Good Samaritan Society Millard: Pressure Ulcer Failures - NE
The resident was in bed. The Prevalon protective boots were not on their feet. They had not been documented as used at any point in the preceding month.
Resident 26 has a traumatic brain injury and hemiplegia, the condition that causes paralysis down one vertical half of the body. They have limited range of motion on one side, require extensive help with bathing and toileting, and have both short-term and long-term memory problems. Their April 2026 assessment noted they were at risk of developing a pressure ulcer. They already had one, a stage 3 wound on the right foot and right heel, meaning the skin had been lost entirely through its full thickness, down to the tissue beneath.
The wound had first appeared months earlier. A Wound Data Collection Sheet from January 13, 2026 documented a new stage 3 pressure ulcer on the right foot, measuring just over a centimeter long and nearly two centimeters wide. The order for Prevalon boots came the following day, January 14, requiring staff to encourage the resident to wear them at all times while in bed.
There had been no such order in November 2025. There had been no such order in December 2025. The boots were not ordered until after the wound had already reached stage 3.
By March, a new wound had appeared. A progress note dated March 4, 2026 documented a deep tissue injury near the toe on the same right foot, a purple or maroon discoloration caused by damage to the soft tissue underneath the skin. It measured less than a centimeter across but represented the body continuing to break down in the same area that was supposed to be protected.
The care plan, revised in March 2026, listed interventions that included providing a pressure-relieving device. It did not specify which device. It did not specify which part of the body the device should protect. It did not specify how often it should be used.
That gap between what a care plan says and what actually happens to a resident is where inspectors found the clearest failure. The facility's own electronic records showed a task listed for Prevalon boots to the right and left foot from April 27 through May 26. In that entire period, there was no documentation that the boots had been applied.
When inspectors interviewed the Director of Nursing on the afternoon of May 26, she confirmed it: the facility had not initiated pressure-relieving boots until after Resident 26 had already developed the stage 3 ulcer.
The inspection was a complaint survey. The facility had 74 residents at the time. Inspectors rated the violation as causing minimal harm or the potential for actual harm, one of the lower severity designations available under federal inspection standards. The finding applied to one of four residents whose records were reviewed.
What the designation does not capture is the arithmetic of the situation. A resident at high risk for pressure ulcers went through November and December without the protective equipment that could have reduced that risk. A stage 3 wound developed. An order was finally written. Months later, the boots were found in a wheelchair.
A stage 3 pressure ulcer is not a surface wound. The dermis, the layer of skin beneath the outer surface, is completely gone. What remains is exposed tissue. These wounds are painful, slow to heal, and vulnerable to infection. For a resident with hemiplegia and limited mobility, the ability to reposition independently, to shift weight, to relieve pressure on a vulnerable heel, is exactly what the disease has taken away. The boots exist because the resident cannot protect themselves.
They were in the wheelchair.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Millard from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
Good Samaritan Society - Millard in Omaha, NE was cited for violations during a health inspection on May 26, 2026.
The Prevalon protective boots were not on their feet.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.