Good Samaritan Society - Atkinson
Inspection history, citations, penalties and survey trends for this long-term care facility in Atkinson, Nebraska.
- Location
- 409 Neely Street, Atkinson, Nebraska 68713
- CMS Provider Number
- 285177
- Inspections on file
- 25
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Good Samaritan Society - Atkinson during CMS and state inspections, most recent first.
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.
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.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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