Every finding on record at The Evangelical Lutheran Good Samaritan Society

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 1/20/26 through 1/22/26, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 1/20/26 through 1/22/26, a recertification survey was conducted. This resulted in a partial extended survey at Good Samaritan Society - Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 399 Total home visits conducted: 4 List Hours of Operation: 8:00 a.m. to 4:30 p.m. List total number of records reviewed: 10

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure plans of care included a list of durable medical equipment (DME), including non-routine DME, used to meet patient needs, for 1 of 4 patients (P3) reviewed during home visits. Findings include: P3's plan of care (POC) for certification period 12/12/25 through 2/9/26, included chronic obstructive pulmonary disease (COPD), type 2 diabetes, acute on chronic systolic congestive heart failure. Skilled nurse orders to preform management and evaluation to observe and assess underlying conditions, complications and the effects of the non-skilled plan of care based on the registered nurse assessment to promote the patient’s recover and medical safety. The list of DME and orders section did not include oxygen or oxygen equipment. During a home visit on 1/21/26 at 10:30 a.m., registered nurse case worker (RNCW)-A HH, assessed P3’s seated vital signs and respiratory status which were baseline, except for the standing blood pressure which was low at 81/58, (normal blood pressure is less than 120/80). RNCW-A then completed medication set up. P3’s bedroom was observed to have an oxygen concentrator and steel portable oxygen cylinder, which were not being used. The steel portable oxygen cylinder was free standing and in an upright position. P3 stated he has not used the oxygen but kept it on hand for emergencies. On P3’s bedroom floor approximately 8 feet away from the oxygen, there was a propane heater set up but not running. P3 stated it was used over a week ago when his furnace went out. He stated he wouldn’t have used the oxygen with the propane but wasn’t sure about storage of the green tank. RNCW-A stated the oxygen was not a current order and would need to talk to the nursing manger. During an interview on 1/22/26 at 10:45 a.m., the nursing manager (NM) stated all DME should be included on the POC. The NM stated she knew P3 had oxygen on-hand, but not used currently, and should probably get an order to keep it if the patient wanted and so nursing could continue to educate on safety. The NM stated oxygen teaching was on a previous POC and was not sure why it was discontinued. A policy on oxygen use and DME was requested and not provided. The American Lung Association Oxygen Therapy: Using Oxygen Safely dated 1/28/26, identified to keep sources of heat and flame at least five feet away from where your oxygen unit is being used or stored. The section titled Oxygen Therapy: Getting Started with Oxygen in Metal Tanks dated 1/28/26, identified single tanks not in carriers or in use should be kept lying flat so they do not fall over.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and document review, the agency failed to ensure wound care was administered to patients only as ordered by the physician, for 1 of 1 patient (P2), reviewed for wound care. Findings include: P2’s plan of care (POC) orders dated 1/14/26, identified a certification period of 12/10/25 through 2/7/26. P2’s diagnoses included pressure ulcer of sacral region and right buttock stage 4 (wound that extends through skin and underlying tissues exposing muscle, tendon, or bone), pressure ulcer of left buttock unstageable (wound that cannot be accurately assessed due to the presence of necrotic tissue), unspecified open wound right hip, pressure ulcer of other site stage 2 (partial thickness skin loss, presenting as shallow open wound), paraplegia (condition that causes partial or complete paralysis of the lower half of the body) and dementia. Skilled nurse orders to observe and assess integumentary status to identify changes and intervene to minimize complications, provide skilled teaching related to altered skin integrity including pathophysiology, nutrition, and medication regimen. Skilled nurses were to report significant changes in status to physician for early intervention. P2’s wound care orders dated 1/14/26, included in the POC identified wound care for the right hip, sacral, right and left ischial wounds: remove old dressing, cleanse with Vashe (prescription-only product that cleans, irrigates, moistens and debrides acute and chronic wounds) and gauze. Apply new Vashe moistened gauze, 4x4 gauze, Optilock (a non-adherent, super absorbent dressing), ABD pad (padded highly absorbent dressing), and tape. Change twice daily. During a home visit on 1/21/26 at 8:30 a.m., registered nurse case worker (RNCW)-A removed the left ischial wound dressing which was packed with gauze. Family member (FM)-A was also present to help with positioning. After about an arm’s length of gauze packing was removed from the wound, tunneling could be seen with moderate amount of reddish-brown drainage. RNCW-A cleaned the wound with gauze and Vashe. FM-A and RNCW-A had a conversation and decided to pack the wound with dry gauze instead of wet gauze as ordered. RNCW-A proceeded to pack the wound with about an arm’s length of dry gauze, covered with Optilock, ABD pad and tape. RNCW-A stated they had packed the wounds dry in the past when the wounds were too wet with drainage, and they should probably have an order for the dry dressing as needed. FM-A and RNCW-A stated the wounds were chronic and progress on wound healing fluctuated over the years. During an interview on 1/22/26 at 10:45 a.m., the nursing manager (NM) stated wound care should be provided according to current orders. A policy for wound care was requested and not provided.

On September 28th through September 29nd, 2021, an abbreviated survey was conducted at your agency, Preston Good Samaritan Society Home Care to conduct a complaint investigation. And was found NOT to be in compliance with requirements at 42 CFR Part 484, requirements for Home Health Agencies. During the survey, the following complaint(s) were investigated and substantiated H8009001C (Complaint ID 31970) The Condition of Participation: Patient Rights 42 CFR 484.50 at G406 was found not met. As a result a partial extended survey was completed

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on observation, interview and document review, the home health agency (HHA) failed to meet the Condition of Participation at 484.50, Patient Rights. The HHA failed to ensure 1 of 1 patients (P1) who was reviewed for missing narcotics was free from misappropriation of property. Refer to G-430: Based on observation, interview and document review, the home health agency (HHA) failed to ensure 1 of 1 patients (P1) was free from misappropriation of property when a staff was aware in July 2021 R1 dosage count of her oxycodone (narcotic pain medication) was off, and short and again in September 2021 and did not report to the administrator and state agency (SA) according to facility policy.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the home health agency (HHA) failed to ensure 1 of 1 patients (P1) was free from misappropriation of property when a staff was aware in July 2021, R1 dosage count of her oxycodone (narcotic pain medication) was short, and again was short in September 2021, however, did not report to the administrator or state agency (SA) according to facility policy. P1's start of care was 3/10/21, and certification period from 9/06/21 to 11/04/21, indicated P1 had major depressive disorder, lumbago with sciatica on the left and right side (Pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). P1's POC further indicated she received Hydrocodone 5-325 milligrams (mg) orally one tab every 8 hours as needed for pain in addition to scheduled 8 a.m., 5 p.m. and as needed 1:30 p.m. In addition to the POC indicated P1 also received Alprazolam by mouth 1 mg four times daily as needed and scheduled 8 a.m., 12 p.m., 5 p.m. and 8 p.m. for anxiety. The POC indicated she received skilled nursing 2-3 times a month to prefill medication planner, meds set in four dose medication dispensers, sing strip of Hydrocodone (Norco), and repot signs and symptoms of abuse and neglect to appropriate state agency. A reported incident dated 9/21/21, from P1's county worker indicated a few weeks ago a nurse came in to set up [P1]'s medications and there were 19 hydrocodone medications missing from the bottle that is used to fill her dose health pill minder machine and in additions she was missing pills from her Alprazolam bottle . During interview on 9/28/21, at 5:00 p.m. licensed practical nurse (LPN)-A stated she fills P1's medications every two weeks in her home. LPN-A stated she noticed problems with P1's medications running short in July 2021, when P1 was was missing some of her Hydrocodone and and again this last Friday when she was setting up her medications she noticed she was missing 84 tablets of her Alprazolam. After the incident in July 2021 she started counting her medications. LPN-A stated she knew registered nurse (RN)-A case manager was aware but was not sure if the director of nursing was (DON) was aware who is also the agencies administrator. LPN-A stated she never reported the missing medications to the state agency (SA). LPN-A further stated the pharmacy was also aware of the missing medications and they informed me they had their suspicions for quite some time and in fact questioned why they did not report this to the SA. In addition LPN-A stated P1 has a house keeper coming in to her home several times a week from a different agency and does not know her and P1 has commented maybe she could have taken her medications, LPN-A stated "I just don't know what happened to them! I know she has a signed contract with her primary physician for her narcotics I am not sure if she has abused her medications in the past. P1 is also very forgetful and could have missed placed them also." During interview on 9/28/21, at 5:28 p.m. RN-A stated she is P1's case manager and she oversees some of LPN-A's patients and remembers when P1's Hydrocodone's count was off back in July 2021 and can’t remember exactly how many pills were missing but it was several. RN-A then stated on 9/3/21, she noticed she was short 6 tablets of Hydrocode and LPN-A went back on 9/17/21, and tried to order P1's Alprazolam and was told by the pharmacy it was too soon to order and P1 called her physician and was told they just wrote a script that was filled on 7/20/21, for 326 tablets. RN-A stated she did not report this to the agency administrator or the state agency because she just never thought of it and said she needs a refresher on training of reporting of the abuse policy. During interview on 9/29/21, at 8:11 a.m. county case manager (CCM), stated P1 has agoraphobia (anxiety disorder that often develops after one or more panic attacks. Symptoms include fear and avoidance of places and situations that might cause feelings of panic, entrapment, helplessness, or embarrassment). and when P1 found out she could not re-fill her Alprazolam she was in a panic mode, and she was freaking out. After the incident of her missing meds her daughter told me she no long wanted the home care agency to provide medication assistance for her mother and she will be taking over assisting her with this. In addition CCM stated her primary physician Dr. Post informed her P1 has had a history of trying to order her meds to early going back a year ago. The CCM stated she does not believe P1 could have taken the medications since she receives scheduled Alprazolam four times a day, and then to take an extra 84 on top of that would almost be impossible. During interview on 9/29/21, at 9:02 a.m. with P1's housekeeper stated she had working with P1 for almost two years, and P1 keeps her medications in a basket by her shower. The housekeeper stated she was unaware P1 was missing medications and does not think anyone would have taken them but P1 could have miss placed them her house is very cluttered and she can be forgetful. The housekeeper stated she would never have taken and she has a clean record! On 9/29/21, at 9:05 a.m. attempted to reach P1's pharmacy and was informed I would need to email a request for documents. E-mail sent with no return response. During observation and interview on 9/29/21, at 9:38 a.m. at P1's house. In observation P1 has a very small house with multiple knickknack's through out her house. P1 showed surveyor where she kept her medications in the back of her house on a shelf across from her shower. The medication dose dispensers the nurse filled were kept in her kitchen on top of her microwave. P1 explained to me when P1 was last at her house she was filling her Alprazolam and noticed 84 pills were missing and told me she could not refill them per the pharmacy. P1 explained she had agoraphobia and atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow) needs the medication to live a normal life and if she does not receive it she has so much anxiety she just cant take it and does not want to ever have that feeling of anxiety. P1 stated the county worker luckily was able to have my doctor fill a new prescription because a report was filled to the stated he agreed to fill it. P1 stated "I don't know what happened to the pills, but they just don't walk away!" P1 further stated a police officer was at her house along with another person from social services and they cant figure out where my pills went. During interview on 9/29/21, at 11:00 a.m. agency’s DON stated she was not informed of P1's missing medications by LPN-A or RN-A in July 2021 and in September 2021, and should have been according to the agency policy. A facility policy Loss Spillage and Disposal of Controlled Medication-Home Health revised 8/07/2020, indicated depending on state requirements, controlled medications will be monitored each visit to count number of controlled medication remaining in the home. The name of the medication, dosage and the number of medications remaining should be documented in clinical notes in the electronic medical record application. A facility policy Abuse Prevention Plan-Home Health revised 7/23/20, indicated If a patient or is/her legally authorized representative claims he/she was abused, neglected, or harassed by a Sanford provider or staff member during the course of care, please contact Risk Management immediately.

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to immediately report to the State Agency (SA), and administrator an allegation of misappropriation of property for 1 of 1 patients (P1), who had missing antianxiety medication Alprazolam and narcotic Hydrocodone for pain. P1's plan of care (POC) indicated her start of care was 3/10/21, and certification period from 9/06/21 to 11/04/21, the POC indicated P1 had major depressive disorder, lumbago with sciatica on the left and right side (Pain radiating along the sciatic nerve, which runs down one or both legs from the lower back). P1's POC further indicated she received Hydrocodone 5-325 milligrams (mg) orally one tab every 8 hours as needed for pain in addition to scheduled 8 a.m., 5 p.m. and as needed 1:30 p.m. In addition to the POC indicated P1 also received Alprazolam by mouth 1 mg four times daily as needed and scheduled 8 a.m., 12 p.m., 5 p.m. and 8 p.m. for anxiety. The POC indicated she received skilled nursing 2-3 times a month to prefill medication planner, meds set in four dose medication dispensers, single strip of Hydrocodone (Norco), and report signs and symptoms of abuse and neglect to appropriate state agency. During interview on 9/28/21, at 5:00 p.m. licensed practical nurse (LPN)-A stated she fills P1's medications every two weeks in her home. LPN-A stated she noticed problems with P1's medications running short in July 2021 and she was missing some of her Hydrocodone and last Friday when she was setting up her medications she noticed P1 was missing 84 tablets of her Alprazolam. After the incident in July 2021 she started counting her medications. In addition LPN-A stated she knew registered nurse (RN)-A case manager was aware but was not sure if the director of nursing was (DON) was aware who is also the agencies administrator. LPN-A stated she never reported the missing medications to the state agency (SA) . LPN-A further stated the pharmacy was also aware of the missing medications and they informed me they had their suspicions for quite some time and in fact questioned why they did not report this to the SA. During interview on 9/28/21, at 5:28 p.m. RN-A stated she was P1's case manager and she oversees some of LPN-A's patients and remembers when P1's Hydrocodone's count was off back in July 2021 and can't remember exactly how many pills were missing but it was several. RN-A then stated on 9/3/21, she noticed she was short 6 tablets of Hydrocode and LPN-A went back on 9/17/21, and tried to order P1's Alprazolam and was told by the pharmacy it was too soon to order and P1 called her physician and was told they just wrote a script that was filled on 7/20/21, for 326 tablets. RN-A stated she did not report this to the agency administrator or the state agency because she just never thought of it and said she needs a refresher on training of reporting of the abuse policy. During interview on 9/29/21, at 11:00 a.m. DON stated she was not informed of P1's missing medications by LPN-A or RN-A in July 2021 and in September 2021, and should have been according to the agency policy. A facility policy Loss Spillage and Disposal of Controlled Medication-Home Health revised 8/07/2020, indicated depending on state requirements, controlled medications will be monitored each visit to count number of controlled medication remaining in the home. The name of the medication, dosage and the number of medications remaining should be documented in clinical notes in the electronic medical record application. A facility policy Abuse Prevention Plan-Home Health revised 7/23/20, indicated If a patient or is/her legally authorized representative claims he/she was abused, neglected, or harassed by a Sanford provider or staff member during the course of care, please contact Risk Management immediately.