Good Samaritan Society - Superior
Inspection history, citations, penalties and survey trends for this long-term care facility in Superior, Nebraska.
- Location
- 1710 Idaho Street, Superior, Nebraska 68978
- CMS Provider Number
- 285187
- Inspections on file
- 19
- Latest survey
- July 10, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Good Samaritan Society - Superior during CMS and state inspections, most recent first.
Surveyors observed a thick, yellow-white flakey buildup on the ice machine in the common dining area, affecting areas where ice and water are dispensed. The Dietary Manager confirmed the buildup made the machine uncleanable and unsanitary, and acknowledged there was no process in place to ensure regular cleaning by the dietary department. This unsanitary condition had the potential to affect all residents in the facility.
Two staff members began working and completed multiple shifts before their required pre-employment health assessments were completed and reviewed, contrary to facility policy and licensure requirements. The Facility Administrator confirmed that the assessments were not done prior to the staff starting their job duties.
Multiple resident bathroom exhaust fans were found to be non-functional in several halls, with maintenance staff confirming the issue had persisted for years and some fans producing excessive noise or failing to operate. The problem affected the majority of residents, and staff noted foul odors in rooms after toileting, while administration was previously unaware of the extent of the ventilation failure.
The facility did not provide or retain required Advance Beneficiary Notices (ABN) for two residents whose Medicare Part A coverage ended, as confirmed by the Facility Administrator and record review.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restricted their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
The facility did not document a resident or representative's decision regarding bed hold during a hospital transfer, and also failed to notify the Ombudsman of another resident's discharge, as confirmed by record review and staff interviews.
The facility inaccurately coded the MDS for three residents by documenting respiratory therapy minutes for treatments administered by nurses without proper respiratory credentials and by recording an insulin injection that was not ordered or given. These errors were confirmed through record review and staff interviews.
A resident with multiple serious diagnoses was admitted to hospice, but the facility did not update the comprehensive care plan to include specific hospice-related objectives, goals, or interventions as required. The care plan only noted a terminal prognosis and listed a hospice nurse's contact, without further detail. The DON confirmed the care plan was not revised to address hospice needs.
A resident with dementia and constipation did not have their provider notified of repeated pharmacist recommendations to review and modify their bowel regimen, despite ongoing use of as-needed cathartic medications. Additionally, after an incident resulting in arm injury, the facility failed to document or monitor the injury for several days, with assessment and provider notification only occurring later.
Two residents were involved in a physical altercation after a verbal exchange, with one resident using a walker to make contact with another. Staff intervened, but the facility did not conduct or document an investigation, nor did it submit the required report to the state agency. The DON confirmed the absence of an investigation and reporting, despite facility policy and state requirements.
The facility failed to provide written transfer notices to two residents or their representatives when they were transferred to the hospital. Despite verbal notifications, the required written documentation was not provided, as confirmed by the Social Services Designee.
The facility failed to provide a notice of bed hold policy to two residents upon their transfer to the hospital. Despite the facility's policy requiring notification and documentation, there was no record of this being done for a resident with a history of stroke and another with TIA and dementia. Interviews confirmed the lack of communication and documentation regarding the bed hold policy.
A facility failed to maintain accurate medical records for a resident who passed away. The resident, with multiple health issues and a DNR status, was found deceased by a Medication Aide. Despite the Registered Nurse's assessment confirming the absence of vital signs, the details of the death and preceding events were not documented in the progress notes, highlighting a deficiency in record-keeping.
An LPN at the facility failed to follow proper hand hygiene protocols during medication administration for two residents. The LPN did not wash hands for the required 20 seconds and neglected to sanitize hands between glove changes, contrary to the facility's policy. Interviews confirmed these lapses, resulting in a deficiency in infection prevention and control.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary condition, as observed during a survey. A thick, yellow-white flakey buildup was present on the front of the ice machine where ice is dispensed, as well as in the black water dispensing area, the fluid drain area, and the black grate covering the drain. The Dietary Manager confirmed that the buildup rendered the machine's surfaces uncleanable and unsanitary. It was also confirmed that the dietary department was responsible for cleaning these areas, but there was no process in place to ensure this cleaning was completed. The unsanitary condition of the ice machine had the potential to affect all residents in the facility, which had a census of 32 at the time of the observation.
Failure to Complete Pre-Employment Health Assessments Prior to Staff Start Date
Penalty
Summary
The facility failed to ensure that pre-employment health assessments were completed prior to the first day of employment for two of five sampled staff members, as required by facility policy and licensure regulations. Record reviews showed that both Food Service Assistants began working and were scheduled for shifts before their Communicable Disease Screening forms were completed and reviewed by a nurse. Specifically, one staff member started work and completed several shifts before the health assessment was signed and reviewed, while the other also worked multiple shifts prior to the completion of their health assessment. Interviews with the Facility Administrator confirmed that new staff typically undergo two days of online orientation followed by on-the-job training, and acknowledged that the required pre-employment health assessments for these two staff members were not completed before they began their job duties. The failure to complete these assessments prior to employment was in direct violation of the facility's own hiring and screening policy, which mandates that employment is contingent upon successful completion of a pre-employment health assessment to prevent the potential for transmissible diseases.
Non-Functioning Bathroom Ventilation Fans in Resident Rooms
Penalty
Summary
The facility failed to ensure that ventilation in all resident rooms was in working order, specifically in the bathrooms of rooms located in the 100 and 200 halls, as well as some rooms in the 400 hall. Multiple observations were made where the bathroom exhaust ventilation fans did not function, as evidenced by their inability to pull up a 1-ply square of toilet paper. Staff confirmed that these fans had not worked for at least three years, and maintenance staff acknowledged that the fans in the affected halls either did not operate or produced excessive noise due to burned-out bearings. During one observation, a foul odor was noted in a resident's room after toileting assistance, further indicating the lack of effective ventilation. Interviews with the Maintenance Director confirmed longstanding knowledge of the non-functioning fans in the 100 and 200 halls, and additional confirmation was provided that some fans in the 400 hall were also inoperable. The Interim Administrator was unaware of the issue prior to the survey and acknowledged that non-working bathroom fans could cause resident embarrassment due to odors. The deficiency affected 27 out of 37 sampled residents, with a total facility census of 37.
Failure to Issue and Retain Advance Beneficiary Notices for Medicare Coverage
Penalty
Summary
The facility failed to provide the required Advance Beneficiary Notices (ABN) to two of three sampled residents whose Medicare Part A coverage ended during their stay. For one resident, who was re-admitted after an acute hospitalization with diagnoses of generalized muscle weakness and fatigue, there was no evidence that the ABN was issued or retained when Medicare Part A coverage began and ended. Similarly, for another resident admitted with Medicare Part A as the payor source, the facility did not retain a copy of the ABN to show it was provided to the resident or their representative. The Facility Administrator confirmed in interviews that there was no documentation to support that the required notices were given, as mandated by facility policy and Medicare regulations.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Document Bed Hold Choice and Ombudsman Notification
Penalty
Summary
The facility failed to obtain and document the resident or resident representative's choice regarding bed hold during a hospital transfer for one resident. Specifically, although the facility's policy requires that written information about the bed hold policy be provided and that the resident or representative be contacted to document their decision, the record for a resident with COPD and heart failure showed that while the bed hold policy was sent with the resident to the hospital, there was no documentation of any contact with the resident or representative to obtain their decision. The relevant form was incomplete, lacking both the resident or representative's choice and signatures, and there was no evidence of attempts to reach the representative. Additionally, the facility did not document notification to the Ombudsman regarding the discharge of another resident with COPD and hypertension. The facility administrator confirmed that there was no documentation reflecting that the Ombudsman was notified of the resident's discharge, as required. These findings were based on record review and staff interviews.
Inaccurate MDS Coding for Respiratory Therapy and Injections
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, resulting in deficiencies related to the assessment and documentation of care. For two residents, the MDS was coded to indicate that respiratory therapy was provided by a respiratory therapist or respiratory nurse, when in fact, the therapy consisted of nurses administering ultra-sonic nebulizer treatments. The nurses had only completed a brief online course and did not hold formal certification as respiratory nurses, nor did the facility employ a respiratory therapist. The minutes spent by these nurses administering the treatments were incorrectly counted as respiratory therapy on the MDS, contrary to the requirements outlined in the Resident Assessment Instrument User's Manual. Additionally, for another resident, the MDS was coded to reflect that an insulin injection was administered during the look back period. However, a review of the resident's medical record revealed there were no physician orders for insulin during that time. Instead, the resident had an order for Ozempic, a non-insulin injectable medication. Both the MDS Coordinator and the DON confirmed that this was a coding error and that the resident did not receive insulin. These inaccuracies in MDS coding were identified through record review and staff interviews.
Failure to Update Comprehensive Care Plan with Hospice Objectives and Interventions
Penalty
Summary
The facility failed to update and implement objectives, goals, and interventions related to hospice care on the comprehensive care plan for a resident who was admitted to hospice. The facility's policy requires a coordinated care plan to be jointly developed with hospice, including directives for managing pain and other symptoms, and mandates that the care plan be revised as necessary to reflect the resident's current condition. Despite these requirements, the comprehensive care plan for the resident only noted a terminal prognosis and listed a hospice nurse's phone number, without including specific hospice-related objectives, goals, or interventions. The resident involved had multiple significant medical diagnoses, including chronic pulmonary embolism, pressure-induced deep tissue damage, malignant neoplasm of the lung, chronic kidney disease stage 3, dementia, and pain. The deficiency was confirmed through record review and an interview with the DON, who acknowledged that the care plan was not updated with measurable goals and interventions after the resident was placed on hospice care.
Failure to Notify Provider of Pharmacist Recommendations and Inadequate Injury Monitoring
Penalty
Summary
The facility failed to notify the provider of pharmacist recommendations regarding a resident's bowel regimen and did not monitor or document an injury sustained by the resident. Specifically, the consulting pharmacist repeatedly documented concerns about the resident's use of as-needed cathartic medications and recommended that the bowel regimen be reviewed and possibly modified. Despite these recommendations, there was no documentation that the provider was notified or that any changes were made to the resident's medication orders. The Director of Nursing confirmed that there was no evidence of provider notification or review of the pharmacist's recommendations, as required by facility policy. Additionally, the facility did not adequately monitor or document a resident's injury following an incident in which the resident's arm was bent behind their back, resulting in swelling and bruising. There was no documentation of the incident or monitoring of the resident's arm or psychosocial state for several days after the event. Documentation of the injury and assessment only began several days later, when swelling and bruising were noted and the resident was seen by a provider. The Director of Nursing confirmed that there was no investigation or continued monitoring documented between the time of the incident and the later assessment.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an incident of resident-to-resident abuse as required by policy and state regulations. On the date of the incident, staff observed one resident using a walker to make physical contact with another resident after a verbal exchange in the hallway. Staff intervened to prevent further confrontation. Both residents involved had incident reports completed, but these reports did not include any investigation of the event. Additionally, there were no progress notes or documentation in either resident's medical record regarding the incident or any investigation. The facility's policy requires that all alleged or suspected abuse be promptly reported, thoroughly investigated, and submitted to the state agency within five working days. However, the Director of Nursing confirmed that no investigation was conducted or submitted to the state agency for this incident. The care plan for the resident who initiated the contact indicated a history of aggressive behavior and the need for supervision in public areas, but there was no evidence that these interventions were followed up in response to the incident.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of transfer to residents or their representatives upon transfer to the hospital for two residents. Resident 8, who had a history of transient ischemic attack and cerebral infarction with hemiparesis and hemiplegia, was sent to the emergency room with shortness of breath and admitted to the hospital. There was no documentation of a written notice of transfer being provided to Resident 8 or their representative. Similarly, Resident 21, with a history of TIA, cerebral infarction, high blood pressure, and dementia, was sent to the emergency room for diarrhea, weakness, and low blood pressure, and admitted to the hospital. Again, there was no documentation of a written notice of transfer being provided to Resident 21 or their representative. Interviews with the Social Services Designee (SSD) revealed that while residents and/or their representatives were verbally notified of transfers, they were not provided with a copy of the Transfer or Discharge Notice form. The facility's policy requires that residents and their representatives be notified in writing of transfers or discharges, including the reason for the move, and be given information on how to obtain and submit an appeal form. The SSD confirmed that these discussions were not being documented, leading to the deficiency in providing the required written notices.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a notice of bed hold policy to two residents, Resident 8 and Resident 21, upon their transfer to the hospital. This deficiency was identified through a review of the facility's policies and resident records, as well as interviews with the Social Services Designee (SSD). The facility's policy requires that the Social Worker or designated individual provide the Notice of Bed-Hold Policy to the resident and/or their representative at the time of transfer, and document this action. However, there was no documentation that this policy was followed for either resident. Resident 8, who had a history of transient ischemic attack and cerebral infarction with hemiparesis and hemiplegia, was transferred to the hospital with shortness of breath and returned to the facility without any record of the bed hold policy being communicated. Similarly, Resident 21, with a history of TIA, cerebral infarction, high blood pressure, and dementia, was transferred to the hospital for diarrhea, weakness, and low blood pressure, and also returned without documentation of the bed hold policy being provided. Interviews with the SSD confirmed the lack of documentation and communication regarding the bed hold policy for both residents.
Incomplete Documentation of Resident's Death
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for one resident, identified as Resident 38, out of three residents surveyed. The deficiency was identified during a review of Resident 38's medical records, which revealed a lack of documentation regarding significant events surrounding the resident's death. The resident had multiple diagnoses, including expressive language disorder, developmental disorder of scholastic skills, dysphagia, a history of falling, essential hypertension, mild intellectual disabilities, pain, fever, complete loss of teeth, xerosis cutis, and an unspecified cataract. The Medication Administration Record indicated that the resident was a DNR (Do Not Resuscitate). However, the Progress Notes lacked detailed information about the circumstances leading to the resident's death, such as who found the resident, the resident's condition, and position at the time of discovery. Interviews with facility staff, including the Director of Nursing, Medication Aide D, and Registered Nurse B, confirmed the absence of comprehensive documentation. Medication Aide D found the resident unresponsive and cold to the touch, and subsequently contacted RN-B, who assessed the resident and confirmed the absence of vital signs. Despite these actions, RN-B did not document the assessment and vital signs in the resident's progress notes. The lack of detailed documentation regarding the resident's death and the events leading up to it constitutes a failure to maintain medical records in accordance with accepted professional standards.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration, affecting two residents. The facility's hand hygiene policy, reviewed on 03/29/2022, requires health care workers to use alcohol-based hand sanitizer or soap and water after removing gloves and to wash hands for at least 15-20 seconds. However, observations revealed that an LPN did not adhere to these guidelines. During an injection for one resident, the LPN washed their hands for only ten seconds after removing gloves. In another instance, while administering a nebulizer treatment to a different resident, the LPN washed their hands for eight seconds before putting on gloves and for seven seconds after removing them. Additionally, the LPN failed to sanitize their hands between glove changes. Interviews with the LPN and the Director of Nursing confirmed the handwashing should be done for 20 seconds and that hand sanitizing should occur between glove changes. The LPN acknowledged the inadequacy of their handwashing duration and the omission of hand sanitizing between glove changes. These actions were inconsistent with the facility's hand hygiene policy, leading to a deficiency in infection prevention and control during medication administration.
Latest citations in Nebraska
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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