Good Samaritan Society - Auburn
Inspection history, citations, penalties and survey trends for this long-term care facility in Auburn, Nebraska.
- Location
- 1322 U Street, Auburn, Nebraska 68305
- CMS Provider Number
- 285112
- Inspections on file
- 16
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Good Samaritan Society - Auburn during CMS and state inspections, most recent first.
Menu Portion Sizes Not Followed: Staff were observed serving rice, pureed pork cutlet, and minced and moist pork using smaller portions than listed on the menu. The Dietary Dept Director confirmed the serving sizes in use, and the Consultant RD later confirmed the correct serving sizes had not been followed. The Consultant RD also stated the facility had no policy related to serving sizes, although menu serving sizes are to be followed.
Food Safety Deficiencies in Egg Preparation and Sanitizer Monitoring: The facility failed to use pasteurized eggs for soft-cooked eggs and failed to have test strips available to verify quat sanitizer concentration at the 3-compartment sink. During observation, whole eggs in the walk-in refrigerator were not documented as pasteurized, and the DDD and RD confirmed the wrong eggs had been ordered even though facility policy requires pasteurized eggs for soft eggs. The DDD also could not locate sanitizer test strips, and the sink sanitizer log was incomplete and not current.
A nursing assistant failed to perform hand hygiene while alternating dining assistance between three residents, including wiping a resident’s mouth and handling another resident’s silverware without cleaning hands between contacts. The facility also stored oxygen tubing improperly for two residents with O2 orders, leaving tubing wrapped or draped over equipment and wheelchairs instead of secured in a bag, which the RN confirmed was not done as required.
Failure to follow bowel management orders for two residents. One resident with severe cognitive impairment and multiple chronic conditions had standing PRN orders for Dulcolax suppository and Milk of Magnesia with instructions to notify the provider after three days without a significant BM, but bowel records showed multiple stretches of no BM and staff did not notify the provider. Another resident with constipation, reduced mobility, and total bowel incontinence also went several days without a BM; no PRN bowel meds were given and there was no evidence the provider was notified as ordered.
Restorative Services Not Provided as Planned: A resident with hemiplegia and hemiparesis after a CVA had restorative interventions on the care plan for transfers and ambulation with a hemi-walker, CGA, and gait belt. Documentation showed the resident received transfer restorative care only once and no ambulation restorative care during the review period. An LPN confirmed the program was not being done, the restorative aide said staffing duties kept the aide from providing the services, and the Administrator confirmed there was not adequate staffing to provide restorative services as scheduled.
A resident had a medication cup with pills left on the bedside table during an observation. The resident could not recall when the pills were placed there. An MA said they had not given the meds and did not know what they were, and an LPN confirmed they had administered the meds but did not stay to witness the resident take all of them.
The facility failed to maintain cleanliness in the kitchen, with a condenser fan and air conditioner covers coated in dark substances, and a scoop improperly stored in flour. These issues were confirmed by the DM, who acknowledged the lack of a cleaning schedule for these items. All 62 residents consumed food prepared in this environment, highlighting the potential impact of these deficiencies.
The facility failed to maintain cleanliness in 15 resident bathrooms, with ventilation covers coated in dust and corrosion around toilet bases. Observations confirmed these issues, and no active work orders were in place to address them.
A facility failed to properly secure a urinary catheter bag for a resident, leading to potential cross-contamination. The resident, with multiple diagnoses, was observed twice with the catheter bag touching the floor. Staff interviews confirmed that catheter bags should not touch the floor or be hung on a trash can, as per the facility's catheter care policy.
Menu Portion Sizes Not Followed
Penalty
Summary
The facility failed to ensure that portion sizes identified on the menu were followed when serving foods to residents. During observation of the steam table, staff were using a #10 scoop for rice and pureed pork cutlet and serving minced and moist pork in 3-ounce portions. In interview, the Dietary Department Director confirmed those were the serving sizes being used. However, review of the facility lunch menu showed the identified serving sizes were #8 scoops, or 1/2 cup, for rice, pureed pork cutlet, and minced and moist pork. The Dietary Department Director and Consultant Registered Dietitian later confirmed the correct serving sizes had not been used, and the Consultant Registered Dietitian stated the facility did not have a policy related to serving sizes but that the menu serving sizes are to be followed.
Food Safety Deficiencies in Egg Preparation and Sanitizer Monitoring
Penalty
Summary
The facility failed to ensure pasteurized eggs were used for preparation of soft, cooked eggs. During observation, the label on the box of whole eggs in the walk-in refrigerator did not show documentation that the eggs were pasteurized. In interview, the Dietary Department Director and Consultant Registered Dietitian confirmed the eggs were not pasteurized and that the wrong eggs had been ordered. They also confirmed that resident eggs are cooked to order and may be ordered over easy, and that facility policy requires pasteurized eggs when residents are served soft eggs. The facility also failed to ensure test strips were available to check the sanitizer concentration in the 3-compartment sink. During observation, quaternary sanitizer was being used for sanitizing pots and pans, but the Dietary Department Director could not locate test strips to evaluate the sanitizer concentration. A sanitizer log posted on the wall by the sink was not for the current month and was incomplete. In interview, the Dietary Department Director confirmed that test strips could not be found and that the sanitizer log for the 3-compartment sink was not being completed.
Infection Control Lapses During Dining Assistance and Oxygen Storage
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified when a nursing assistant did not perform hand hygiene while moving between residents during dining assistance. During an observation, the nursing assistant was feeding one resident, then moved to another resident’s wheelchair and began feeding that resident without completing hand hygiene, wiped one resident’s mouth, handled another resident’s silverware, and continued alternating between three residents without hand hygiene between contacts. The nursing assistant confirmed that hand hygiene was not completed while switching between residents and stated it should have been. The facility also failed to store oxygen tubing in a manner to prevent cross contamination for two residents who had oxygen orders. One resident had diagnoses including COVID-19, morbid obesity, and wheezing, and had an order for oxygen 1-4 L via nasal cannula as needed to maintain O2 above 90%. Observations showed the oxygen concentrator against the wall with tubing wrapped around it and not protected or secured in a bag. Another resident had diagnoses including personal history of COVID-19, pneumonia, and personal history of pulmonary embolism, with an order for oxygen 1-4 L via nasal cannula as needed for dyspnea, hypoxia, or acute angina. Observations showed the oxygen cylinder on the back of the wheelchair with the tubing and nasal cannula draped over the wheelchair and not stored in a bag; the RN confirmed the tubing was not stored as required and acknowledged the potential for cross-contamination.
Failure to Follow Bowel Management Orders
Penalty
Summary
The facility failed to implement physician orders for bowel management for two residents. One resident had severe cognitive impairment, multiple chronic diagnoses including diabetes, seizure disorder, atrial fibrillation, coronary artery disease, chronic kidney disease, and osteoarthritis, and had active orders for Dulcolax suppository and Milk of Magnesia with instructions to contact the provider if there were three days without a significant bowel movement. The facility’s bowel management protocol also called for intervention and provider notification when a resident had no bowel movement for three days. For one resident, the bowel record showed no bowel movements on January 19, 20, 21, 22, and 23, and again on February 4, 5, 6, and 7. An LPN confirmed the resident had no bowel movements on those dates and confirmed the order required provider notification after three days without a bowel movement, but did not know why the provider had not been notified. The LPN also described the facility process in which the night shift nurse prepared a report of residents at day three without a bowel movement, the day shift nurse notified the MA of residents needing bowel medication, and the DON was responsible for notifying the family or representative of changes in condition. For the second resident, the record showed diagnoses including constipation, muscle weakness, need for assistance with personal care, and reduced mobility. The resident was dependent on staff for toileting hygiene, lower body dressing, and transfers, was always incontinent of bowel, was not on a toileting program, and had constipation present. The bowel record showed no bowel movements on February 4, 5, 6, 7, and 8, yet the MAR showed no PRN bowel medications were given and progress notes showed no evidence the provider/practitioner was notified of no significant bowel movement in three days. An LPN confirmed the missed bowel movements, the lack of PRN bowel medication use, and the lack of provider notification.
Restorative Services Not Provided as Planned
Penalty
Summary
The facility failed to ensure restorative services were provided for one resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident’s quarterly MDS showed a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment, and no information on mobility impairment of range of motion on one side for the upper and lower extremities. The care plan, dated 10/22/24, identified restorative interventions for limited physical mobility related to the cerebrovascular accident, including transfers with a hemi-walker and gait belt twice weekly and ambulation up to 90 feet with a hemi-walker, CGA, gait belt, and wheelchair follow twice weekly. Restorative documentation from 1/11/26 to 2/9/26 showed the resident received transfer restorative services only one time on 1/18/26 and did not receive any ambulation restorative services during that period. In interviews, an LPN confirmed the restorative program was not being done, and the restorative aide stated the resident had only received restorative services one time because the aide had been working on the floor as an aide or medication aide instead of as the restorative aide. The Administrator confirmed the facility did not have adequate staffing to provide restorative services for the number of days indicated. The facility policy stated each resident would receive restorative nursing care to the extent possible based on individual strengths, needs, and problems as defined in nursing assessments.
Medications Left at Resident Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for Resident 53. During an observation on 2/8/2026 at 10:25 AM, a medication cup containing pills was seen on the resident’s bedside table. Resident 53 stated they could not remember when the pills were placed there. A Medication Aide confirmed that they had not given Resident 53 the medications in the cup and did not know what the medications were, and stated the medications should not have been left at the resident’s bedside. A Licensed Practical Nurse later confirmed that they had administered medications to Resident 53 but had not witnessed the resident take all of the medications, and stated they should have remained in the room until the resident had taken all of the medications.
Deficiencies in Kitchen Cleanliness and Food Safety Practices
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, specifically in the walk-in cooler and food preparation areas, as observed by surveyors. A condenser fan in the walk-in cooler was found to be coated with a dark gray/black substance, and the interior walls and ceiling of the cooler had a dark gray fuzzy coating. Additionally, two large air conditioner covers above a food preparation table were also coated with a similar dark gray/black substance. These conditions were confirmed by the Dietary Manager (DM) during an observation. Furthermore, a plastic scoop was found in a flour bin with its handle in contact with the flour, which was also confirmed by the DM. The DM acknowledged that the scoop should not have been in contact with the flour and that the air conditioner covers, located directly above a food preparation area, could potentially cause foodborne illness if dust fell into the food. The DM admitted that the fan in the cooler and the air conditioner covers were not included in the dietary cleaning schedule, and was unsure of the last time they had been cleaned. A review of the dietary cleaning schedules confirmed that these items were not listed. The facility's Registered Dietician confirmed that all 62 residents consumed food prepared in the facility kitchen, indicating the potential impact of these deficiencies on the entire resident population.
Facility Fails to Maintain Cleanliness in Resident Bathrooms
Penalty
Summary
The facility failed to maintain the cleanliness and condition of bathroom ventilation covers and toilet bases in 15 out of 62 occupied resident rooms. Observations conducted on two separate occasions revealed that the ventilation covers in several resident bathrooms were coated with a dark, fuzzy substance resembling dust. Additionally, there was corrosion and a dark brown substance present around the base of the toilets, along with cracked caulking in multiple rooms. During an environmental tour with the facility Maintenance Director and Administrator, these issues were confirmed. The Maintenance Director acknowledged the presence of dust on the ventilation covers and the corrosion and cracked caulking around the toilet bases. It was also confirmed that there were no active work orders addressing these concerns at the time of the observations.
Improper Securing of Urinary Catheter Bag
Penalty
Summary
The facility failed to secure a urinary catheter bag properly, leading to a potential risk of cross-contamination for Resident 14. The resident, who has diagnoses of Diabetes Mellitus Type 2, heart failure, and obstructive uropathy, requires partial assistance with personal hygiene and total assistance with lower body dressing, transfers, and toileting. Observations on two separate occasions revealed the resident's urinary catheter bag hanging from a trash can with the bottom of the bag touching the floor. Interviews with a Nursing Assistant, an LPN, and the Director of Nursing confirmed that catheter drainage bags should not touch the floor or be hung on a trash can. The facility's policy on catheter care, dated 7-30-2024, states that catheters should always be properly secured, connected, and maintained using a sterile closed drainage system.
Latest citations in Nebraska
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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