Good Samaritan Society - Bloomfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomfield, Nebraska.
- Location
- 300 North Second St, Bloomfield, Nebraska 68718
- CMS Provider Number
- 285156
- Inspections on file
- 18
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Good Samaritan Society - Bloomfield during CMS and state inspections, most recent first.
Staff did not consistently perform hand hygiene between glove changes during catheter and incontinence care for a resident with multiple medical conditions, and the urinary catheter drainage bag was repeatedly handled and positioned inappropriately. Additionally, the facility did not follow its own COVID-19 protocols, as symptomatic staff were not tested for COVID-19 despite policy requirements.
A resident with complex medical needs requiring total assistance for toileting and transfers experienced significant delays in receiving care, waiting over an hour for help after activating the call light. Facility records showed repeated instances of call lights going unanswered for extended periods, and staffing schedules revealed that CNA coverage often fell below the facility's own requirements, leading to ongoing delays in resident care.
A resident with significant medical needs, who required total staff assistance, reported that a nurse aide removed their call light from reach after a request for help. The incident, along with similar occurrences, was reported to the facility Administrator but was not reported to the State Agency, and no investigation was completed or submitted as required by policy. The DON confirmed the failure to follow reporting and investigation procedures.
A resident with multiple medical conditions and intact cognition required total staff assistance and had clearly communicated preferences for morning and evening routines during a care plan conference attended by their spouse. Despite this, the care plan was not updated to include the resident's preferred times for getting up and going to bed, as confirmed by the DON.
A resident who was fully dependent on staff for toileting and transfers waited over an hour for assistance after repeatedly requesting help, resulting in involuntary fecal incontinence. Staff were aware of the resident's needs but delayed care due to limited staffing and other duties, and the resident's care plan for timely incontinence management was not followed.
The facility did not maintain sufficient NA and housekeeping staff to meet resident needs, resulting in delayed call light responses, missed ADL care such as bathing, and inconsistent room cleaning. Several residents with cognitive and physical impairments experienced prolonged waits for assistance and infrequent bathing, while the only housekeeping staff was often reassigned to NA duties, leaving cleaning tasks incomplete.
A resident with mobility and self-care deficits did not receive timely assistance with ADLs, including inconsistent bathing and delayed call light responses, due to inadequate nurse aide staffing. Both the resident and their family reported ongoing concerns about insufficient staff, and the DON confirmed that posted staffing levels were not being met.
A resident with severe cognitive impairment and multiple physical limitations experienced repeated falls without documented implementation or revision of fall prevention interventions. Despite facility policy requiring proactive measures and care plan updates after each fall, no new interventions were documented, and the care plan was not revised following multiple incidents, as confirmed by the DON.
The facility did not provide required clinical documentation when declining to reduce psychotropic medication doses for two residents, despite recommendations from the consultant pharmacist. One resident with dementia and behavioral symptoms continued on Seroquel and Paroxetine without documented rationale for not attempting a dose reduction, and another resident with sleep disturbances remained on Trazadone without clinical justification for not reducing the dose. Nursing staff confirmed the lack of timely response and documentation.
A resident did not receive prescribed Yupelri due to unavailability, and repeatedly refused Novolog insulin and Oxycodone without practitioner notification or alternative treatments being offered, contrary to facility policy. Interviews confirmed the resident and spouse were not provided alternatives, and the DON acknowledged the lapses in medication administration and documentation.
A resident assessed as high risk for falls experienced multiple falls related to toileting, despite care plan interventions such as an anti-roll back device and a scheduled toileting plan. Staff interviews revealed that the routine toileting intervention was not communicated or followed, and the DON confirmed that staff were not completing this fall prevention approach.
A resident with heart failure, heart disease, and mild cognitive impairment was not offered a COVID-19 vaccine booster or provided with education about the vaccine upon admission, despite facility policy requiring such actions. Documentation showed no consent or declination for the vaccine, and the resident was not current on COVID-19 vaccination.
A resident with multiple health conditions developed pressure ulcers that were not consistently assessed or documented according to facility policy. There were significant delays and omissions in wound measurements, incomplete documentation of wound characteristics, and a lack of evidence that recommended nutritional interventions were implemented. The resident's ulcers worsened, showing signs of infection and requiring hospitalization, while staff failed to ensure regular assessments and timely interventions.
The facility failed to implement effective fall prevention interventions for three residents, leading to repeated falls. Despite having orders for alarms, these were often not in place or functioning, and staff did not consistently secure them to the residents. Interviews confirmed that necessary interventions were not implemented to prevent future falls.
The facility failed to document and account for discontinued medications awaiting destruction for four residents, as required by their policy. Medications were found in a locked drawer without proper labeling or documentation, risking potential loss or theft. Interviews confirmed the lack of necessary records for medications like Erythromycin, Moxifloxacin, Naphcon A, Ativan, and Lorazepam.
A facility failed to address repeat grievances and ensure sustainable resolutions for a resident's care and activities. The resident's family reported issues such as incomplete oral care, an unplugged fall alarm, and inadequate toileting. Despite initial resolutions, these concerns persisted, and the resident did not consistently receive 1:1 activities as per their care plan. Interviews confirmed ongoing issues with care provision, highlighting a continued deficiency.
A facility failed to notify a resident's family about significant changes in the resident's condition, including weight loss and nutritional interventions. The resident, with severe cognitive impairment, experienced a substantial weight loss, and although the PCP was informed, the family was not. Additional communication failures included not informing the family about diet changes, initiation of Arginaid, and changes in the use of Magic Cup. Interviews confirmed these lapses, indicating a breach of the facility's notification policy.
Infection Control Failures in Hand Hygiene, Catheter Care, and COVID-19 Protocols
Penalty
Summary
Staff failed to perform hand hygiene at appropriate intervals during the provision of care, specifically when removing soiled gloves and before donning clean gloves. Observations showed that nurse aides did not complete hand hygiene before putting on personal protective equipment or after removing gloves during catheter care and incontinence care for a resident. The urinary catheter drainage bag was repeatedly placed on bed linens and positioned above the level of the resident's bladder and head during transfers, contrary to facility policy and best practices for infection prevention. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes. The resident required total staff assistance for hygiene and had an indwelling urinary catheter. During care, the catheter drainage bag was handled inappropriately, including being placed on the bed and attached to the lift above the resident's bladder, and staff did not consistently perform hand hygiene between glove changes while managing incontinence and catheter care. Additionally, the facility failed to follow its COVID-19 protocols. The DON was observed with respiratory symptoms but had not completed a COVID-19 test and stated there was no intention to do so. It was confirmed by a registered nurse that the facility did not test staff or residents presenting with respiratory symptoms or increased temperature, despite facility policy requiring symptomatic employees to be restricted from work until COVID-19 infection was ruled out by testing.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of all residents, specifically resulting in delayed toileting and incontinence care for a resident with significant medical needs. The resident, who had diagnoses including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, required total staff assistance for toileting, hygiene, dressing, bed mobility, and transfers, and was frequently incontinent of bowel with an indwelling urinary catheter. On the observed morning, the resident activated the call light at 7:15 AM for assistance to use the commode, but did not receive help until 8:39 AM, resulting in an involuntary bowel movement due to the prolonged wait. Interviews confirmed that only two direct care staff were working that shift for a census of 30, and the resident was often left waiting for extended periods due to insufficient staffing. Review of the facility's Device Activity Report and call light activity logs revealed numerous instances where call light response times exceeded the facility's policy of a 15-minute response, with some calls going unanswered for up to 138 minutes. These delays were not isolated to a single day but occurred repeatedly over a two-week period, affecting multiple residents. The facility's own policy required prompt response to call lights, and staff interviews confirmed that the expectation was to answer within 15 minutes, which was not consistently met. Further review of staffing schedules showed that the facility frequently scheduled fewer CNAs than required, particularly on weekends and overnight shifts. The Director of Nursing confirmed that the number of CNAs scheduled often did not meet the facility's own standards for adequate staffing. This chronic understaffing directly contributed to the inability to provide timely care and respond to residents' needs as required by both facility policy and regulatory standards.
Failure to Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency, did not complete an investigation, and did not submit the investigation within the required 5 working days. According to the facility's Abuse and Neglect Policy, all alleged or suspected violations, including abuse, neglect, or injuries of unknown origin, were to be reported immediately to the Administrator and to the State Survey and Certification Agency within 5 working days. However, a review of facility records and interviews revealed that an incident involving a resident's call light being removed from their reach by a nurse aide was reported to the Administrator but was not reported to the State Agency, and no investigation was completed or submitted as required. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, and required total staff assistance for most activities of daily living. The resident and their spouse reported that it was common for staff to remove the call light from the resident's reach, and specifically recounted an incident where a nurse aide removed the call light after the resident requested assistance. The Director of Nursing confirmed that the facility did not report the allegation or complete and submit the required investigation to the State Agency.
Care Plan Not Updated to Reflect Resident's Routine Preferences
Penalty
Summary
The facility failed to update a resident's comprehensive care plan to reflect the individual's stated preferences for morning and evening routines. The resident, who had diagnoses including heart failure, previous stroke with right side paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, was assessed as having intact cognition but required total staff assistance for activities of daily living such as toileting, dressing, hygiene, bed mobility, and transfers. The resident was also frequently incontinent of bowel and had an indwelling urinary catheter. During a care plan conference attended by the resident and spouse, the preference for being up and out of bed at 7:00 AM and going to bed at 8:30 PM was clearly communicated. However, a review of the care plan, last revised after this conference, showed no documentation of these preferences. The care plan only included interventions related to positioning and transfer assistance, without addressing the resident's specific requests for daily routine times. The DON confirmed in an interview that the care plan had not been updated to include these preferences.
Failure to Provide Timely Toileting Assistance for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who required total staff assistance for activities of daily living, including toileting, was not provided timely assistance. The resident, who had a history of heart failure, stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, was cognitively intact and dependent on staff for bed mobility, transfers, and toileting. The care plan specified that the resident should be checked and changed every two hours when in bed and required two staff members and a full lift for transfers. On the morning in question, the resident activated the call light at 7:15 AM after completing a nebulizer treatment, indicating a need to use the commode for a bowel movement. Although a medication aide entered the room, the resident was not assisted with toileting at that time. The call light was activated multiple times, and staff were aware of the resident's request. Despite repeated requests and activation of the call light, the resident waited a total of 1 hour and 24 minutes before two nurse aides arrived to assist with transfer to the commode. During this time, the resident became incontinent of feces. Staff interviews confirmed that only two direct care staff were working that morning, and the resident was left waiting while staff assisted other residents. The resident's care plan interventions for timely toileting and incontinence management were not followed, resulting in the resident remaining soiled until staff were available to provide assistance.
Failure to Provide Adequate Nursing and Housekeeping Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by multiple documented instances of insufficient nurse aide (NA) coverage and delayed response times to call lights. Review of staffing records showed that, over a period of several weeks, the facility did not meet its own predetermined NA staffing levels for its census, with some days having as few as two NAs on the floor during the day shift. This staffing shortage was confirmed by both staff interviews and the Director of Nursing, who acknowledged that the facility had not met required NA staffing levels as the census increased from 27 to 35 residents. Residents with significant care needs, including those with cognitive impairments, limited mobility, and self-care deficits, experienced delays in receiving assistance with activities of daily living (ADLs) such as bathing, toileting, and hygiene. Documentation revealed that one resident, who required assistance with ambulation and bathing, did not receive baths at the frequency specified in their care plan, with gaps of up to 14 days between baths. Multiple residents had call light response times that exceeded the facility's standard of 10 minutes, with some instances of call lights going unanswered for up to 53 minutes. These delays were noted repeatedly for several residents, particularly during periods of low staffing. In addition to nursing staff shortages, the facility also failed to maintain daily cleaning of resident rooms as required. The only housekeeping staff member was frequently reassigned to work as a NA, resulting in missed cleaning duties. Interviews with environmental services and maintenance staff confirmed that there was no clear schedule or record of which rooms were cleaned during certain periods, and that maintenance and laundry staff were sometimes tasked with cleaning in the absence of dedicated housekeeping personnel. These combined staffing and housekeeping deficiencies had the potential to affect all residents in the facility.
Failure to Provide Timely ADL Assistance Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADLs) to a resident who required help due to self-care deficits, limited mobility, and a history of dizziness and arthritis. The resident's care plan specified the need for assistance with ambulation, bathing, toileting hygiene, transferring, and clothing adjustment, with a preference for bathing twice weekly during the summer. However, records showed inconsistent bathing schedules, with gaps of up to two weeks between baths, and multiple instances where call light response times exceeded the facility's stated standard of 10 minutes, including one instance where the response time was over 50 minutes. Interviews with the resident and their family member revealed ongoing concerns about insufficient staffing, particularly during day and evening shifts and on weekends, leading to delays in care and unmet personal hygiene needs. The resident reported feeling unsafe when forced to attempt self-care due to long wait times and expressed dissatisfaction with the frequency of bathing and call light responses. The Director of Nursing confirmed that the facility was not meeting its own nurse aide staffing levels as posted, which contributed to the deficiencies in providing timely and adequate ADL assistance.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to review, revise, and implement care plan interventions to prevent falls for a resident with severe cognitive impairment, limited range of motion on one side, and dependence on staff for ambulation, transfers, and toileting. The resident had multiple diagnoses, including non-Alzheimer's dementia, anxiety, and depression, and experienced several falls over a one-month period. Despite the facility's policy requiring proactive fall prevention, post-fall assessment, and care plan updates, there was no documentation that interventions were put in place after each fall. Record reviews showed that after each fall, there was no evidence of new or revised interventions to prevent future incidents, and the resident's care plan was not updated accordingly. The DON confirmed that interventions to prevent future falls were not implemented following each event, and the care plan should have been updated as per facility policy. This deficiency was identified through record review and staff interview.
Failure to Document Clinical Rationale for Not Reducing Psychotropic Medications
Penalty
Summary
The facility failed to document a clinical rationale for not completing Gradual Dose Reductions (GDR) for psychotropic medications for two residents. Facility policy required that residents on psychotropic medications receive GDRs unless clinically contraindicated, and that any contraindication be documented. For one resident with dementia, anxiety, depression, and behavioral symptoms related to psychosis, the consultant pharmacist requested a dosage reduction for Seroquel and Paroxetine. The provider responded to the request after 45 days but did not document any clinical reason for not reducing the doses. For another resident with sleep disturbances and insomnia, the consultant pharmacist recommended a dosage reduction for Trazadone. The provider declined the reduction but again failed to document a clinical rationale. Interviews with nursing staff confirmed that the facility did not address pharmacist recommendations for GDRs in a timely manner and did not provide required documentation when declining to reduce psychotropic medication doses. The facility's policies outlined the need for regular review and documentation regarding psychotropic medication use, but these procedures were not followed for the two residents identified in the report.
Failure to Follow Practitioner Orders and Notify of Medication Unavailability or Refusals
Penalty
Summary
The facility failed to follow practitioner orders and its own medication administration policy for a resident with multiple chronic conditions. The resident did not receive Yupelri Inhalation Solution for 18 days due to unavailability, and there was no documentation that the practitioner was notified or that an alternative treatment was provided. Additionally, the resident refused multiple doses of Novolog insulin and Oxycodone over several days, but there was no evidence that the practitioner was informed of these repeated refusals or that alternative treatments were considered, as required by facility policy. Interviews with the resident and spouse confirmed that the resident was not offered alternative options when medications were unavailable or refused. The resident had a history of only using sliding scale insulin at home and refused Oxycodone in the morning due to side effects impacting participation in therapy and social visits. The DON confirmed that the resident did not receive the prescribed medications as ordered and that the necessary notifications and documentation were not completed.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and monitor fall prevention interventions as outlined in the care plan for a resident identified as high risk for falls. Despite documented falls and a care plan that included specific interventions such as the use of an anti-roll back device on the wheelchair and a routine toileting schedule, staff interviews revealed that these interventions were not consistently communicated or followed. Nurse aides were unaware of the routine toileting plan, and the resident continued to toilet independently without the scheduled assistance intended to reduce fall risk. The care plan had been updated to address the resident's needs after each fall, but the interventions were not effectively put into practice or monitored by staff. The resident had a history of weakness, difficulty walking, and was assessed as high risk for falls on multiple occasions. Event documentation showed the resident experienced falls while attempting to use the bathroom independently, including one incident where an unlocked wheelchair brake contributed to the fall. Although the care plan was revised to address these risks, including scheduled toileting and equipment adjustments, staff interviews and the DON's confirmation indicated a lack of awareness and implementation of these interventions, resulting in continued risk for the resident.
Failure to Offer and Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine or provided with education on the benefits and risks of the vaccine, as required by facility policy. The policy specified that residents should be given the opportunity to receive immunizations, have their immunization status reviewed upon admission and on an ongoing basis, and receive documented education about the vaccines for which they are eligible. Documentation should include written consent or declination, and administration or referral for vaccination. In this case, the resident was admitted with a history of heart failure, heart disease, and mild cognitive impairment, and was being treated for an upper respiratory infection. Review of the resident's records showed that the most recent COVID-19 booster was received several months prior to admission, and there was no documentation of consent or declination for a new COVID-19 vaccine. The Infection Preventionist confirmed that the resident was not offered a COVID-19 vaccine booster at admission or since, resulting in the resident not being current on COVID-19 vaccination.
Failure to Monitor and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to properly evaluate, monitor, and document pressure ulcers for a resident who was at risk for skin breakdown. Upon admission, the resident was assessed as being at risk for pressure ulcer development but had no existing ulcers. The resident was dependent on staff for most activities of daily living and had multiple diagnoses, including hip fracture, diabetes, and end stage renal disease. Despite the facility's policy requiring systematic assessment and documentation, the resident developed a stage 2 pressure ulcer on the right heel, which was not consistently measured or assessed as required. There were significant gaps in documentation, with weeks passing between wound measurements and incomplete assessments of wound characteristics. The resident subsequently developed a pressure ulcer on the left heel, but treatment for this new ulcer was delayed. The documentation continued to lack regular measurements and comprehensive assessments, making it difficult to determine whether the wounds were healing or deteriorating. The right heel ulcer progressed to a stage 3 ulcer with signs of infection, including increased drainage, foul odor, and a larger wound area. Despite the worsening condition, there were still missing measurements and incomplete documentation of the wound's status. Additionally, a dietary recommendation for a nutritional supplement to aid in wound healing was made, but there was no evidence in the medical record that this intervention was implemented. The resident's condition continued to decline, requiring multiple changes in wound care orders and eventually leading to hospitalization for further evaluation. Throughout the course of care, the facility staff failed to ensure weekly assessments, proper documentation, and timely interventions as outlined in their own policies, resulting in the development and worsening of pressure ulcers.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to identify causal factors and revise or develop fall interventions to prevent ongoing falls for three residents, leading to repeated incidents. Resident 6, who was severely cognitively impaired and required assistance with daily activities, experienced multiple falls without long-term interventions being implemented. Despite having an order for a pull tab alarm, observations revealed that the alarm was often not in place or functioning, and staff failed to secure it to the resident. Interviews with staff confirmed that the necessary interventions were not consistently implemented to prevent future falls. Resident 25, who had severe cognitive impairment and required assistance with daily activities, also experienced multiple falls without long-term interventions being implemented. The resident had a personal alarm to alert staff of ambulation attempts, but incident reports indicated that no additional interventions were identified to prevent ongoing falls. Interviews with the Director of Nursing confirmed that interventions were not implemented to prevent future falls for this resident. Resident 79, who had a history of a hip fracture and required substantial assistance with daily activities, experienced several falls without causal factors being identified or interventions being revised. Despite having a pull tab alarm and a silent fall alarm, incident reports revealed that these alarms were not always in place or functioning. Interviews confirmed that no investigations were conducted to determine why the alarms malfunctioned, and no new interventions were developed to prevent further falls.
Failure to Document Discontinued Medications
Penalty
Summary
The facility failed to ensure proper accounting and documentation for medications that were discontinued and awaiting destruction for four residents. The facility's policy on medication disposition, revised on 8/1/23, required that discontinued medications be immediately removed from the resident's supply, stored securely, and documented with specific details before being returned to the pharmacy or destroyed. However, during an observation of the medication storage room, it was found that a locked cabinet drawer contained five medications without any labeling or documentation, indicating a lack of compliance with the policy. Interviews with LPN-H and RN Consultant-P confirmed that the medications were awaiting destruction but lacked the necessary documentation. The medications involved included Erythromycin ophthalmic ointment and Moxifloxacin solution for Resident 6, Naphcon A ophthalmic drops for Resident 8, Ativan for Resident 17, and Lorazepam for Resident 83. The absence of documentation for these medications put them at risk of potential loss or theft, as there was no record of the residents' names, medication details, or quantities, which was required by the facility's policy.
Failure to Address Repeat Grievances and Ensure Resident Care
Penalty
Summary
The facility failed to address repeat grievances and ensure sustainable resolutions for concerns related to the care and activities provided to Resident 21. The grievances documented by the resident's family included issues such as incomplete oral care, lack of use of towels and washcloths, an unplugged fall alarm, and inadequate toileting before breakfast. Despite initial resolutions, these concerns persisted, indicating a lack of effective follow-up and resolution. Further grievances were raised by the family regarding insufficient assistance with meals, which was particularly concerning given the resident's weight loss. The family also reported finding a room tray from the previous evening left uncovered, suggesting neglect in meal assistance. Additionally, the resident's care plan included 1:1 activities, which were not consistently provided, as documented in the facility's records. Interviews with the resident's family and facility staff confirmed ongoing issues with the provision of care, including assistance with food and fluids, toileting, oral care, and repositioning. Despite previous staff education and counseling, there was no evidence of additional 1:1 activities being provided, highlighting a continued deficiency in addressing the family's concerns and ensuring the resident's care needs were met.
Failure to Notify Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the family or responsible party of Resident 21 about significant changes in the resident's condition, specifically regarding weight loss and the initiation of nutritional interventions. The resident, who had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and depression, experienced a substantial weight loss of 14 pounds over two months. Despite notifying the resident's primary care physician about the weight loss and starting a nutritional supplement called Magic Cup, there was no evidence that the family or responsible party was informed of these changes. Further review of Resident 21's medical records revealed additional failures in communication. The family or responsible party was not notified about a change in the resident's diet to soft, bite-sized food, the initiation of Arginaid for wound healing, the discontinuation of Magic Cup due to supplier issues, or its subsequent reintroduction. Interviews with the resident's family and the Director of Nursing confirmed these lapses in communication, highlighting the facility's failure to adhere to its policy of notifying family members of significant changes in a resident's condition.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
