Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Atkinson during CMS and state inspections, most recent first.
Delayed Call Light Response Due to Insufficient Nursing Staffing: The facility failed to ensure enough nursing staff were available to answer resident call lights within the expected 20-minute timeframe. Review of the call light activity report showed 66 activations with response times over 20 minutes, including multiple delays of 30 to 130 minutes. The DON/Administrator confirmed the delays and stated call lights were expected to be answered within 20 minutes.
Failure to maintain required RN coverage: The facility did not document 8 consecutive hours of RN coverage on multiple days in the staffing schedules, despite its Nursing Services policy requiring an RN for at least 8 consecutive hours each day, 7 days a week. The DON confirmed the staffing gaps, and the facility census was 28.
Failure to Implement QAPI Program: The facility failed to carry out its QAPI plan to prevent repeat deficient practices involving accidents, weight loss, staffing, unnecessary meds, and Emergency Preparedness. Survey review found no evidence the QAPI team was meeting at least quarterly or using current data to monitor identified concerns or prior non-compliance, and the Administrator confirmed the lack of quarterly QAPI meetings.
Failure to use required PPE during EBP care and to maintain infection surveillance. Staff provided catheter and incontinence care to a resident with an indwelling urinary catheter without wearing the required gown during multiple direct care activities, even though the resident was on EBP and the resident stated staff sometimes forgot PPE and had to be reminded. The facility also had no evidence that infections and antibiotic use were tracked for two months, and the IP confirmed ongoing surveillance records were missing.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility did not document informed consent or provide information on benefits, risks, side effects, or alternative treatment options for psychotropic meds for several residents. A resident with quadriplegia and mood disorder was on Celexa, a resident with vascular dementia and hallucinations had PRN Lorazepam, and two residents with dementia, anxiety, depression, or agitation received Seroquel, including one with a dose increase, but the EMR lacked consent documentation. The DON and RN-O confirmed the missing documentation.
A resident with dementia, anxiety, depression, and impaired cognition was started on Seroquel 25 mg nightly after episodes of refusal and aggression. The EMR had no evidence of a baseline AIMS before the antipsychotic was initiated, and the consultant pharmacist twice recommended AIMS monitoring for potential movement-disorder side effects before the assessment was finally completed months later.
The facility failed to notify the State LTC Ombudsman of two resident discharges. Record review showed no evidence that discharge notifications were sent for either resident, and the Administrator confirmed there was no evidence of the required Ombudsman notifications.
The facility failed to complete and update care plans as required. One resident with diabetes, cancer, ESRD, and significant weight loss had a care plan that did not address malnutrition or weight-loss interventions, despite MDS and RD findings showing severe nutritional decline. Another resident with CHF, stroke, impaired hearing, and no speech had a care plan that did not show the legal guardian/sister was invited to care plan meetings, and the Social Services Director confirmed there was no documentation of guardian participation.
A resident with diabetes, cancer, ESRD, and psychiatric diagnoses experienced ongoing weight loss and was found malnourished/risk for malnutrition on nutritional assessments. The RD documented severe weight loss and recommended changing the supplement to a higher-calorie, higher-protein formula, but the PCP did not address the recommendation, and the DON confirmed the resident’s continued weight loss and the lack of response to the RD’s request.
A resident was not treated with dignity during personal and catheter care when staff left the room curtains open, exposed the resident’s torso and lower body, and opened the room door while care was in progress. An NA and an LPN provided incontinence and catheter care in a semiprivate room without privacy curtains or window coverings, and the resident reported nausea, discomfort, and being upset when curtains were left open during care.
A resident who was cognitively intact and required extensive to total staff assistance reported that a NA refused care at first, then handled the resident roughly, was short tempered, slammed items around, and emptied the urinary catheter bag into the resident’s sink after being told not to. The facility investigated the allegation, but the grievance was not reported to the State Agency and the investigation results were not submitted within the required timeframe.
Failure to revise fall interventions after repeated falls. A resident with impaired cognition, dementia, diabetes, anxiety, and depression had multiple falls despite daily use of bed/chair alarms and substantial to maximal assistance needs. The fall investigations documented issues such as barefoot ambulation, self-transfers, alarm problems, toileting-related falls, and the resident being found on the floor in the room or bathroom, yet several events had no new interventions or revised interventions identified.
The facility failed to ensure the daily nursing staff posting included the resident census. Review of the staffing forms showed the census was not documented, and the DON confirmed the posting did not contain the required census information.
The facility did not notify practitioners and resident representatives of significant changes in condition, missed medication administration, and multiple falls involving three residents with complex medical histories. Required notifications were not made following episodes of lethargy, low blood glucose, and falls, despite facility policy and regulatory requirements. The DON confirmed that charge nurses were responsible for these notifications, which were not consistently completed.
A resident was found with bruising to both hands, identified as an injury of unknown origin. The facility did not report the incident or conduct and submit an investigation to the State Agency as required by policy. The Administrator confirmed the lack of reporting and investigation.
The facility did not conduct thorough investigations into two residents' allegations of staff-inflicted harm, including one with advanced dementia and another who reported pain after personal care. In both cases, key investigative steps such as interviewing witnesses or staff were omitted, and one allegation was not reported to APS within the required timeframe.
The facility failed to provide adequate staffing, resulting in unmet resident needs such as delayed call light responses and insufficient bathing assistance. Residents with cognitive impairments and dependencies did not receive care as per their plans, with significant gaps in bathing schedules. Staff interviews and Resident Council Meeting minutes confirmed these ongoing issues.
The facility failed to meet the ADL and bathing needs of several residents, including one who required substantial assistance with toileting and was not assisted as per their care plan. Additionally, multiple residents did not receive weekly baths as required, with significant gaps in bathing schedules confirmed by staff interviews. These deficiencies highlight a systemic issue in meeting residents' basic hygiene needs.
Two residents in the facility experienced multiple falls due to the failure to revise or develop new interventions. Despite having a fall prevention policy, staff did not consistently update care plans after falls, leading to ongoing incidents. The DON and RN confirmed that Charge Nurses were responsible for these updates, but lapses were noted.
A resident experienced significant weight loss due to the facility's failure to revise and implement effective nutritional interventions. Despite being on a weight loss list, the resident was not weighed weekly, and there was inadequate documentation of nutritional supplement intake. The facility did not address suggestions for additional interventions, leading to continued weight loss.
A facility failed to document the rationale for continuing an antidepressant for a resident, despite policy requirements for psychotropic medication management. The resident, diagnosed with depression, was on Sertraline, and a GDR request was made to the provider, who noted a good response but did not document resident-specific information. The Director of Nursing confirmed the absence of documentation, leading to a deficiency.
A facility failed to implement proper hand hygiene and PPE use for a resident with an indwelling catheter. Staff did not perform hand hygiene between glove changes and did not wear PPE when changing bed linens, contrary to facility policy. The lapses were confirmed by staff and acknowledged by the facility's administration.
A resident with cognitive impairment and a diagnosis of diabetes and dementia was not offered a pneumococcal vaccine in accordance with facility policy and CDC guidelines. The facility's policy requires annual review of immunization records and ongoing assessment of vaccine eligibility, but the resident had not received the vaccine since 1997. RN-G confirmed the oversight, indicating non-compliance with the vaccination policy.
The facility failed to provide adequate staffing, resulting in unmet bathing needs, delayed call light responses, and poor housekeeping. Residents did not receive baths as per their care plans, and call light response times often exceeded 15 minutes. Housekeeping was insufficient, with rooms found dusty and unclean, and no staff scheduled on weekends.
The facility failed to maintain cleanliness and safety in 12 resident rooms, with issues such as urine residue, strong odors, and improper storage of incontinence briefs. Observations revealed cluttered spaces and uncleanable surfaces, while interviews highlighted a lack of systematic cleaning schedules and insufficient staffing. The RN Consultant confirmed that resident care items should not be stored on the floor, and soiled items should be promptly removed.
The facility failed to provide adequate bathing assistance to four residents dependent on staff for this activity. Due to staffing issues, residents received fewer baths than required, leading to irregular bathing schedules and skin health issues. Interviews and records confirmed the inconsistency in bathing, highlighting the facility's failure to adhere to its policy.
A resident, dependent on assistance for daily activities and receiving hospice care, was observed multiple times with the call light out of reach while sitting in a recliner. The facility's policy requires that call lights be accessible, but the resident's call light was attached to the bedrail on the other side of the room. An RN confirmed that call lights should be accessible to residents.
A facility failed to notify a resident's responsible party about significant care changes, including medication adjustments and medical appointments. Despite attempts to contact the responsible party, there was no documentation of successful notification. Interviews confirmed the lack of communication, and staff acknowledged the absence of a notification policy.
A resident with a terminal diagnosis and an indwelling urinary catheter was found with the catheter drainage bag lying directly on the floor, contrary to the facility's policy. Staff confirmed the improper practice, which could lead to potential infections.
A facility failed to track antibiotic use for a resident with urinary tract infections, despite having a policy for infection prevention and control. The resident, who had multiple health conditions and required assistance with daily activities, received antibiotics that were not documented in the facility's tracking log. This oversight was confirmed by an RN, indicating a deficiency in the facility's infection surveillance efforts.
Delayed Call Light Response Due to Insufficient Nursing Staffing
Penalty
Summary
The facility failed to ensure sufficient nursing staffing to answer resident call lights in a timely manner. The cited requirement stated the facility must provide enough nursing staff every day to meet resident needs and have a licensed nurse in charge on each shift. The facility census was 28 residents, and the issue was identified through record review and interview. Facility policies reviewed stated that call lights were to be answered promptly, staff were to go to the resident’s room as soon as possible when a call light was observed, and the call light was to be turned off after the resident’s request was addressed. The Nursing Services policy also stated the facility must have sufficient nursing staff with the appropriate competencies and skills to provide nursing and related services based on resident assessments, care plans, acuity, diagnoses, and the facility assessment. The Device Activity Report for 2/6/26 through 2/9/26 showed 66 call light activations with response times greater than 20 minutes. Multiple responses were delayed by 20 to 130 minutes, including several over 30, 40, 50, and 70 minutes. During interview, the Administrator stated call lights were expected to be answered within 20 minutes and confirmed the report showed multiple response times exceeding that expectation.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure 8 hours of consecutive RN coverage in a 24-hour period, 7 days per week, as required. Review of the facility policy on Nursing Services stated that the facility would use the services of an RN for at least eight consecutive hours a day, seven days a week. Review of the Nursing Staff Schedule for August 2025 showed no documentation of 8 hours of RN coverage on 8/9, 8/10, 8/30, and 8/31, and review of the schedule for January 2026 showed no documentation of 8 hours of RN coverage on 1/3 and 1/4. During interview on 2/10/26 at 10:05 AM, the DON confirmed the facility did not have 8 hours of consecutive RN coverage on those dates. The facility census was 28.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to implement its QAPI plan to maintain a system that would prevent repeat deficient practices involving accidents, weight loss, sufficient staffing, unnecessary medications, and Emergency Preparedness. Review of the facility’s QAPI policy dated 5/20/25 showed the program was intended to be ongoing, comprehensive, data driven, and used to measure, analyze, and track quality indicators, adverse events, and other aspects of performance, with governing body oversight and action on identified problem areas. During survey review on 2/10/26, there was no evidence that the facility was meeting at least quarterly or evaluating current data to ensure identified performance improvement concerns and previously cited areas of non-compliance were being monitored or addressed. In interview on 2/10/2026 at 10:32 AM, the Administrator confirmed there was no evidence the QAPI team had been meeting at least quarterly and that the QAPI program had failed to maintain a plan to prevent repeat deficient practices involving accidents, weight loss, sufficient staffing to ensure prompt response to call lights, unnecessary medications, and Emergency Preparedness.
Failure to Use Required PPE During EBP Care and to Maintain Infection Surveillance
Penalty
Summary
The facility failed to prevent cross contamination during personal and catheter care for a resident who was on Enhanced Barrier Precautions (EBP) due to an indwelling urinary catheter. During an observation of care, staff entered the room, performed hand hygiene, and donned gloves, but did not use gowns or goggles while emptying the urinary drainage bag, cleansing the drainage tube, and providing incontinence and catheter care after the resident had a loose stool. Staff also repositioned the resident, cleansed the groin, perineal area, and foley catheter insertion site, and provided buttocks hygiene while continuing care without the required gown. The resident was lying in bed with the head of the bed elevated and had nausea and discomfort during the care episode. The observation further showed that staff repeatedly removed and replaced gloves and performed hand hygiene, but continued direct care activities without the disposable gown required for EBP. Staff assisted with turning the resident side to side, placed a sling for a full lift, brought in an emesis basin, retrieved a soaker pad, and positioned the resident for comfort, all while not using the gown identified in the facility's EBP procedure. The resident confirmed that staff were supposed to wear gowns and gloves when providing care because the resident was on EBP, and stated that staff sometimes forgot to use the PPE and the resident had to remind them. The facility also failed to ensure ongoing infection surveillance. Review of the infection surveillance records showed no evidence that infections and antibiotic use had been tracked for January and February 2026. The Infection Preventionist confirmed that the facility did not have evidence of ongoing infection surveillance for those months, despite the facility policy stating that surveillance was to be an ongoing process used to identify, track, and control infectious diseases and healthcare-associated infections.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent and provide information about benefits, risks, potential side effects, and alternative treatment options for psychotropic medications for Residents 3, 6, 24, and 30. The facility policy required a signed consent form for psychotropic medication use and documentation that the resident and/or representative were informed of the risks and benefits, including when a resident was admitted on psychotropic medications, returned from the hospital on new psychotropic medications, or had a change in psychotropic medication. Review of the records showed no evidence that these requirements were met for the identified residents. Resident 3 was receiving Celexa 10 mg daily for a mood disorder and had quadriplegia secondary to spinal cord syndrome following a fall on the ice, but the EMR contained no evidence of informed consent or discussion of alternatives. Resident 24 had anxiety disorder, impaired cognition including delirium and hallucinations, and vascular dementia, and was ordered Lorazepam 0.5 mg every 4 hours as needed, but the EMR showed no evidence that the resident or representative was informed about the medication. Resident 30 had non-Alzheimer dementia, anxiety, depression, severe cognitive impairment, and received Seroquel for dementia with behaviors; the record showed no consent for the increase in Seroquel on 1/16/26 or documentation of alternative treatments. Resident 6 had anxiety, major depressive disorder, and agitation and was receiving Seroquel 25 mg at bedtime, but the EMR contained no evidence of informed consent or information about alternative treatment options. The DON and RN-O confirmed the lack of required documentation during interviews.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure Resident 6’s medication regimen was free from unnecessary medications because staff did not monitor for potential side effects of a psychotropic medication. The resident was admitted with diagnoses including non-traumatic brain dysfunction, diabetes, Alzheimer’s disease, non-Alzheimer’s dementia, anxiety, and depression. The MDS indicated impaired cognition, no behaviors or mood indicators, substantial to maximal assistance needed for dressing, personal hygiene, bed mobility, and transfers, and use of antipsychotic, antidepressant, antianxiety, and opioid medications. Nursing progress notes documented episodes of refusal and aggression, including yelling during a blood pressure attempt, swatting at staff when awakened for bed, spitting out medications, and slapping staff during bedtime care. The PCP ordered Seroquel 25 mg daily before bedtime, and the DON confirmed the medication was started. The EMR contained no evidence that an AIMS assessment was completed before the Seroquel was initiated. The consultant pharmacist identified on two occasions that antipsychotic medications could cause tardive dyskinesia and other movement disorders and recommended an AIMS test now and every 6 months, but the assessment was not completed until months after the medication was started.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of facility discharges for two residents. Review of the facility policy on discharge and transfer stated that with a transfer or discharge, the facility sent a copy of an approved discharge form to the office of the State Long-Term Care Ombudsman. Record review showed that one resident was admitted to the facility and later discharged on 1/31/26, and there was no evidence that the Ombudsman was notified of the discharge. A second resident was admitted to the facility and later discharged on 12/7/25, and there was no evidence that the Ombudsman was notified of that discharge either. During interview, the Administrator confirmed the facility had no evidence of Ombudsman notifications for either discharge.
Care Plan Deficiencies for Nutrition and Family Participation
Penalty
Summary
The facility failed to develop a complete care plan within 7 days of the comprehensive assessment and failed to have the plan prepared, reviewed, and revised by a team of health professionals. The care plan policy stated that a comprehensive, individualized, person-centered plan of care was to address identified medical, nursing, mental, and psychosocial needs, and that the resident, family, and/or legal representative were to have the opportunity to participate in care planning to the extent practicable. For Resident 28, the MDS dated 10/22/25 showed diagnoses including diabetes, cancer, end stage renal disease, parastomal hernia with obstruction, anxiety, bipolar disorder, and depression. The resident’s cognition was intact, the resident required setup assistance and supervision with eating and drinking, and the resident had lost 5% of body weight in the last month or 10% or more in the last 6 months. A Mini-Nutritional Assessment showed a score of 6.0 indicating malnutrition, with decline in food and fluid intake and weight loss greater than 7 lbs. in the last 3 months. The comprehensive care plan dated 11/3/25 addressed impaired cognition, cancer, and eating with verbal cues, but did not address the resident’s nutritional status or risk for weight loss. A later RD note documented the resident’s weight had decreased from 149 lbs. to 131 lbs., a severe 12% weight loss in 180 days, and recommended a change in nutritional supplement. However, the care plan still did not include the resident’s altered nutrition or weight loss interventions. For Resident 12, the MDS dated 1/14/26 showed CHF, stroke, intact cognition, highly impaired hearing, no speech, hospice care, and antidepressant use. The care plan reflected these conditions and communication needs, but the facility had no documentation that the resident’s legal guardian/sister was invited to care plan meetings or that family participation occurred, and the Social Services Director confirmed there was no documentation to show who attended the meetings.
Failure to Address Ongoing Weight Loss
Penalty
Summary
The facility failed to implement nutritional interventions to address a resident’s ongoing weight loss. Resident 28 had diagnoses including diabetes, cancer, end stage renal disease, a parastomal hernia with obstruction, anxiety, bipolar disorder, and depression. The resident’s MDS showed intact cognition, setup assistance and supervision with eating and drinking, and a weight of 142 lbs. with documented weight loss of 5% in one month or 10% or more in six months. Weight records showed a decline from 149 lbs. to 144 lbs. to 142 lbs., and a Mini-Nutritional Assessment indicated the resident was malnourished and had declined food and fluid intake, weight loss greater than 7 lbs. in 3 months, and severe dementia or depression. Subsequent records showed the resident’s weight continued to fall to 133 lbs., then 131 lbs., and a later Mini-Nutritional Assessment showed the resident remained at risk for malnutrition. The RD documented severe weight loss of 12% in 180 days and noted the resident was receiving a nutritional supplement of choice due to weight concerns. The RD recommended discontinuing the current supplement and starting Med Pass 2.0, 120 cc twice daily to provide more calories and protein, and the PCP was notified by fax of the recommendation. The PCP failed to address the RD’s request to change the nutritional supplement, and the DON confirmed the resident had ongoing weight loss and that the PCP had failed to address the RD’s recommendations.
Resident Exposed During Personal and Catheter Care
Penalty
Summary
The facility failed to ensure Resident 7 was treated with respect and dignity during personal and catheter care. During an observation of care, the resident was lying in bed with the head of the bed elevated in a semiprivate room next to a large picture window with the curtains open and no shades or blinds in place. There was also no privacy curtain available. Nurse Aide and LPN staff entered the room, performed hand hygiene, and provided incontinence and catheter care while the resident’s torso and lower extremities remained exposed and visible from outside the room. During the care, staff removed the resident’s linens and brief, repositioned the resident from side to side, cleansed the groin and perineal area including the indwelling catheter insertion site, and placed a sling for a full lift. One staff member left the room to retrieve the lift while the resident remained uncovered, and the room door was opened again while the resident was still exposed. The resident stated the care caused nausea and discomfort and said the resident no longer wanted to get up. The resident remained uncovered while staff left and re-entered the room for supplies, and the resident later stated it upset the resident when staff left the curtains open during cares and that this happened occasionally.
Failure to Report Alleged Abuse and Submit Investigation Results
Penalty
Summary
The facility failed to timely report an allegation of potential staff-to-resident abuse and failed to submit the results of its investigation to the State Agency within the required timeframe for a resident. The facility’s Abuse and Neglect policy stated that alleged or suspected abuse, neglect, exploitation, or misappropriation of property was to be promptly reported and investigated, and that investigation results were to be reported to the State survey and certification agency within 5 working days of the event. Resident 7’s MDS showed the resident was cognitively intact, required extensive to total staff assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, was always incontinent of bowel, had an indwelling urinary catheter, and had pain rated 8 out of 10 that limited day-to-day activities. A grievance dated 8/15/25 stated a Nurse Aide initially refused to assist with bowel care, then provided care roughly, was short tempered, slammed things around, did not clean the resident well, and emptied the urinary catheter drainage bag into the resident’s handwashing sink after being told not to. The resident said the aide asked, "what are you going to do about it," and the resident did not want the aide in the room anymore. Review of investigations from 1/15/25 through 2/5/26 showed no evidence the allegation was reported to the State Agency, and although the facility investigated and directed the aide not to provide care to the resident, the investigation results were not submitted to the State Agency within the required timeframe. During interview, the Social Service Director confirmed the grievance was not reported and the investigation results were never submitted.
Failure to Revise Fall Interventions After Repeated Falls
Penalty
Summary
The facility failed to revise existing fall interventions and/or develop new interventions to prevent ongoing falls for one resident. The resident had diagnoses of non-traumatic brain dysfunction, diabetes, Alzheimer's disease, non-Alzheimer's dementia, anxiety, and depression, with impaired cognition and a need for substantial to maximal assistance with personal hygiene, toileting hygiene, dressing, bed mobility, and transfers. The resident also used bed/chair alarms daily. Review of the fall investigation records showed repeated falls and repeated identification of fall-related issues, including being barefoot, self-transferring and losing balance, alarms sounding or not being properly placed or plugged in, and the resident being found on the floor in the room, outside the bathroom, or in the bathroom. Across multiple fall events, the documentation showed that some interventions were noted, such as gripper socks, assistance to the bathroom before and after meals, and re-education about alarms, but the record also showed several falls where no new interventions were developed and current interventions were not revised. One fall huddle noted the resident had removed the chair alarm and used the wheelchair to transfer into the bathroom, and another noted the resident had been toileted 30 minutes earlier but was incontinent of bowel and bladder, with no additional fall interventions identified. The DON and RN consultant verified the fall investigations and the lack of new or revised interventions for several of the events.
Daily Nursing Staff Posting Missing Resident Census
Penalty
Summary
The facility failed to ensure the daily staff posting included the resident census as required. Review of the facility policy Nursing Staff Daily Posting showed the posting was to include the location name, current date, resident census, and staffing information by category, and to be displayed in a clear and readable format. However, review of the facility's Daily Nursing Staffing forms for January 1 through 31, 2026 and February 1 through 9, 2026 showed no documentation that the census was included on the forms. During interview on 2/9/26 at 5:10 PM, the DON confirmed the daily staff posting did not contain the census.
Failure to Notify Practitioners and Representatives of Resident Changes and Incidents
Penalty
Summary
The facility failed to notify practitioners and resident representatives of significant changes in condition and incidents involving multiple residents, as required by policy and regulation. For one resident with multiple complex diagnoses including diabetes, end stage renal disease, and dementia, staff did not inform the practitioner of increased lethargy, decreased appetite, low blood glucose levels, and the withholding of insulin doses due to poor intake. Documentation showed that over a 24-hour period, the resident was lethargic, refused or was unable to eat, and required increased assistance, yet there was no evidence of practitioner notification regarding these changes or the missed insulin administration. For two other residents with histories of falls and significant medical conditions, the facility did not consistently notify either the practitioner or the resident's representative following falls or changes in condition. In one case, a resident experienced multiple falls, some with injury, and episodes of slurred speech and unresponsiveness, but there was no documentation that the family or practitioner were notified as required. In another case, a resident was found on the floor after a fall and, on a separate occasion, experienced a fall due to an unlocked wheelchair; in both instances, either the physician or the family was not notified as per policy. Interviews with the DON confirmed that charge nurses were responsible for these notifications and acknowledged that required notifications were not made in several instances. The facility's own policies stipulated immediate notification of practitioners and representatives following significant changes or incidents, but these procedures were not followed for the residents involved.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin and did not submit an investigation to the State Agency within the required 5 working days for one resident. According to the facility's Abuse and Neglect Policy, all alleged or suspected violations, including injuries of unknown origin, were to be reported immediately to the Administrator or a delegated individual and thoroughly investigated, with results submitted to the State Agency. The policy also outlined steps to protect residents and ensure a complete review of such incidents. A review of the facility's Incident and Accident Log showed that a resident was found with bruising to both hands, identified as an injury of unknown origin. Nursing progress notes documented specific measurements of the bruises on the resident's fingers and knuckles. However, there was no evidence that this incident was reported or that an investigation was conducted and submitted to the State Agency as required. The facility Administrator confirmed that the injury was neither reported nor investigated.
Failure to Thoroughly Investigate and Timely Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse involving two residents and did not report one allegation within the required timeframe. For one resident with advanced dementia and a history of knee/leg pain, the resident reported leg pain and indicated a staff member had caused the injury. Although Adult Protective Services (APS) were notified, the facility's investigation concluded there were no concerns of staff involvement without conducting a thorough investigation to rule out abuse. Documentation did not show that all necessary investigative steps were taken. In another case, a resident reported pain and alleged that a staff member had penetrated them during assistance with a bath. The facility notified the Administrator and, two days later, APS. The investigation did not substantiate the allegation, citing the resident's behavioral history and a diagnosis of urinary tract infection, but failed to include interviews with the roommate, other residents, or staff to ensure a comprehensive review. The facility Administrator confirmed that thorough investigations were not completed for either incident and that timely reporting requirements were not met for the second allegation.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, resulting in unmet daily living activities and delayed call light response times. Observations and interviews revealed that call lights were not answered within the expected timeframe of 10-12 minutes, with several instances exceeding 15 minutes, and some taking over an hour. This deficiency was acknowledged by both the Director of Nursing and the Administrator, who confirmed the lack of a formal policy for call light response times. Multiple residents, including those with severe cognitive impairments and dependencies for activities of daily living, did not receive adequate bathing assistance as per their care plans. Resident 11, for example, was documented to have received baths less frequently than the weekly schedule outlined in their care plan. Similarly, Resident 16 and Resident 3 experienced significant gaps between bathing sessions, with intervals extending up to 28 days. These lapses were confirmed by nursing staff during interviews. Additionally, Resident 20, who required substantial assistance with toileting and was frequently incontinent, was observed not being assisted to the bathroom for extended periods, contrary to their care plan requirements. Resident 24 also reported ongoing issues with bathing frequency, which was corroborated by their bathing records and staff interviews. The Resident Council Meeting minutes further highlighted recurring concerns about call light response times and staff availability, indicating a systemic issue with staffing levels and care provision.
Failure to Meet ADL and Bathing Needs
Penalty
Summary
The facility failed to meet the Activities of Daily Living (ADL) needs for several residents, including Resident 20, who required substantial to maximal assistance with toileting and transfers. Despite the care plan indicating that Resident 20 should be checked for incontinence before and after each meal, observations revealed that the resident was not assisted to the bathroom from breakfast until after lunch, as confirmed by staff interviews. This lack of assistance did not align with the resident's care plan, which specified frequent checks and assistance due to the resident's incontinence and cognitive impairments. Additionally, the facility did not consistently meet the bathing needs of Residents 3, 11, 16, and 24. Resident 24 reported that weekly baths were not always provided, and records confirmed gaps in bathing schedules. For instance, Resident 24 did not receive a bath between December 21, 2024, and January 4, 2025. Similarly, Resident 16 did not receive a bath from December 18, 2024, to January 15, 2025, despite requiring substantial assistance due to cognitive impairments and self-care deficits. Resident 3, who was dependent on staff for all ADLs, including bathing, experienced significant gaps between baths, with intervals of up to 20 days. Resident 11, who had severe cognitive impairment and required assistance with bathing, also experienced irregular bathing intervals, with a notable 12-day gap in January 2025. These findings were corroborated by staff interviews, confirming that the residents did not receive baths as frequently as care planned, highlighting a systemic issue in meeting the residents' basic hygiene needs.
Failure to Revise Fall Interventions for Residents
Penalty
Summary
The facility failed to develop new interventions or revise current interventions to prevent ongoing falls for two residents, identified as Resident 182 and Resident 26. Resident 182, who was admitted with diagnoses including colon cancer and high blood pressure, experienced multiple falls without injury. Despite the implementation of some interventions, such as a non-slip pad and a push button alarm, there were instances where no new interventions were developed after falls, specifically on 6/9/24, 6/28/24, and 8/23/24. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that staff were responsible for assessing residents after falls and revising interventions, but this was not consistently done. Resident 26, who had a history of stroke, dementia, and schizophrenia, also experienced multiple falls. The resident's care plan included interventions like a fall mat and pressure pad alarm, but these were not consistently effective or maintained. For instance, the fall mat was removed due to being a fall risk, and the pressure pad alarm failed to sound during some incidents. Despite these issues, no new interventions were put into place after several falls, including those on 9/28/24, 10/7/24, and 10/31/24. The DON and RN-B verified that the Charge Nurses were responsible for updating care plans with new interventions, but this was not consistently done. The report highlights a deficiency in the facility's fall prevention and management program, as staff failed to consistently assess causal factors and update interventions following falls. This lack of action contributed to ongoing fall incidents for both residents, indicating a need for improved adherence to the facility's fall prevention policy. The deficiency was confirmed through interviews with the DON and RN-B, who acknowledged the lapses in revising or developing new interventions after falls occurred.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to revise nutritional interventions and develop new strategies to address ongoing weight loss for a resident. The resident, who was independent with eating and drinking, experienced significant weight loss over several months. Despite being on a weight loss list and reviewed in risk meetings, the facility did not adequately document or adjust the nutritional interventions to address the resident's declining weight. The resident's weight decreased from 158 lbs to 135 lbs over a few months, indicating a severe weight loss of 11.4% in 90 days. The facility's policy required residents at nutritional risk to be weighed weekly and for significant weight changes to be reported to the physician and family. However, the resident was not weighed weekly, and there was a lack of documentation regarding the amount of nutritional supplement consumed by the resident. Interviews with facility staff revealed that the resident's dietary intake was reviewed by the Dietician and Dietary Manager, but the only intervention in place was the administration of a house supplement three times per day. Despite suggestions for additional interventions, such as the use of Remeron to stimulate appetite, these were not addressed. The facility's failure to implement and document effective nutritional interventions contributed to the resident's continued weight loss.
Lack of Documented Rationale for Antidepressant Use
Penalty
Summary
The facility failed to ensure a documented rationale for the use of an anti-depressant for a resident, leading to a deficiency. The facility's policy on psychotropic medications, revised on 12/30/24, mandates that each resident's drug regimen must be free from unnecessary drugs, and any psychotropic medication should be justified with adequate indications for use. The policy also requires that the need for such medications be reviewed every three months, with a documented rationale for continuing the medication. However, in the case of Resident 4, who was cognitively intact and diagnosed with heart failure, diabetes, anxiety, and depression, there was no documented rationale for the continued use of Sertraline, an anti-depressant, despite a GDR request to the resident's provider. The resident's Minimum Data Set (MDS) and Care Plan indicated the use of Sertraline for depression, with an order start date of 3/23/23. A GDR request was sent to the resident's provider on 4/2/24, and the provider noted a good response to the medication, recommending maintaining the current dose. However, the provider failed to add resident-specific information to the physician progress notes, and there was no documented rationale for the GDR contraindication. This lack of documentation was confirmed by the Director of Nursing during an interview, highlighting the facility's failure to comply with its own policy and federal regulations regarding psychotropic medication management.
Failure to Implement Proper Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to implement proper hand hygiene and use of Personal Protective Equipment (PPE) for Resident 15, who was dependent on assistance for toileting, dressing, and transfers, and had an indwelling catheter. The facility's policy on Standard and Transmission-Based Precautions required Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, such as catheters, to prevent the spread of infections. However, during an observation, it was noted that staff did not adhere to these precautions. During the observation, Nursing Assistant (NA)-E and Registered Nurse (RN)-F were involved in the care of Resident 15. NA-E initially performed hand hygiene and donned a gown and gloves but failed to perform hand hygiene between glove changes while providing care, including when the resident's urinary catheter became unhooked. RN-F also failed to perform hand hygiene between glove changes while applying a new catheter bag and tubing. Additionally, NA-E did not wear PPE when changing the resident's bed linens and performed hand hygiene only after completing the task. Interviews with the staff confirmed the lapses in hand hygiene and PPE use. The facility's policy required hand hygiene to be performed between glove changes and PPE to be worn during high-contact care activities, including changing bed linens. The failure to adhere to these infection control practices was acknowledged by the facility's Administrator, Director of Nursing, and RN-G during interviews.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to offer a pneumococcal vaccine to a resident, identified as Resident 16, in accordance with its own policy and CDC guidelines. Upon review, it was found that the facility's policy, revised on 9/21/23, mandates that residents be provided with the opportunity to receive immunizations, including pneumococcal vaccines, as part of their healthcare goals. The policy also requires that immunization records be reviewed annually and that residents' vaccine eligibility be assessed continuously as recommendations change. However, Resident 16, who was cognitively impaired and had a diagnosis of diabetes and dementia, was not offered the pneumococcal vaccine since admission, despite the policy stating that all residents should receive the vaccine per CDC guidelines. The review of Resident 16's records revealed that the last documented pneumococcal vaccine was administered on 8/11/97, which was over [AGE] years ago, and there was no evidence of a more recent vaccination. During an interview, RN-G confirmed that the resident had not been offered the vaccine since admission. This oversight indicates a failure to adhere to the facility's vaccination policy and CDC guidelines, resulting in the resident not being current with the recommended pneumococcal vaccination schedule.
Staffing and Housekeeping Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, particularly in terms of bathing, timely response to call lights, and housekeeping. Observations and interviews revealed that several residents did not receive baths according to their care plans, with one resident only receiving one bath in 55 days. The facility's staffing records showed that a bath aide was often not present, which was confirmed by the staff as a common occurrence. The facility also struggled with timely responses to call lights, with numerous instances of response times exceeding 15 minutes, some extending to over 50 minutes. Despite being aware of these delays through their Quality Assurance Performance Improvement program, no corrective actions were reported to have been taken. Interviews with staff indicated that a response time of 10 to 15 minutes was considered acceptable, yet this standard was frequently not met. Housekeeping deficiencies were also noted, with resident rooms found to have heavy dust and unclean conditions. The facility's environmental services schedule showed limited staffing, with no housekeepers on weekends. Interviews with housekeeping staff revealed a lack of a systematic cleaning schedule, with tasks such as floor scrubbing and dusting being performed irregularly and based on visual assessment rather than a set routine.
Facility Fails to Maintain Cleanliness and Safety in Resident Rooms
Penalty
Summary
The facility failed to maintain cleanliness and safety in resident rooms and bathrooms, affecting 12 out of 33 rooms. Observations revealed issues such as black scuff marks and gouges on floors, urine residue and strong odors in bathrooms, and cluttered spaces with soiled items. Disposable urinary incontinence briefs were improperly stored directly on bathroom floors, and assistive devices were found with uncleanable surfaces due to attached materials. Additionally, heavy dust and debris were noted on furniture in several rooms. Interviews with staff highlighted a lack of systematic cleaning schedules and insufficient staffing, particularly on weekends. Housekeeping staff were sometimes tasked with changing bed linens and doing laundry, leaving little time for thorough cleaning. There was no established schedule for scrubbing floors or dusting furniture, contributing to the observed deficiencies. The Registered Nurse Consultant confirmed that resident care items should not be stored on the floor, and soiled items should be promptly removed to maintain a clean and odor-free environment.
Inadequate Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing assistance to four residents who were dependent on staff for this activity. The facility's policy, revised on 9/3/24, emphasized the importance of bathing for cleanliness, hygiene, and skin health. However, due to staffing issues, the facility was unable to maintain a consistent schedule for bathing, resulting in residents receiving fewer baths than required. For instance, Resident 4, with severe cognitive impairment and functional limitations, received only one bath in 55 days, leading to skin irritation and a yeast-like odor. Resident 5, who had a traumatic spinal cord dysfunction and other health issues, requested two baths per week but only received four baths in August and three in September, instead of the expected eight and six, respectively. This inconsistency was confirmed by the resident during an interview. Similarly, Resident 2, with moderate cognitive impairment and a recent pelvic fracture, was bathed only four times in 56 days, despite needing weekly baths. The resident reported receiving only one bath in three weeks, which was corroborated by the facility's records. Resident 1, who was cognitively intact but required assistance with various activities, including bathing, also experienced irregular bathing schedules. The resident received only three baths in August and had significant gaps between baths in September. Interviews with the resident and their responsible party confirmed the irregularity, and the RN acknowledged the deficiency in the bathing schedule. These findings highlight the facility's failure to adhere to its own policy and provide necessary care to its residents.
Resident's Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a requirement to reasonably accommodate the needs and preferences of each resident. The facility's policy, revised on 7/29/24, mandates that residents always have a method for calling for assistance and that call lights are answered promptly. Resident 3, who was admitted to the facility and is dependent on assistance for dressing, hygiene, bathing, and transfers, was observed multiple times on 9/25/24 sitting in a recliner with the call light attached to the bedrail on the other side of the room, out of reach. This resident, who is receiving hospice services for a terminal diagnosis and has an indwelling urinary catheter, was unable to access the call light to request assistance. A registered nurse confirmed that call lights should be accessible to residents when they are in their rooms.
Failure to Notify Responsible Party of Resident Care Changes
Penalty
Summary
The facility failed to ensure that the responsible party of a resident was notified of significant changes in the resident's care, including medication adjustments, medical appointments, and procedures. The resident, who was cognitively intact and had multiple diagnoses including diabetes, heart failure, anxiety, depression, and respiratory failure, required assistance with daily activities. Despite attempts to contact the responsible party regarding a change in gabapentin dosage, there was no documentation confirming successful notification. Additionally, new medication orders, a dentist appointment requiring teeth extractions, and a CTA scan were not communicated to the responsible party. Interviews with the resident's responsible party and facility staff confirmed the lack of notification. The responsible party reported not being informed of changes, including dental procedures. Facility staff acknowledged the absence of documentation for notifications and revealed that there was no existing policy for notifying responsible parties. This deficiency highlights a failure in communication and documentation processes within the facility, impacting the resident's care management.
Improper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper care and maintenance of a urinary catheter for a resident, leading to a potential infection risk. The facility's policy on catheter care, dated 7/30/24, mandates that catheter tubing and drainage bags should be kept covered, secured, and maintained using a sterile closed drainage system. The tubing should be secured to the resident's leg, coiled on the bed without kinks or obstructions, and should not touch the floor. However, during an observation on 9/25/24, it was noted that the resident's urinary catheter drainage bag was lying directly on the floor beside the bed, and the catheter strap was around the resident's left ankle. The resident involved was admitted to the facility with a terminal diagnosis and was receiving hospice services. The resident was dependent on staff for dressing, hygiene, bathing, and transfers, and had an indwelling urinary catheter in place. During interviews, both a nurse aide and a registered nurse confirmed that the catheter bag was left on the floor uncovered, which is not an acceptable practice according to the facility's policy. This oversight in catheter care could lead to potential infections or complications for the resident.
Failure to Track Antibiotic Use in Infection Control Program
Penalty
Summary
The facility failed to implement an ongoing system for tracking antibiotic use to identify trends in infections, as evidenced by the case of a resident who received three antibiotics in July 2024 for urinary tract infections. The facility's policy on Infection Prevention and Control Program, last revised on October 30, 2023, outlined the need for a surveillance system to track infections and antibiotic use. However, a review of the Monthly Infection Summary for July 2024 revealed that the resident's antibiotics were not documented on the facility's tracking log, indicating a lapse in the facility's infection surveillance and antibiotic stewardship efforts. The resident involved was cognitively intact and had diagnoses including diabetes, heart failure, anxiety, depression, and respiratory failure. The resident required assistance with daily activities and was frequently incontinent of urine. Despite receiving antibiotics such as Ceftriaxone and Cefdinir for urinary tract infections, these medications were not included in the facility's tracking system. An interview with a registered nurse confirmed the omission, highlighting a deficiency in the facility's infection prevention and control program.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 3 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Atkinson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkside Manor | 10.1 mi | ★★★★★ | 2 | 0 |
| Accura Healthcare Of O'neill | 16.6 mi | ★★★★★ | 1 | 0 |
| Butte Senior Living | 27.6 mi | — | 0 | 0 |
| Rock County Hospital Long Term Care | 28.9 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.