Good Samaritan Society - Beatrice
Inspection history, citations, penalties and survey trends for this long-term care facility in Beatrice, Nebraska.
- Location
- 401 S 22nd Street, Beatrice, Nebraska 68310
- CMS Provider Number
- 285203
- Inspections on file
- 20
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Good Samaritan Society - Beatrice during CMS and state inspections, most recent first.
Failure to follow the meatloaf recipe during meal prep. A Lead Cook prepared meatloaf by using 20 lbs. of ground beef instead of the 17.5 lbs. listed, poured eggs directly over the beef rather than mixing eggs and milk separately, added extra amounts of ingredients by eyeballing, and mixed the batch by hand instead of using the mixer. The cook also said the meatloaf would sit overnight and more eggs or milk might be added if it looked too dry, while the FSD stated cooks are expected to follow the recipes provided.
Food was served below the required hot-holding temperature on a unit dining room. An insulated food cart brought hot lunch items from the kitchen showed several foods at acceptable or borderline temperatures at first, but lids were left off during plating, room trays were covered with a Styrofoam plate instead of insulated covers, and dessert was delivered uncovered. Later temperature checks showed the breaded chicken, potato casserole, and peas had dropped well below 135 degrees Fahrenheit, and the survey team found the food barely warm.
Bathroom ventilation was not operational in seven resident bathrooms, including rooms 120, 301, 303, 305, 308, 309, and 313. Surveyors observed the issue during two tours, and WM confirmed the vents should have been working. WM stated the HVAC vendor reported frozen coils due to cold temperatures, and the vents were not checked when temperatures dropped below freezing; the most recent vent log showed the last check was completed in October 2025.
Missing discharge summaries and transfer notifications: The facility failed to complete required discharge documentation for two residents who were transferred out of the facility. One resident was sent from an appointment to the hospital for kidney failure and had no documented transfer notice or discharge summary, including required medical and contact information, and the DON confirmed the resident’s representative was not notified in writing. Another resident was discharged without a facility Discharge Summary, which the DON confirmed.
A resident with obstructive sleep apnea had a CPAP machine in the room, and the MDS and care plan documented CPAP use and risk for altered respiratory status. However, the order summary contained no physician order for CPAP pressure settings, and the DON and an LPN confirmed the EMR lacked an order; the CCL stated the facility did not have a system to ensure residents admitted with a personal CPAP had an order.
Infection Control Lapses During Catheter and Wound Care: An LPN failed to follow HH and PPE practices during catheter care and wound care for multiple residents. Observations showed gloves and a gown that touched the floor were still used, HH was missed between glove changes or done for only a few seconds, and a catheter drainage bag was placed on the floor. The residents involved had urinary retention, an indwelling device, chronic wounds, MASD, and a heel DTI.
A lead cook in the facility failed to follow proper hand hygiene protocols after handling raw chicken, washing their hands for only 10 seconds instead of the required 20 seconds. This deficiency was confirmed by both the cook and the Dietary Manager, potentially affecting all 60 residents served by the kitchen.
The facility failed to follow proper infection control practices during wound and catheter care for two residents. An LPN did not change gloves or perform hand hygiene between tasks, compromising the care of residents with chronic ulcers and other conditions. The facility's policies were not adhered to, as confirmed by staff interviews.
A facility failed to maintain proper respiratory care for a resident by not keeping the oxygen tubing nasal cannula off the floor and failing to date the tubing. The resident, with chronic heart failure and COPD, uses oxygen as needed. Observations showed undated tubing and the nasal cannula touching the floor, contrary to facility policy requiring weekly dating and proper storage.
The facility failed to provide stop dates for PRN antianxiety medications and did not monitor specific target behaviors for antipsychotic medications for four residents. Despite the facility's policy requiring evaluation of behavioral interventions before using psychotropic medications, residents were prescribed such medications without adequate monitoring or non-pharmacological interventions. The Director of Nursing confirmed these deficiencies, highlighting a lack of adherence to guidelines and regulatory requirements.
Failure to Follow Meatloaf Recipe During Meal Preparation
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature when the facility failed to follow the meatloaf recipe during meal preparation. During observation on 01/22/2026 at 11:16 AM, the Lead Cook began preparing meatloaf for the following day by removing 20 lbs. of ground beef from the walk-in refrigerator, applying gloves, removing the beef from its outer wrap, and then washing hands after removing the gloves. The cook referred to the recipe, which called for 17.5 lbs. of ground beef for 70 servings along with specific amounts of liquid eggs, milk, tomato paste, garlic, salt, onion, breadcrumbs, and pepper. The Lead Cook placed the 20 lbs. of ground beef into a pan, poured the liquid eggs directly over the beef instead of combining eggs and milk in a separate mixing bowl as directed, and stated that because the recipe called for 17.5 lbs. of beef and there were 20 lbs. in the pan, more of each ingredient would be added and the amounts would be eyeballed. The cook then measured each ingredient and added extra amounts, mixed the ingredients with gloved hands instead of using the mixer, covered the meatloaf with foil, and placed it in the walk-in refrigerator. The cook stated the meatloaf would sit overnight and, if it looked too dry the next day, extra eggs or milk would be added. The cook also stated that recipes are sometimes adjusted by taste testing and changing seasoning or broth, and that the extra 2.5 lbs. of beef were not removed because it would go to waste unless it could be browned for another meal. The cook confirmed the recipe should have been followed as written but was not. The Food Service Director stated that cooks are expected to follow the recipes provided.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to maintain and serve food at a safe and appetizing temperature on unit 1. During observation, an insulated food cart was brought from the main kitchen to the 100's dining room with hot lunch items in stainless steel pans. The hot foods were initially measured at temperatures including breaded chicken at 150 degrees Fahrenheit, pureed chicken at 115 degrees Fahrenheit, potato casserole at 160 degrees Fahrenheit, un-breaded chicken at 140 degrees Fahrenheit, peas at 140 degrees Fahrenheit, and cauliflower at 140 degrees Fahrenheit. The food service staff then obtained drinks, performed hand hygiene, applied gloves, and began plating food at 11:45 AM, but the pan lids were left off and were not replaced during service. For room trays, the staff member could not locate insulated covers and placed a Styrofoam plate over the food instead. The dessert, a room temperature mixed fruit cobbler with ice cream, was delivered to rooms uncovered. When temperatures were rechecked later, the breaded chicken was 120-130 degrees Fahrenheit, the potato casserole was 138-140 degrees Fahrenheit, and the peas were 120 degrees Fahrenheit. At the time of tasting, the breaded chicken was 110 degrees Fahrenheit, the potato casserole was 106 degrees Fahrenheit, and the peas were 105 degrees Fahrenheit; the survey team noted the chicken was tough and all items were barely warm. The staff member confirmed that serving temperatures should be over 135 degrees Fahrenheit, and the facility policy stated hot foods should be held above 135 degrees Fahrenheit and served at an appetizing temperature.
Nonfunctioning Bathroom Ventilation in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were operational in seven resident bathrooms, including rooms 120, 301, 303, 305, 308, 309, and 313, out of 24 resident rooms sampled in a facility with a census of 60. During the initial tour on 1.21.2026, surveyors observed that the bathroom ventilation was not functioning in these seven rooms. On a later tour on 1.26.2026 with Water Management, the same bathrooms were again observed to have nonfunctioning ventilation. In interview, Water Management confirmed the bathroom ventilation was not working in those rooms and stated it should be functioning. Water Management also confirmed the HVAC service company had been notified and reported the bathroom vents were not working because cold temperatures caused the coils to freeze. It was further confirmed that the bathroom vents were not checked when temperatures dropped below freezing, and the issue would have been identified when the vents were checked that month; the vents were checked quarterly. A record review showed the most recent bathroom vent check was completed in October 2025.
Missing discharge summaries and transfer notifications
Penalty
Summary
The facility failed to complete required discharge documentation and notification related to two residents who were transferred out of the facility. For Resident 67, record review showed an admission date of 10/16/2025 and a hospital discharge summary listing sepsis, severe thrombocytopenia, and cirrhosis of the liver with ascites. The EMAR contained no documentation of a transfer notice or discharge summary with the resident’s medical information, emergency contact information, special instructions for ongoing care, or other required details. The Social Service Director stated the facility transported the resident to an appointment in [NAME], and the clinic then sent the resident to the hospital due to kidney failure. For Resident 69, record review showed the resident was admitted on [DATE] and discharged on 12/19/2025, but no facility Discharge Summary was completed in the EHR. The DON confirmed in interview on 01/27/2026 that the facility did not complete a Discharge Summary for Resident 69. The DON also confirmed the facility did not notify Resident 67’s representative in writing of the transfer to the hospital or the subsequent discharge from the facility.
Missing Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for Resident 2's CPAP machine and pressure settings. Resident 2 was admitted with a diagnosis of obstructive sleep apnea, and observation of the resident's room on 01/21/2026 showed a CPAP machine on the bedside table, a CPAP mask in the drawer, and the water chamber 1/4 full of water. Record review showed the resident's order summary contained no order for CPAP pressure settings, while the MDS dated 12/30/2025 indicated the resident used a noninvasive ventilator or CPAP. Resident 2's care plan, revised on 07/10/2025, identified the resident as at risk for altered respiratory status related to sleep apnea. During interviews, an LPN stated the resident wore the CPAP every night and that the CPAP was removed in the morning, and confirmed there was no order in the EMR. The DON confirmed there was no physician's order for the CPAP settings, later stating the facility could not locate an order because the resident was admitted from home with the CPAP. The CCL stated the facility did not have a system in place to ensure residents admitted with a personal CPAP had an order.
Infection Control Lapses During Catheter and Wound Care
Penalty
Summary
The facility failed to follow infection control practices during catheter care for 2 residents and during wound care for 2 residents. The facility’s hand hygiene policy required alcohol-based hand rub or soap and water for 15 to 20 seconds and stated that hand hygiene should be performed between changing gloves. The catheter care policy stated that catheter tubing should never touch the floor and that gloves should be removed, hand hygiene performed, and new gloves donned before touching the catheter. The wound dressing change policy stated that after removing and discarding the old dressing, staff should remove gloves and perform hand hygiene before putting on clean gloves. One resident had diagnoses including skin cancer, obstructive uropathy, and urinary retention and was on enhanced barrier precautions because of an indwelling medical device. During observed wound and catheter care, an LPN removed gloves, performed hand hygiene, then put on new gloves; one glove fell on the floor and was picked up and used. The LPN later washed hands with soap and water for six seconds before catheter care. The LPN confirmed the glove that fell on the floor should have been discarded and that handwashing should have been done for 20 seconds. The infection preventionist confirmed that PPE that touches the floor should be thrown away and that hand hygiene should have been performed when gloves were changed. Another resident had urinary retention and a stage 2 pressure ulcer on the right buttock, and a wound clinic note identified open areas on both buttocks as MASD rather than pressure ulcers. During observed wound and catheter care, the LPN changed gloves multiple times without performing hand hygiene, placed the catheter drainage bag on the floor, and later washed hands for seven seconds and four seconds during separate glove changes. The LPN also used the same gloves while washing and dressing both buttocks, then performed suprapubic catheter site care with glove changes that were not followed by hand hygiene, and later left the room without performing hand hygiene after removing gown and gloves. A third resident had MS and a chronic wound on the left heel; during wound care preparation, the LPN dropped a gown on the floor, picked it up, and wore it during wound care. The LPN confirmed the gown should not have been used, and the infection preventionist confirmed PPE that touches the floor should be discarded.
Improper Hand Hygiene in Food Preparation
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, which could potentially lead to foodborne illness affecting all 60 residents served by the kitchen. During an observation, a lead cook (LC-B) was seen preparing a meal without following the facility's hand hygiene policy. After handling raw chicken, LC-B washed their hands for only 10 seconds instead of the required 20 seconds, as per the facility's policy and CDC guidelines. This improper handwashing occurred after removing gloves and before touching other kitchen surfaces, which could lead to cross-contamination. Interviews with LC-B and the Dietary Manager (DM-C) confirmed the deficiency in hand hygiene practices. LC-B acknowledged not washing their hands for the required duration and admitted to not following the correct procedure after handling raw chicken. The Dietary Manager also confirmed that the handwashing procedure was not performed as indicated in the facility's policy, highlighting a lapse in maintaining professional standards for food safety.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care and catheter care for two residents. For Resident 208, the LPN did not change gloves or perform hand hygiene between tasks while providing wound care and catheter care. The LPN used the same gloves to handle clean supplies and perform tasks that required clean gloves, such as cleansing the urethral meatus and catheter tubing. This was confirmed by the LPN and the Director of Nursing, who acknowledged that the facility's policy was not followed. Resident 208's medical history included Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and a non-pressure chronic ulcer of the right ankle. The resident was at risk for pressure ulcers and had specific physician orders for wound care, which included using specific dressings and maintaining cleanliness. However, during the observed care, the LPN did not adhere to the required hand hygiene and glove-changing protocols, potentially compromising the resident's care. Similarly, for Resident 8, the LPN did not change gloves or perform hand hygiene after handling various items and before starting the wound dressing change. The LPN also failed to use a barrier on the tray table, which was used to hold supplies. The Regional Educator intervened during the procedure to remind the LPN to change gloves. Resident 8 had a history of contusions and open wounds on the lower legs, requiring careful wound management. The facility's policy for wound dressing changes was not followed, as confirmed by interviews with the LPN and the Regional Educator.
Failure to Maintain Proper Oxygen Tubing Care
Penalty
Summary
The facility failed to maintain proper respiratory care for a resident by not keeping the oxygen tubing nasal cannula off the floor and failing to date the tubing. This deficiency was observed for one resident, who was admitted on December 4, 2023, and had a BIMS score of 15, indicating full cognitive function. The resident's medical history includes chronic systolic heart failure and chronic obstructive pulmonary disease, and they use oxygen at night and as needed. Observations on multiple occasions revealed that the oxygen tubing was undated and the nasal cannula was touching the floor. The facility's policy requires that oxygen equipment be kept clean and maintained in good condition, with disposable equipment changed weekly and marked with the date and initials. The Director of Nursing confirmed that nurses are expected to date the oxygen tubing weekly and ensure the nasal cannula does not touch the floor, storing it in a protective bag when not in use. Despite these guidelines, the facility did not adhere to the policy, resulting in the observed deficiency.
Failure to Monitor Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide a stop date for the use of as-needed antianxiety medication and did not monitor specific target behaviors for antipsychotic medications, nor did it implement non-pharmacological interventions for four residents. The facility's policy on psychotropic medications emphasizes evaluating behavioral interventions and alternatives before using such medications and ensuring that PRN orders have clear parameters and are limited to 14 days unless extended with documented rationale. However, the facility did not adhere to these guidelines, as evidenced by the lack of stop dates and monitoring for the residents involved. Resident 29, who is cognitively intact with a BIMS score of 15, was prescribed multiple psychotropic medications, including Abilify and Lorazepam, without a stop date for the PRN Lorazepam. The resident's care plan did not identify specific target behaviors or non-pharmacological interventions, and there was no documentation of behavior monitoring for the continued use of antipsychotic medication. Similarly, Resident 19, who is cognitively impaired, had a PRN order for Ativan cream without a stop date and no non-pharmaceutical interventions in place. The Director of Nursing confirmed these deficiencies during an interview. Resident 212, diagnosed with generalized anxiety disorder and other conditions, also lacked behavior documentation and non-pharmacological interventions for antianxiety and antidepressant medications. The resident's PRN Lorazepam did not have a stop date, and there was no monitoring of targeted behaviors. Resident 32, with diagnoses including anxiety disorder and unspecified dementia, was prescribed Seroquel and Sertraline without specific target behaviors or non-pharmacological interventions documented in the care plan. The facility's failure to adhere to its policy and regulatory requirements resulted in these deficiencies, as confirmed by the Director of Nursing.
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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