suprapubic catheter was inserted or that the resident returned from the procedure and was assessed after the surgery. Interview and record review showed the DON and administrator did not have discharge instructions from the hospital for the new suprapubic catheter, and the DON stated the nurse should have called the hospital to request them. The DON acknowledged there was no documentation that the resident left the facility for the procedure, returned, or was assessed on return, and she expected a progress note and assessment to be entered. The RN stated she expected any completed treatment to be documented in the TAR and that if it was not documented, she would assume it had not been completed. The DON also acknowledged the treatment order was not entered correctly into the EMR so it did not appear on the TAR as intended, and that the lack of cleaning and dressing documentation could increase infection risk. The facility also failed to accurately transcribe a physician order for another resident’s Haldol. The original order directed Haldol 1 mg to be given one hour before a scheduled shower, but it was entered into the MAR as a PRN order for one hour prior to bath. The DON acknowledged the medication was not administered as ordered because it had been entered incorrectly, and she could not determine how the transcription error occurred. The facility’s policy stated physician/practitioner orders must be processed and transcribed accurately and immediately upon receipt, and prescriber-entered orders must be confirmed by a licensed nurse.
Medication Labels Did Not Match MARs for Two Residents
Penalty
Summary
The facility failed to ensure medication labels matched the residents’ MARs during medication administration for two residents. During an observed medication pass, a CNA/UAP found that one resident’s Blink Tears Solution 0.25% pharmacy label directed instilling 1 drop in both eyes every morning and at bedtime, while the February 2026 MAR ordered 1 drop in both eyes four times a day for macular degeneration. The CNA/UAP stopped the administration and notified the floor nurse because the label did not match the MAR. A second observed medication administration showed the same type of discrepancy for another resident. The resident’s Genteal Tears Solution Moderate pharmacy label directed 1-2 drops 2-3 times a day into the affected eye as directed, while the February 2026 MAR ordered Artificial Tears Solution 1.4% to be given as 1 drop in both eyes three times a day for dry eyes and irritation. The CNA/UAP again recognized the mismatch, notified the DON, and waited before administering the eye drops. During interviews, the RN and DON acknowledged the mismatches and stated that the pharmacy had received updated physician orders that were not reflected in the facility’s MARs for one resident and that a dose change had not been received for the other resident. The DON stated that medication containers needing new labels were to be removed from the medication carts and sent to the pharmacy for relabeling, and that staff were responsible for identifying discrepancies between pharmacy labels and MARs during medication safety checks. The pharmacy pharmacist also stated that specialty physicians sometimes sent new orders to the pharmacy without forwarding them to the facility’s primary physician, creating discrepancies between pharmacy labels and MARs.
Failure to Ensure Proper Sanitation Levels in Kitchen
Penalty
Summary
The provider failed to ensure that staff were able to verify the chemical sanitation level required to sanitize the dishes used for preparation and serving residents' food. This deficiency was identified through observations, interviews, and record reviews. The survey revealed that the dishwasher's chemical sanitation was not functioning, and staff were not aware of any process to follow when this occurred. Additionally, staff could not accurately verify the chemical sanitation level of the dishwasher due to the use of expired test strips. During the survey, it was observed that the sanitizing testing strips located by the three-compartment sink had expired. Interviews with dietary staff confirmed that these expired strips were being used to test the sanitizing solution, which was not at the correct parts per million (PPM) for effective sanitization. The Nutrition and Food Services Supervisor confirmed that the test strips were outdated and that there were no other test strips available for use. Furthermore, the dishwasher sanitizer was tested and found to be insufficient, with a reading of 10 ppm instead of the required 50 ppm. The deficiency was further compounded by the lack of awareness among staff regarding the expiration of test strips and the proper procedures to follow when the dishwasher was not functioning correctly. The provider's policies and procedures for sanitizing food contact surfaces and warewashing were not effectively implemented, as evidenced by the expired test strips and the inadequate sanitizing solution levels. This failure increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen and served to the residents.
Removal Plan
- Provide dishwasher manufacturer manual and disinfectant information to support instructions are being followed and appropriate sanitation is occurring.
- Use disposable paper plates, cups, and silverware until dishwasher is running appropriately.
- Place new non-expired strips in for the 3 comp sink.
- Remove all expired strips in kitchen.
- Wash all dishes in the 3-comp sink until dishwasher is fixed to verify levels.
- Implement the use of a Monitoring Use of Ecolab disinfectant Test Strips form for staff to sign off on expiration date of a cartridge when replaced and label in the cartridge holder on the wall.
- Complete education with all dietary staff on proper procedure for non-working dishwasher and education on non-expired test strips with return demonstration.
- Educate all staff via PCC Communications that kitchen staff must ensure all chemical test strips are not expired for the dishwasher and the 3 comp sink.
- Add to the TELS Service Provider a task for Director of Environmental Services to monitor weekly if a cartridge is near expiration and needs replacement.
- Contact EcoLab to fix dishwasher. In the meantime, try a new bucket of Ultra San Ecolab 5 gallon liquid sanitizer in the dishwasher and retest.
Neglect of Resident's Basic Care Needs
Penalty
Summary
The provider failed to ensure the well-being of a blind resident, identified as resident 15, by not protecting him from neglect and ensuring his basic care needs were met. The resident reported having to wait up to three hours for staff to respond to his care requests, including incontinence care, which was supposed to be provided every two hours. He also experienced issues with flies on his food and in his drink during a meal with visitors, who reportedly killed 12 flies at the table. The interim director of nursing acknowledged the problem with flies and the lack of timely incontinence care but was unsure if these issues were addressed in the resident's care plan. The resident also faced neglect in personal hygiene care. He was scheduled to have a bath once a week, but on the day before attending a funeral, he requested a bath twice and was not accommodated due to a lack of hot water in the tub room. He was not offered alternative bathing options or assistance with shaving, resulting in him attending the funeral unbathed and unshaven. The resident expressed dissatisfaction with the care provided, stating it was the worst place he had been in his life. The resident's daughter confirmed her father's reports of neglect, stating that he had called her for help when his call light was not answered for over an hour, leading to a bowel incontinence episode. She observed that he had not been bathed or cleaned, and his bedding was dirty. The business office manager confirmed receiving a call from the resident's daughter but did not report the incident or verify if the resident had been assisted. The facility's abuse and neglect policy emphasized the right of residents to be free from neglect, but the incidents reported indicate a failure to uphold this standard.
Resident Left on Bedpan Overnight, Leading to Pressure Injuries
Penalty
Summary
The deficiency involves a resident who developed facility-acquired pressure injuries after being left on a bedpan for an extended period. The resident, who is bedridden and dependent on staff for care due to a back injury and dementia, was left on a bedpan from the evening of one day until the morning of the next day. This incident was confirmed by multiple staff interviews, including a registered nurse and a certified medication aide, who noted that the resident had been on the bedpan throughout the night, resulting in red marks on his buttocks. The resident's care routine involved the use of a mesh sling for repositioning and a mechanical lift due to his size and mobility issues. Despite these measures, the resident was not on a turning or repositioning program, which is critical for preventing pressure ulcers. Observations and interviews revealed that the resident had existing wounds that were improving, but the prolonged time on the bedpan led to additional skin issues, including redness and potential bruising from the bedpan. Interviews with staff, including the interim director of nursing, revealed a lack of comprehensive education and training regarding bedpan use and repositioning. Although some staff were informed about the incident, there was no documented education or attendance records to ensure all staff were aware of the proper procedures. The resident's medical history, including stage 4 pressure ulcers and other conditions, highlights the critical need for diligent care and monitoring to prevent further deterioration of his skin condition.
Inadequate Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program. During an interview, the interim director of nursing admitted that she had not taken any significant actions regarding the infection control program in the month she had been in her position, aside from creating two binders. She acknowledged the absence of updated policies and procedures, a lack of infection surveillance, and no process for antibiotic stewardship, with no one monitoring antibiotic use or orders. The administrator confirmed the absence of an active infection prevention and control program. Additionally, the quality assurance specialist revealed that the former director of nursing, who had been the infection preventionist, resigned at the beginning of August 2024, leaving the facility without a qualified infection preventionist.
Lack of Qualified Infection Preventionist in Facility
Penalty
Summary
The nursing home failed to designate a qualified infection preventionist (IP) to oversee its infection prevention and control program. During an interview, the interim Director of Nursing (DON) revealed that she was informed she would assume the role of IP, but her certification had expired, and she was not planning to renew it due to her interim status. The facility administrator confirmed the absence of a qualified IP. Additionally, a quality assurance specialist noted that the previous DON, who had been the IP, resigned at the beginning of the month, leaving the facility without a qualified infection preventionist.
Deficiencies in QAPI Program and Incident Management
Penalty
Summary
The provider failed to maintain an effective, ongoing, and comprehensive Quality Assurance and Performance Improvement (QAPI) program. The QAPI coordinator, who had been in the role for three years, acknowledged that the committee met monthly and had previously completed a performance improvement plan (PIP) for pressure ulcer prevention and treatment. However, there was no current PIP in place. The coordinator was aware of issues such as resident baths not being completed as scheduled and abuse concerns involving specific male residents, but these issues had not been addressed through the QAPI committee. Additionally, the dietary department's outdated chemical sanitation test strips were not identified through the QAPI process, and communication issues within the facility were noted, with the last all-staff meeting held several months prior. The QAPI coordinator was not aware of any facility-reported incidents through the state department of health's online reporting system and only tracked adverse events through the provider's electronic medical record system. There was an adverse event involving a resident left on a bedpan for an extended period, which was communicated to the nursing staff but not addressed through the QAPI committee. Furthermore, the grievance process was not effectively monitored, with some concern forms going missing or not being addressed, and customer satisfaction survey feedback was not reviewed through the QAPI committee. The provider's policies outlined the importance of addressing grievances promptly and ensuring a comprehensive QAPI program. However, the QAPI committee failed to track and trend performance, systematically analyze and prioritize quality deficiencies, and develop action plans to correct identified issues. The administrator's job description emphasized the responsibility for ensuring a QAPI program is in place, but the deficiencies in the program's implementation and oversight were evident in the findings.
Ineffective Pest Control Measures
Penalty
Summary
The facility failed to ensure effective pest control measures, as evidenced by multiple observations of live and dead insects within the premises. On several occasions, surveyors observed live beetles, flies, and dead crickets in various areas, including the conference room, dining room, hallways, and resident rooms. Notably, a resident was found with live flies on his blanket, and another resident, who is blind, was informed by friends about flies in his food and drink during a meal. These observations indicate a significant issue with pest control, particularly concerning flies, which were found in areas where residents eat and reside. Interviews with facility staff revealed that a professional pest control company visits monthly, and certain areas have automatic spray systems and devices to catch flies. However, the dining room lacked any fly control measures, and staff were unaware of the fly issue in that area. The facility's proximity to a bird seed plant and city sewer lagoon was mentioned as a potential contributing factor to the pest problem. Despite efforts such as distributing fly swatters and frequent exterminator visits, the interim director of nursing acknowledged the persistent issue with flies, especially during times when doors are open throughout the day.
Failure to Follow Resident Bathing Preferences
Penalty
Summary
The provider failed to adhere to the bathing preferences of three residents, as identified through a resident council meeting, observations, interviews, and record reviews. Residents expressed concerns about not receiving baths on their scheduled days, which had been discussed during care plan meetings. One resident, who preferred three baths a week, only received one bath per week after admission and missed scheduled baths for two consecutive weeks. Another resident, who was satisfied with one bath a week, did not receive a requested bath before attending a funeral, despite asking staff twice. The third resident, who required assistance with bathing, missed a scheduled bath due to equipment issues and was uncertain about her bathing frequency. The facility's records revealed discrepancies between the residents' documented bathing preferences and the actual bathing schedule. The first resident's care plan was not updated to reflect her preference for three baths a week, and there was no documentation of a bath for 12 days. The second resident's records indicated a preference for two or more baths per week, but he did not receive a bath as requested before the funeral. The third resident's care plan noted a preference for one or two baths a week, but she went 15 days without a documented bath. Interviews with staff highlighted issues with the bathing schedule due to staffing changes. The regular bath aide had reduced hours, and the administrative assistant was responsible for scheduling available staff to cover baths. The interim director of nursing acknowledged the bathing issues and had begun tracking residents' bathing to ensure compliance with their preferences. The administrative assistant confirmed that bathing was not being completed according to resident preferences, as the full-time bath aide had recently left, and scheduling was challenging.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to ensure that care plans for four out of five sampled residents were followed, updated, and revised promptly to reflect their current status and care needs. Resident 27's care plan did not include his use of an electronic neuropathy machine, his suicidal ideations, inappropriate sexual behavior towards staff, or his possession and use of a car, which he was deemed unsafe to drive. Despite being aware of these issues, the facility did not complete an assessment of his cognitive abilities related to driving, and his care plan was not updated to address these concerns. Resident 1 expressed dissatisfaction with her bathing schedule, as she was receiving only one bath per week, contrary to her preference for three baths a week, which she had received in assisted living. Her care plan was revised to include two weekly whirlpool baths, but this did not align with her stated preference. Similarly, Resident 18's care plan indicated a preference for one or two whirlpool baths a week, but she reported missing a bath due to equipment issues and was unsure of her bathing frequency. Additionally, her care plan did not specify the appropriate height for her bed, which was observed to be in the highest position, contrary to safety protocols. Resident 15 reported not receiving incontinence care as needed, despite his care plan indicating he should be checked and changed every two to three hours. The facility's interim director of nursing was unsure if his incontinence care needs were included in his care plan. The facility's policy required comprehensive, person-centered care plans to be developed and updated to meet residents' needs, but the interdisciplinary team failed to ensure these plans were accurate and reflective of the residents' current care requirements.
Failure to Notify Physician of Resident's Suicidal Ideation and Unsafe Driving
Penalty
Summary
The provider failed to notify the physician of a resident's suicidal ideation and unsafe driving practices. The resident, identified as Resident 27, had a car parked at the facility and was observed driving it despite concerns about his safety. The interim director of nursing and a registered nurse acknowledged that they did not believe the resident was safe to drive and had notified the police, who informed them they could not revoke his driver's license. However, no assessment of the resident's cognitive abilities related to driving was conducted, and the physician was not informed of these concerns. Additionally, the resident's medical records indicated several incidents that warranted physician notification. On one occasion, the resident threatened self-harm with a sharp object, which he later claimed was a joke. There were also reports of the resident nearly being involved in a car accident and driving recklessly. Furthermore, the resident engaged in inappropriate behavior by squeezing a female's buttock. Despite these significant changes in the resident's mental and psychosocial status, there was no documentation to show that the physician had been informed, which is a requirement according to the facility's Notification of Change policy.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for a resident who was transferred to the hospital. The resident, identified as resident 21, was transferred to the hospital on two occasions, once on May 15, 2024, and again on June 18, 2024. In both instances, the resident's power of attorney (POA) was notified of the transfers, but there was no documentation indicating that bed hold information was provided to either the resident or her POA. Interviews with the facility's local ombudsman and the facility administrator revealed that the facility typically filled out a report online about hospitalizations and had one month to notify the ombudsman of such transfers. However, the ombudsman confirmed that they had not received notifications for either of the resident's hospital transfers. The facility's social services coordinator was responsible for submitting these reports, but the administrator was unaware that every hospital transfer needed to be reported to the ombudsman. The facility's policy indicated that copies of notices for emergency transfers must be sent to the ombudsman, but this was not done in the case of resident 21.
Failure to Provide Bed-Hold Notices During Hospital Transfers
Penalty
Summary
The provider failed to provide bed-hold notices to a resident and their representative during two hospital transfers. The resident, identified as resident 21, was transferred to the hospital on two occasions, once on 5/15/24 and again on 6/18/24. In both instances, while the resident's power of attorney (POA) was notified of the transfers, there was no documentation indicating that bed-hold information was provided to either the resident or the POA. Interviews with the resident, a registered nurse, the business office manager, and the administrator confirmed the absence of bed-hold notices for these hospital stays. The facility's bed-hold policy, dated 12/7/23, requires that written information regarding the bed-hold and reserve bed payment policy be provided to the resident or their representative at the time of admission, transfer, or therapeutic leave. The policy also outlines the responsibilities of the charge nurse and social worker in ensuring notification procedures are completed. However, in the case of resident 21, these procedures were not followed, as evidenced by the lack of documentation and confirmation from staff interviews.
Failure to Ensure Safety and Proper Documentation for Infra-red Device Use
Penalty
Summary
The provider failed to ensure that a resident using an infra-red device for neuropathy pain had a current physician order and had been assessed for the safety of its use. The resident, who had diagnoses including dementia, chronic atrial fibrillation, chronic kidney disease, and heart failure, did not have a diagnosis for neuropathy. Despite this, he used an electronic neuropathy machine daily for pain in his feet. The device was observed in his room, placed on a folding chair, and had uncleanable surfaces with carpet and electrical tape attached to it. There was no current physician order for the device's use, and it was not included in the resident's care plan. Interviews with the interim director of nursing and a registered nurse revealed that the resident did not have a diagnosis of neuropathy and that the nurse was unaware of the device until the morning of the interview. There was no safety assessment conducted for the device's use, and it was confirmed that the device should have been stored in the medication room and documented in the treatment administration record. Despite these findings, the device was still observed in the resident's room later that day. The facility did not provide a policy regarding electronic medical equipment when requested.
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What surveyors actually found near you
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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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Nursing homes near Miller
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highmore Health | 22.5 mi | ★★★★★ | 1 | 0 |
| Eastern Star Home Of South Dakota, Inc | 33.2 mi | ★★★★★ | 1 | 0 |
| Avantara Redfield | 33.5 mi | ★★★★★ | 9 | 0 |
| Faulkton Senior Living | 36.1 mi | ★★★★★ | 3 | 0 |
| Weskota Manor Inc | 36.7 mi | ★★★★★ | 3 | 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.