Good Samaritan Society - St John's
Inspection history, citations, penalties and survey trends for this long-term care facility in Kearney, Nebraska.
- Location
- 3410 Central Avenue, Kearney, Nebraska 68847
- CMS Provider Number
- 285189
- Inspections on file
- 22
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Good Samaritan Society - St John's during CMS and state inspections, most recent first.
A resident did not receive an ordered extension of antibiotic therapy because the provider’s order was never entered, and the resident later required hospital care with IV antibiotics for a UTI. Another resident with a documented Oxycontin allergy was given Oxycontin, and although the provider ordered monitoring for an allergic reaction, the record did not show continued observation beyond the initial assessment.
Failure to obtain informed consent for psychotropic medications. The DON confirmed that the facility did not educate or obtain consent before giving psychotropic meds to multiple residents. One resident had antidepressants ordered without any consent in the record, another had a psychotropic consent form that did not list the meds, risks, benefits, or non-pharmacological alternatives, and a cognitively intact resident receiving Rexulti had an incomplete consent form with no signatures or dates.
Failure to Monitor Antipsychotic Medication Effects: The facility failed to monitor a resident for adverse effects related to antipsychotic use. A cognitively intact resident was receiving Rexulti for dementia-related diagnoses, but the MAR had no monitoring orders and the CCP had no plan for antipsychotic monitoring. The DON confirmed the required monitoring was not completed as required by facility policy.
The facility failed to complete discharge summaries for two residents who were discharged from the LTC facility. One resident was transferred to the hospital after reporting intolerable abdominal pain and did not return, and another resident was discharged home with home care services. The DON confirmed that no discharge summaries were completed for either resident.
A resident with renal insufficiency received dialysis three times per week, and facility transport staff were observed bringing the resident back from the dialysis center with a dressing on the right forearm from treatment. However, the MDS did not mark dialysis in the special treatments section, and the DON confirmed the assessment should have identified the resident’s dialysis need.
The facility failed to complete baseline care plans for two residents upon admission and did not document the required care conference notes. One resident had Parkinson’s disease, sleep apnea, and dysphagia, and the other had dysphagia, esophageal cancer, and sepsis. The MDSC confirmed the baseline care plans were not completed as required.
A resident with DM who received insulin did not have a comprehensive care plan that addressed diabetes care. The care plan lacked a focus area for DM and did not identify monitoring for signs of high or low blood sugar, and the DON confirmed the omission.
A resident with repeated falls and moderate cognitive impairment had a care-planned wheelchair anti-rollback brake intervention, but observation showed the wheelchair did not have the device and rolled backward without resistance. The MDSC confirmed the intervention was not in place, and staff were unaware whether it had ever been implemented.
A resident receiving dialysis three times weekly had no physician order for dialysis in the chart, and the facility did not complete or retain the required dialysis communication/referral forms for the resident’s treatments. The resident returned from dialysis with a fistula dressing in place, but nursing staff did not perform the required post-dialysis assessment or monitor the dressing and fistula site; RN-A and the DON confirmed the assessments were not being done as required.
A resident with a diagnosis of constipation, who was cognitively intact and dependent on staff for toileting, went multiple days without a BM. Although PRN orders were in place for Dulcolax, Milk of Magnesia, prune juice, and senna, the MAR showed none were given, and there was no documentation of assessment or PRN treatment for constipation. The DON confirmed the ordered PRN constipation meds were not offered or provided as ordered.
A resident with ongoing respiratory symptoms received multiple nebulizer treatments for wheezing and cough, but the facility failed to complete required assessments and did not consistently follow physician orders. Documentation showed that medication aides, rather than licensed nurses, often monitored the effectiveness of treatments, and the facility did not use its change in condition evaluation process as required. Staff interviews confirmed that appropriate follow-up assessments were not performed.
A resident with advanced dementia, recent falls, and a lumbar fracture was admitted without timely completion of a fall risk assessment or baseline care plan. Despite being placed on alarms and moved closer to the nurses' station, individualized fall prevention interventions were not documented or communicated as required. The resident subsequently experienced an unwitnessed fall, sustaining an abrasion, and staff confirmed that care planning was not completed within the expected timeframe.
The facility failed to ensure complete and reviewed healthcare documentation for new hires, affecting all sampled employees. Records showed incomplete Medical History Questionnaires, missing or unreviewed Tuberculosis Screening Questionnaires, and incomplete Hepatitis B forms. Interviews confirmed these deficiencies, indicating a systemic issue in handling new hire healthcare documentation.
The facility's laundry area, including the ante room, storage room, and dirty laundry area, was found to be unsanitary during an inspection. Observations revealed dusty floors, debris, and improperly stored items, including water-damaged cardboard boxes and a soap scum-covered sink. Interviews with the Facility Administrator and Infection Control Preventionist indicated that the area was rarely inspected, and the Housekeeping/Laundry Supervisor had not addressed the cleanliness issues despite being instructed to do so. These conditions had the potential to affect all laundry staff and residents.
The facility failed to provide necessary bathing assistance to residents, affecting four out of five sampled individuals. A resident with a fractured pelvis had not received a bath since early December, while another resident at risk for skin breakdown had only two baths in December. A hospice care resident had no recorded baths in the previous 30 days, and another resident with a suprapubic catheter also lacked documented showers. Staffing issues and the termination of the bath aide contributed to the deficiency, as confirmed by the Facility Administrator.
The facility failed to maintain a clean and safe environment for residents, as evidenced by soiled wheelchairs and unclean bathrooms. Observations revealed that wheelchairs were not regularly cleaned, with visible debris on wheels and frames. Bathrooms had soiled exhaust vents and toilets, and sinks with drainage issues. These deficiencies were confirmed by the Facility Administrator, who acknowledged the need for cleaning and maintenance.
A facility failed to involve a resident and their representative in quarterly care plan meetings as required. Despite policies mandating invitations and documentation, there was no record of the resident or their family being invited to or attending care plan meetings throughout the year. The Social Services Director confirmed the absence of documentation regarding the resident's participation in these meetings.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss due to the facility's failure to monitor and address nutritional needs. Despite a care plan including a modified diet and supplements, the facility did not effectively communicate weight changes or provide consistent nutritional support, leading to continued weight loss.
A resident with severe cognitive impairment was prescribed Amitriptyline for shingles pain, but continued its use without a documented indication or monitoring. The facility's policy requires drug regimens to be free from unnecessary drugs, yet the resident's care plan lacked documentation of the antidepressant use or related interventions.
A facility failed to follow physician orders for bowel protocols for a resident with severe cognitive impairment and constipation. Despite the resident not having a bowel movement for several days, the prescribed interventions, including medications and physician communication, were not carried out as per the facility's policy.
Significant medication errors and incomplete monitoring after an allergic medication administration
Penalty
Summary
The facility failed to ensure that significant medication errors did not occur and that residents were monitored for potential negative effects after the errors. For Resident 17, the provider ordered an extension of antibiotic therapy for a urinary tract infection, but the order was received by the facility and never entered into the resident’s orders, so the resident did not receive the full prescribed course. The resident was later admitted to the hospital for the urinary tract infection and required IV antibiotic therapy. The DON confirmed that the missed transcription of the provider’s order resulted in the resident not receiving the ordered antibiotic extension and that this met the criteria for a significant medication error. For Resident 54, who had a documented allergy to Oxycontin, the resident was given Oxycontin even though it was not prescribed. The provider was notified and instructed staff to monitor the resident for signs of an allergic reaction. The record showed an initial assessment with vital signs within normal limits and no symptoms of an allergic reaction, but there was no evidence of continued monitoring afterward and no further vital signs documented to show ongoing observation for allergic reaction symptoms. The DON confirmed that the resident received a medication they were allergic to and that the record did not show the continued monitoring that should have occurred.
Failure to obtain informed consent for psychotropic medications
Penalty
Summary
The facility failed to inform residents or their representatives in advance of the risks, benefits, options, and alternatives before administering psychotropic medications for 3 of 5 residents reviewed. The deficiency involved Residents 17, 6, and 2, and the facility policy stated that the family or legal representative would be notified before non-emergency psychotropic medications were given and that a Permission for Use of Psychotropic Medications form must be signed. Resident 17 was admitted to the facility on 4/18/25 and had physician orders for Bupropion 150 mg daily and Paroxetine 40 mg daily on admission, as well as Venlafaxine 37.5 mg daily on 3/30/26. The care plan noted antidepressant use and listed side effects including increased risk for suicidal thoughts, increased drowsiness, changes in mood, and changes in condition. The medical record contained no consent for the psychoactive medications, and the DON confirmed that the facility did not provide education on Bupropion, Paroxetine, or Venlafaxine to Resident 17 or the representative and did not obtain consent prior to use. Resident 6 was admitted on 07/02/2019 with a diagnosis of anxiety and had a quarterly MDS showing routine antidepressant use. Physician orders included Venlafaxine 150 mg daily for anxiety and Trazodone 50 mg at bedtime for sleep. A Permission for Use of Psychotropic Medication form dated 07/2025 was present, but it did not list the resident’s use of Venlafaxine or Trazodone and did not list risks, benefits, or non-pharmacological alternatives; it was signed by the resident on 01/28/2026. Resident 2 had a BIMS score of 14, indicating cognitive intactness, and was receiving Rexulti 0.5 mg for unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Permission for Use of Psychotropic Medications form for Rexulti had no signatures or dates of completion, and the DON confirmed that education was not provided and consent was not obtained prior to use.
Failure to Monitor Antipsychotic Medication Effects
Penalty
Summary
The facility failed to monitor for adverse drug reactions related to antipsychotic medication use for one resident. Resident 2 had an admission date of 08/10/2016 and an MDS dated 02/11/2026 showing a BIMS score of 14, indicating the resident was cognitively intact. The resident’s MAR dated 04/02/2026 showed Rexulti 0.5 mg was being administered for unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and the MAR showed no missed doses during March 2026. However, there were no orders on the MAR to monitor for adverse effects related to the antipsychotic medication. The resident’s CCP dated 03/30/2026 contained no plan of care related to antipsychotic use or monitoring for adverse effects. The resident’s AIMS assessments were completed on 04/15/2025 and 01/26/2026. During an interview on 04/02/2026 at 9:45 AM, the DON confirmed that the facility did not complete monitoring for adverse effects for Resident 2 while taking an antipsychotic as required by facility policy.
Missing Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to complete discharge summaries for two discharged residents. One resident was admitted to the facility on 09/22/2020 and was sent to the hospital after complaining of intolerable abdominal pain and wanting to go to the emergency department; the facility later received a call from the emergency department that the resident was being admitted to the hospital, and the resident did not return to the facility. Review of the resident’s EMR showed no discharge summary was completed. The DON confirmed both the hospital transfer and that the discharge summary had not been completed. The second resident was admitted on 01/06/2026 and was discharged to home with home care services on 02/05/2026. Review of that resident’s EMR also showed no discharge summary was completed. During interview, the DON confirmed the resident had been discharged home and acknowledged that no discharge summary had been completed, stating that one should have been.
MDS Did Not Identify Dialysis Services
Penalty
Summary
The facility failed to ensure that the MDS accurately identified dialysis services for Resident 7. Record review showed that Resident 7 had a diagnosis of renal insufficiency and received dialysis outside the facility three times per week. The facility’s dialysis services policy stated that residents receiving dialysis must have care planning specific to dialysis needs, and the care plan policy stated that the interdisciplinary team should develop the comprehensive care plan based on the MDS. Observation and interview confirmed that Resident 7 was transported to and from the dialysis center by the facility’s Patient Transportation Driver, and the resident returned with a dressing on the right forearm that the resident identified as from the dialysis center. Review of the MDS dated 1/12/26 showed that dialysis was not marked in the special treatments section. The DON confirmed that Resident 7 received dialysis three times per week and that the MDS should have identified the dialysis need.
Failure to Complete Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to complete a baseline care plan within 24 hours of admission for 2 of 3 residents reviewed, Residents 4 and 23, and did not document the required care conference note in either resident’s record. The facility policy titled Care Plan stated that a baseline care plan is to be developed upon admission and includes instructions needed to provide effective, person-centered care, with a written summary provided to the resident and resident representative. Staff were also to use the Progress Note-Care Conference Note to document that the meeting occurred and any significant discussion. Resident 4 was admitted with diagnoses of Parkinson’s disease, sleep apnea, and dysphagia, and the medical record contained no evidence of a baseline care plan or care conference note. Resident 23 was admitted with diagnoses of dysphagia, esophageal cancer, and sepsis, and the medical record likewise contained no evidence of a baseline care plan or care conference note. The MDS Coordinator confirmed in interview that the facility did not complete a baseline care plan for either resident upon admission as required.
Incomplete Care Plan for Resident with Diabetes
Penalty
Summary
The facility failed to maintain a comprehensive care plan for one resident with diabetes mellitus. Record review showed the resident had a diagnosis of diabetes mellitus and received insulin all 7 days of the MDS 7-day lookback period. However, the comprehensive care plan dated 3/31/26 did not include a focus area for diabetes care. The care plan also did not identify care required for the resident's diabetes, including monitoring for symptoms of high or low blood sugar levels. The facility policy stated that the comprehensive care plan should include measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs, and the DON confirmed during interview that the resident's care plan did not identify care for diabetes mellitus as required.
Fall Prevention Intervention Not Implemented
Penalty
Summary
The facility failed to ensure that fall prevention interventions were implemented for one resident with a history of repeated falls. The resident was admitted with a diagnosis of repeated falls and had moderate cognitive impairment, with a BIMS score of 9. The resident required verbal cues or intermittent touching/steadying assistance when standing from a chair, wheelchair, or side of the bed, and the facility’s fall history listed 13 falls since admission. The care plan included a fall intervention stating that the resident’s wheelchair was to have anti-rollback brakes to prevent the chair from moving backward when the resident stood up. However, observation showed the wheelchair had no anti-rollback device and rolled backward without resistance when pushed. The MDS Coordinator confirmed that the anti-rollback brake intervention was care planned but was not in place, and was not aware whether it had ever been implemented.
Dialysis Orders, Communication, and Post-Treatment Assessment Not Completed
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with chronic kidney disease who was receiving outpatient dialysis three times per week. The resident was cognitively intact with a BIMS score of 15 and reported going out for dialysis on Mondays, Wednesdays, and Fridays. The facility’s medical record did not contain a physician’s order for dialysis, and the DON confirmed that such an order was required and should include the type and frequency of dialysis. The facility also failed to complete and maintain the required dialysis communication/referral documentation. The facility’s dialysis agreement stated that appropriate medical and administrative information must accompany residents to the dialysis unit and that documented evidence of care and communication must be maintained between the facility and the dialysis center. However, the resident’s record contained no evidence of completed dialysis communication/referral forms for the dialysis treatments during the reviewed period, and the facility could not produce the forms for the requested date range. The DON confirmed that nurses were expected to complete the form before each dialysis appointment, assess vital signs, acute changes, and fistula thrill, send the form with the resident, receive it back from the dialysis center, and scan it into the permanent record. The facility further failed to assess and monitor the resident after dialysis as required. The resident stated that staff did not check the fistula dressing after return from dialysis and that the resident removed the dressing independently. On observation, the resident returned from dialysis with a dressing on the right forearm and was taken directly to the dining room without assessment by nursing staff. RN-A confirmed that no specific assessment was done on return from dialysis and that no physical assessment of the dressing was performed. The record showed only limited progress notes documenting return from dialysis, and the Clinical Monitoring Dialysis assessment was completed only four times in March despite 13 dialysis days. The DON confirmed that the assessment was to be completed each dialysis day upon the resident’s return and that the facility had not been assessing the resident after dialysis treatments as required.
Failure to Follow PRN Constipation Orders
Penalty
Summary
The facility failed to follow practitioner orders for constipation for one resident. The resident had an admission date of 08/10/2016, was cognitively intact with a BIMS score of 14, was dependent on staff for toilet transfers and toileting hygiene, and was always incontinent of bowels. The resident’s care plan listed constipation as a diagnosis, and the MAR showed PRN orders for Dulcolax suppository, Milk of Magnesia, prune juice, and senna for constipation. Record review of toileting tasks showed the resident had no bowel movements for 4 days from 03/07/2026 through 03/10/2026 and for 7 days from 03/14/2026 through 03/20/2026. The MAR for March 2026 showed none of the PRN constipation medications were given on any date, and progress notes from 03/03/2026 through 04/01/2026 showed no evidence that the resident was assessed or that PRN medications were provided for constipation. A NA stated staff only document bowel movements on tasks in the EMR, and the DON confirmed the facility did not offer or provide the PRN constipation medication as ordered.
Failure to Follow Physician Orders and Complete Required Assessments for Resident with Respiratory Issues
Penalty
Summary
The facility failed to follow physician orders and ensure appropriate follow-up assessments for a resident experiencing respiratory issues. Record reviews showed that the facility's policy required thorough evaluation and documentation when a resident had a change in condition, including the use of a Change in Condition Evaluation (CICE) form and communication with providers. However, for the resident in question, there was no evidence that a CICE was completed despite multiple episodes of wheezing and cough, and repeated administration of Ipratropium-Albuterol Inhalation Solution both as scheduled and as needed. Documentation revealed that the resident received several PRN and scheduled nebulizer treatments for wheezing and cough, with varying effectiveness noted by different staff members, including medication aides and nurses. There were instances where the effectiveness of the medication was not properly assessed or documented, and in some cases, medication aides, rather than licensed nurses, were monitoring the efficacy of the treatments. Communication with the physician was documented regarding the resident's worsening symptoms, but there was no evidence that follow-up assessments or changes in treatment were consistently implemented as directed. Interviews with staff, including an LPN and the Director of Nursing Services, confirmed that assessments were not completed as required and that medication aides should not have been responsible for monitoring the effectiveness of the nebulizer treatments. The DNS acknowledged that more could have been done by the nursing staff in response to the resident's change in condition, and that the facility did not adhere to its own policies or physician orders regarding assessment and follow-up care.
Failure to Timely Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to implement a timely and appropriate plan of care to prevent potential injuries for a resident with significant fall risk factors. Upon admission, the resident had a history of multiple recent falls, advanced dementia, and a lumbar fracture, and was unable to communicate effectively. Although the facility's fall prevention policy required completion of a fall risk assessment and baseline care plan (BCP) upon admission, no Falls Tool UDA assessment was completed, and the BCP was not available in the care plan binder at the time of review. The resident was placed on alarms at the request of a family member, and staff were instructed to move the resident closer to the nurses' station, but these interventions were not documented in a timely care plan. The resident was monitored for various health conditions, but the lack of a completed BCP and fall risk assessment meant that individualized interventions to prevent accidents were not formally established or communicated to staff. Subsequently, the resident was found on the floor after an unwitnessed fall, resulting in an abrasion to the right eyebrow. Interviews with staff confirmed that the BCP was not completed within the expected timeframe, and the Director of Nursing acknowledged that interventions were not implemented in a timely manner to prevent accidents for this resident.
Incomplete Employee Healthcare Documentation
Penalty
Summary
The facility failed to ensure that employee healthcare questionnaires were completed, reviewed, and maintained prior to the hire dates for all five sampled employees. This deficiency was identified through record reviews and interviews with the Facility Administrator (FA). The General Orientation Packet (GOP) provided to new hires included several required documents, such as the Medical History Questionnaire, Employee/Candidate Tuberculosis Screening Questionnaire, Hepatitis B Consent and Immunization Form, and Hepatitis B Vaccination Declination. However, the records for the sampled employees showed incomplete documentation and lack of review by facility staff. For instance, the employment file for the Minimum Data Set (MDS) Nurse contained only a Communicable Disease Screening document, with no evidence of review by facility staff. Similarly, the Facility Driver's file had a Tuberculosis Screening Questionnaire reviewed by the Infection Control Preventionist, but no other healthcare information. Other employees, such as Cook-K and Nurse Aide (NA)-L, had incomplete Medical History Questionnaires and missing or incomplete Hepatitis B forms. The Maintenance Technician's file also lacked completed documentation. Interviews with the FA confirmed these deficiencies in the personnel files, indicating a systemic issue in the facility's process for handling new hire healthcare documentation.
Unsanitary Conditions in Laundry Area
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry area, which included the ante room, storage room, and dirty laundry area. During an initial observation tour, it was noted that the ante room contained dusty floors with dirt debris, brownish gray fuzzy matter, and paper trash. Items such as blankets, cardboard boxes, and a metal mouse trap were improperly stored, contributing to the unsanitary conditions. The storage room had a large framed print covered in grey fuzzy substance, and the floor was littered with debris, paper, and overflowing cardboard boxes. In the dirty laundry area, soiled clothing was sorted into containers, but the area was cluttered with water-damaged cardboard boxes, a soap scum-covered sink, and a linen scale and vent covered in grey fuzzy substance. Interviews with the Facility Administrator (FA) and Infection Control Preventionist (IP) revealed that the laundry area was rarely inspected by the IP, and the lack of cleanliness and infection control had been overlooked. The FA acknowledged that the Housekeeping/Laundry Supervisor (EVS) had been instructed multiple times to clean the area but had not done so until the day of the inspection. The unsanitary conditions in the laundry department had the potential to affect all laundry staff and residents, with a current facility census of 44.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to ensure that residents who required assistance with bathing were provided with the necessary care, affecting four out of five sampled residents. Resident 1, who was cognitively intact and required assistance due to a fractured pelvis, had not received a bath since early December, despite expressing a desire for a whirlpool bath. The resident's family intervened, leading to a bath being provided on January 1, 2025. Resident 20, who was at risk for skin breakdown due to morbid obesity, had only received two baths in December and expressed fear of showering alone due to flooding issues in the bathroom. Nursing staff confirmed a lack of training in using the whirlpool bath. Resident 252, admitted for hospice care, required assistance with activities of daily living, including bathing, but had no recorded baths in the previous 30 days. The resident used shower wipes instead of bathing due to early dressing changes and required assistance with oxygen management during showers. Observations revealed signs of inadequate hygiene, such as yellow crusted exudate on the resident's leg. Resident 203, who required assistance with bathing due to a suprapubic catheter, also had no recorded showers in the 30-day look-back period. Observations showed the resident in a soiled hospital gown with unshaven facial hair and food residue around the mouth. The Facility Administrator acknowledged the issue, citing staffing concerns and the termination of the bath aide as contributing factors to the deficiency. The lack of proper charting and documentation for bathing tasks was confirmed, indicating a systemic issue in providing adequate hygiene care for residents. The deficiency highlights a failure to adhere to the facility's policy and procedure for bathing, which aims to promote cleanliness, comfort, and safety for residents.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to ensure that resident equipment was cleaned and maintained, affecting the residents' right to a dignified existence. Observations revealed that wheelchairs used by several residents were soiled with various types of debris, including tan, gray, and brown crusty substances. These observations were confirmed by the Facility Administrator (FA), who acknowledged that the wheelchairs needed cleaning. Interviews with nurse aides revealed that wheelchairs were rarely cleaned and were not on a regular cleaning schedule, despite the expectation that the night shift was supposed to clean them weekly or biweekly. In addition to the issues with wheelchair cleanliness, the facility also failed to maintain a clean and safe environment in residents' bathrooms. Observations showed that bathroom exhaust vents were soiled with fluffy gray debris, and toilets had missing caulking and were soiled with brown and yellow debris. These conditions were confirmed by the FA, who acknowledged the need for cleaning and maintenance in these areas. Furthermore, the facility did not address issues with bathroom sinks, where water was observed to rise and drain slowly, indicating a problem with the drainage system. This was observed in the bathrooms of multiple residents, and the FA confirmed that the drains were not functioning properly and needed to be fixed. These deficiencies highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents, as required by regulations.
Failure to Involve Resident and Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided the opportunity to participate in quarterly care plan reviews as required. Specifically, Resident 29, who had a Power of Attorney (POA) for healthcare, was not invited to participate in care plan meetings throughout 2024. The facility's policy mandates that residents and their representatives be invited to care plan meetings at least two weeks in advance, and any absence of invitation must be documented in the medical record. However, there was no documentation of Resident 29 or their family being invited to or attending care plan meetings, nor was there any explanation for their absence. Interviews and record reviews revealed that the facility's Social Services Director confirmed the lack of documentation regarding Resident 29's participation in care plan meetings. Despite a care plan conference being scheduled in August 2024, there was no follow-up documentation indicating that the meeting occurred or that the resident or family participated. This oversight persisted throughout the year, with no records of care plan meetings or invitations being extended to Resident 29 or their representative, leading to a deficiency in the facility's compliance with care planning requirements.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address ongoing weight loss for a resident with severe cognitive impairment and multiple health issues, including dementia, type 2 diabetes, GERD, and dysphagia. The resident, who was admitted with a weight of 150 lbs, experienced a significant weight loss of 16% over six months, dropping to 125 lbs. Despite the facility's policy to weigh residents at nutritional risk weekly and notify relevant parties of significant weight changes, the resident's weight loss was not effectively managed or communicated to the physician. The care plan for the resident included interventions such as a texture-modified diet, fortified foods, and nutritional supplements like Boost. However, the facility's dietary offerings were limited, and the interdisciplinary team, including the registered dietician, did not review the resident's case regularly, believing no further actions were necessary. This lack of ongoing assessment and intervention contributed to the resident's continued weight loss. Interviews with facility staff revealed gaps in communication and implementation of the care plan. The dietary manager and registered dietician did not communicate the resident's weight loss to the physician, and the facility staff failed to provide mid-day snacks to the resident. Additionally, the resident's intake of nutritional supplements varied, and staff did not consistently encourage consumption. These inactions and oversights led to the deficiency in maintaining the resident's nutritional status.
Lack of Clinical Rationale and Monitoring for Antidepressant Use
Penalty
Summary
The facility failed to provide a clinical rationale and monitoring for the use of psychotropic medication for a resident, identified as Resident 27. The facility's policy on psychotropic medications, dated 12/30/2024, mandates that each resident's drug regimen must be free from unnecessary drugs, defined as those used without adequate indications or monitoring. A review of Resident 27's records revealed that the resident was taking Amitriptyline, an antidepressant, without a documented indication for its use. The medication was initially prescribed for pain associated with shingles, a condition that typically resolves within a few weeks, yet the resident continued to take the medication without a current diagnosis related to depression or any other documented indication. Further examination of Resident 27's records showed that the resident had a severe cognitive impairment, as indicated by a BIMS score of 00/15, and the PHQ-2 to 9 was not completed due to no response from the resident. The resident's care plan did not reflect the use of the antidepressant or any related interventions, and there was no order in place for monitoring the medication's use. Interviews with facility staff, including the Quality Assurance Coordinator and MDS, confirmed the lack of indication and monitoring for the continued use of Amitriptyline, highlighting a deficiency in adhering to the facility's policy and regulatory requirements for medication management.
Failure to Follow Bowel Protocols for a Resident
Penalty
Summary
The facility failed to adhere to physician orders regarding bowel protocols for Resident 38, who was admitted with diagnoses of constipation and communication deficit. The resident, who had severe cognitive impairment and required substantial assistance for activities of daily living, did not receive the prescribed bowel management interventions. According to the facility's policy, specific steps were to be taken on days 3, 4, and 5 without a bowel movement, including administering Milk of Magnesia, Senna, Dulcolax, and prune juice, and contacting the physician if no bowel movement occurred by day 5. However, a review of the Medication Administration Record for December 2024 showed that these medications were not administered, and there was no communication with the physician for further guidance. The deficiency was identified through record reviews and interviews, revealing that the facility did not initiate the bowel protocols as ordered for Resident 38 during December 2024. The Quality Assurance Coordinator confirmed that the protocols were not followed, resulting in the resident experiencing extended periods without a bowel movement. This oversight highlights a failure in the facility's adherence to established bowel management protocols, as evidenced by the lack of documentation and communication regarding the resident's bowel care needs.
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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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