Good Samaritan Society - Bloomfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomfield, Nebraska.
- Location
- 300 North Second St, Bloomfield, Nebraska 68718
- CMS Provider Number
- 285156
- Inspections on file
- 18
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Good Samaritan Society - Bloomfield during CMS and state inspections, most recent first.
Staff did not consistently perform hand hygiene between glove changes during catheter and incontinence care for a resident with multiple medical conditions, and the urinary catheter drainage bag was repeatedly handled and positioned inappropriately. Additionally, the facility did not follow its own COVID-19 protocols, as symptomatic staff were not tested for COVID-19 despite policy requirements.
A resident with complex medical needs requiring total assistance for toileting and transfers experienced significant delays in receiving care, waiting over an hour for help after activating the call light. Facility records showed repeated instances of call lights going unanswered for extended periods, and staffing schedules revealed that CNA coverage often fell below the facility's own requirements, leading to ongoing delays in resident care.
A resident with significant medical needs, who required total staff assistance, reported that a nurse aide removed their call light from reach after a request for help. The incident, along with similar occurrences, was reported to the facility Administrator but was not reported to the State Agency, and no investigation was completed or submitted as required by policy. The DON confirmed the failure to follow reporting and investigation procedures.
A resident with multiple medical conditions and intact cognition required total staff assistance and had clearly communicated preferences for morning and evening routines during a care plan conference attended by their spouse. Despite this, the care plan was not updated to include the resident's preferred times for getting up and going to bed, as confirmed by the DON.
A resident who was fully dependent on staff for toileting and transfers waited over an hour for assistance after repeatedly requesting help, resulting in involuntary fecal incontinence. Staff were aware of the resident's needs but delayed care due to limited staffing and other duties, and the resident's care plan for timely incontinence management was not followed.
The facility did not maintain sufficient NA and housekeeping staff to meet resident needs, resulting in delayed call light responses, missed ADL care such as bathing, and inconsistent room cleaning. Several residents with cognitive and physical impairments experienced prolonged waits for assistance and infrequent bathing, while the only housekeeping staff was often reassigned to NA duties, leaving cleaning tasks incomplete.
A resident with mobility and self-care deficits did not receive timely assistance with ADLs, including inconsistent bathing and delayed call light responses, due to inadequate nurse aide staffing. Both the resident and their family reported ongoing concerns about insufficient staff, and the DON confirmed that posted staffing levels were not being met.
A resident with severe cognitive impairment and multiple physical limitations experienced repeated falls without documented implementation or revision of fall prevention interventions. Despite facility policy requiring proactive measures and care plan updates after each fall, no new interventions were documented, and the care plan was not revised following multiple incidents, as confirmed by the DON.
The facility did not provide required clinical documentation when declining to reduce psychotropic medication doses for two residents, despite recommendations from the consultant pharmacist. One resident with dementia and behavioral symptoms continued on Seroquel and Paroxetine without documented rationale for not attempting a dose reduction, and another resident with sleep disturbances remained on Trazadone without clinical justification for not reducing the dose. Nursing staff confirmed the lack of timely response and documentation.
A resident did not receive prescribed Yupelri due to unavailability, and repeatedly refused Novolog insulin and Oxycodone without practitioner notification or alternative treatments being offered, contrary to facility policy. Interviews confirmed the resident and spouse were not provided alternatives, and the DON acknowledged the lapses in medication administration and documentation.
A resident assessed as high risk for falls experienced multiple falls related to toileting, despite care plan interventions such as an anti-roll back device and a scheduled toileting plan. Staff interviews revealed that the routine toileting intervention was not communicated or followed, and the DON confirmed that staff were not completing this fall prevention approach.
A resident with heart failure, heart disease, and mild cognitive impairment was not offered a COVID-19 vaccine booster or provided with education about the vaccine upon admission, despite facility policy requiring such actions. Documentation showed no consent or declination for the vaccine, and the resident was not current on COVID-19 vaccination.
A resident with multiple health conditions developed pressure ulcers that were not consistently assessed or documented according to facility policy. There were significant delays and omissions in wound measurements, incomplete documentation of wound characteristics, and a lack of evidence that recommended nutritional interventions were implemented. The resident's ulcers worsened, showing signs of infection and requiring hospitalization, while staff failed to ensure regular assessments and timely interventions.
The facility failed to implement effective fall prevention interventions for three residents, leading to repeated falls. Despite having orders for alarms, these were often not in place or functioning, and staff did not consistently secure them to the residents. Interviews confirmed that necessary interventions were not implemented to prevent future falls.
The facility failed to document and account for discontinued medications awaiting destruction for four residents, as required by their policy. Medications were found in a locked drawer without proper labeling or documentation, risking potential loss or theft. Interviews confirmed the lack of necessary records for medications like Erythromycin, Moxifloxacin, Naphcon A, Ativan, and Lorazepam.
A facility failed to address repeat grievances and ensure sustainable resolutions for a resident's care and activities. The resident's family reported issues such as incomplete oral care, an unplugged fall alarm, and inadequate toileting. Despite initial resolutions, these concerns persisted, and the resident did not consistently receive 1:1 activities as per their care plan. Interviews confirmed ongoing issues with care provision, highlighting a continued deficiency.
A facility failed to notify a resident's family about significant changes in the resident's condition, including weight loss and nutritional interventions. The resident, with severe cognitive impairment, experienced a substantial weight loss, and although the PCP was informed, the family was not. Additional communication failures included not informing the family about diet changes, initiation of Arginaid, and changes in the use of Magic Cup. Interviews confirmed these lapses, indicating a breach of the facility's notification policy.
Infection Control Failures in Hand Hygiene, Catheter Care, and COVID-19 Protocols
Penalty
Summary
Staff failed to perform hand hygiene at appropriate intervals during the provision of care, specifically when removing soiled gloves and before donning clean gloves. Observations showed that nurse aides did not complete hand hygiene before putting on personal protective equipment or after removing gloves during catheter care and incontinence care for a resident. The urinary catheter drainage bag was repeatedly placed on bed linens and positioned above the level of the resident's bladder and head during transfers, contrary to facility policy and best practices for infection prevention. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes. The resident required total staff assistance for hygiene and had an indwelling urinary catheter. During care, the catheter drainage bag was handled inappropriately, including being placed on the bed and attached to the lift above the resident's bladder, and staff did not consistently perform hand hygiene between glove changes while managing incontinence and catheter care. Additionally, the facility failed to follow its COVID-19 protocols. The DON was observed with respiratory symptoms but had not completed a COVID-19 test and stated there was no intention to do so. It was confirmed by a registered nurse that the facility did not test staff or residents presenting with respiratory symptoms or increased temperature, despite facility policy requiring symptomatic employees to be restricted from work until COVID-19 infection was ruled out by testing.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of all residents, specifically resulting in delayed toileting and incontinence care for a resident with significant medical needs. The resident, who had diagnoses including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, required total staff assistance for toileting, hygiene, dressing, bed mobility, and transfers, and was frequently incontinent of bowel with an indwelling urinary catheter. On the observed morning, the resident activated the call light at 7:15 AM for assistance to use the commode, but did not receive help until 8:39 AM, resulting in an involuntary bowel movement due to the prolonged wait. Interviews confirmed that only two direct care staff were working that shift for a census of 30, and the resident was often left waiting for extended periods due to insufficient staffing. Review of the facility's Device Activity Report and call light activity logs revealed numerous instances where call light response times exceeded the facility's policy of a 15-minute response, with some calls going unanswered for up to 138 minutes. These delays were not isolated to a single day but occurred repeatedly over a two-week period, affecting multiple residents. The facility's own policy required prompt response to call lights, and staff interviews confirmed that the expectation was to answer within 15 minutes, which was not consistently met. Further review of staffing schedules showed that the facility frequently scheduled fewer CNAs than required, particularly on weekends and overnight shifts. The Director of Nursing confirmed that the number of CNAs scheduled often did not meet the facility's own standards for adequate staffing. This chronic understaffing directly contributed to the inability to provide timely care and respond to residents' needs as required by both facility policy and regulatory standards.
Failure to Report and Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident abuse to the State Agency, did not complete an investigation, and did not submit the investigation within the required 5 working days. According to the facility's Abuse and Neglect Policy, all alleged or suspected violations, including abuse, neglect, or injuries of unknown origin, were to be reported immediately to the Administrator and to the State Survey and Certification Agency within 5 working days. However, a review of facility records and interviews revealed that an incident involving a resident's call light being removed from their reach by a nurse aide was reported to the Administrator but was not reported to the State Agency, and no investigation was completed or submitted as required. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, and required total staff assistance for most activities of daily living. The resident and their spouse reported that it was common for staff to remove the call light from the resident's reach, and specifically recounted an incident where a nurse aide removed the call light after the resident requested assistance. The Director of Nursing confirmed that the facility did not report the allegation or complete and submit the required investigation to the State Agency.
Care Plan Not Updated to Reflect Resident's Routine Preferences
Penalty
Summary
The facility failed to update a resident's comprehensive care plan to reflect the individual's stated preferences for morning and evening routines. The resident, who had diagnoses including heart failure, previous stroke with right side paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, was assessed as having intact cognition but required total staff assistance for activities of daily living such as toileting, dressing, hygiene, bed mobility, and transfers. The resident was also frequently incontinent of bowel and had an indwelling urinary catheter. During a care plan conference attended by the resident and spouse, the preference for being up and out of bed at 7:00 AM and going to bed at 8:30 PM was clearly communicated. However, a review of the care plan, last revised after this conference, showed no documentation of these preferences. The care plan only included interventions related to positioning and transfer assistance, without addressing the resident's specific requests for daily routine times. The DON confirmed in an interview that the care plan had not been updated to include these preferences.
Failure to Provide Timely Toileting Assistance for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who required total staff assistance for activities of daily living, including toileting, was not provided timely assistance. The resident, who had a history of heart failure, stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, was cognitively intact and dependent on staff for bed mobility, transfers, and toileting. The care plan specified that the resident should be checked and changed every two hours when in bed and required two staff members and a full lift for transfers. On the morning in question, the resident activated the call light at 7:15 AM after completing a nebulizer treatment, indicating a need to use the commode for a bowel movement. Although a medication aide entered the room, the resident was not assisted with toileting at that time. The call light was activated multiple times, and staff were aware of the resident's request. Despite repeated requests and activation of the call light, the resident waited a total of 1 hour and 24 minutes before two nurse aides arrived to assist with transfer to the commode. During this time, the resident became incontinent of feces. Staff interviews confirmed that only two direct care staff were working that morning, and the resident was left waiting while staff assisted other residents. The resident's care plan interventions for timely toileting and incontinence management were not followed, resulting in the resident remaining soiled until staff were available to provide assistance.
Failure to Provide Adequate Nursing and Housekeeping Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, as evidenced by multiple documented instances of insufficient nurse aide (NA) coverage and delayed response times to call lights. Review of staffing records showed that, over a period of several weeks, the facility did not meet its own predetermined NA staffing levels for its census, with some days having as few as two NAs on the floor during the day shift. This staffing shortage was confirmed by both staff interviews and the Director of Nursing, who acknowledged that the facility had not met required NA staffing levels as the census increased from 27 to 35 residents. Residents with significant care needs, including those with cognitive impairments, limited mobility, and self-care deficits, experienced delays in receiving assistance with activities of daily living (ADLs) such as bathing, toileting, and hygiene. Documentation revealed that one resident, who required assistance with ambulation and bathing, did not receive baths at the frequency specified in their care plan, with gaps of up to 14 days between baths. Multiple residents had call light response times that exceeded the facility's standard of 10 minutes, with some instances of call lights going unanswered for up to 53 minutes. These delays were noted repeatedly for several residents, particularly during periods of low staffing. In addition to nursing staff shortages, the facility also failed to maintain daily cleaning of resident rooms as required. The only housekeeping staff member was frequently reassigned to work as a NA, resulting in missed cleaning duties. Interviews with environmental services and maintenance staff confirmed that there was no clear schedule or record of which rooms were cleaned during certain periods, and that maintenance and laundry staff were sometimes tasked with cleaning in the absence of dedicated housekeeping personnel. These combined staffing and housekeeping deficiencies had the potential to affect all residents in the facility.
Failure to Provide Timely ADL Assistance Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADLs) to a resident who required help due to self-care deficits, limited mobility, and a history of dizziness and arthritis. The resident's care plan specified the need for assistance with ambulation, bathing, toileting hygiene, transferring, and clothing adjustment, with a preference for bathing twice weekly during the summer. However, records showed inconsistent bathing schedules, with gaps of up to two weeks between baths, and multiple instances where call light response times exceeded the facility's stated standard of 10 minutes, including one instance where the response time was over 50 minutes. Interviews with the resident and their family member revealed ongoing concerns about insufficient staffing, particularly during day and evening shifts and on weekends, leading to delays in care and unmet personal hygiene needs. The resident reported feeling unsafe when forced to attempt self-care due to long wait times and expressed dissatisfaction with the frequency of bathing and call light responses. The Director of Nursing confirmed that the facility was not meeting its own nurse aide staffing levels as posted, which contributed to the deficiencies in providing timely and adequate ADL assistance.
Failure to Implement and Update Fall Prevention Interventions
Penalty
Summary
The facility failed to review, revise, and implement care plan interventions to prevent falls for a resident with severe cognitive impairment, limited range of motion on one side, and dependence on staff for ambulation, transfers, and toileting. The resident had multiple diagnoses, including non-Alzheimer's dementia, anxiety, and depression, and experienced several falls over a one-month period. Despite the facility's policy requiring proactive fall prevention, post-fall assessment, and care plan updates, there was no documentation that interventions were put in place after each fall. Record reviews showed that after each fall, there was no evidence of new or revised interventions to prevent future incidents, and the resident's care plan was not updated accordingly. The DON confirmed that interventions to prevent future falls were not implemented following each event, and the care plan should have been updated as per facility policy. This deficiency was identified through record review and staff interview.
Failure to Document Clinical Rationale for Not Reducing Psychotropic Medications
Penalty
Summary
The facility failed to document a clinical rationale for not completing Gradual Dose Reductions (GDR) for psychotropic medications for two residents. Facility policy required that residents on psychotropic medications receive GDRs unless clinically contraindicated, and that any contraindication be documented. For one resident with dementia, anxiety, depression, and behavioral symptoms related to psychosis, the consultant pharmacist requested a dosage reduction for Seroquel and Paroxetine. The provider responded to the request after 45 days but did not document any clinical reason for not reducing the doses. For another resident with sleep disturbances and insomnia, the consultant pharmacist recommended a dosage reduction for Trazadone. The provider declined the reduction but again failed to document a clinical rationale. Interviews with nursing staff confirmed that the facility did not address pharmacist recommendations for GDRs in a timely manner and did not provide required documentation when declining to reduce psychotropic medication doses. The facility's policies outlined the need for regular review and documentation regarding psychotropic medication use, but these procedures were not followed for the two residents identified in the report.
Failure to Follow Practitioner Orders and Notify of Medication Unavailability or Refusals
Penalty
Summary
The facility failed to follow practitioner orders and its own medication administration policy for a resident with multiple chronic conditions. The resident did not receive Yupelri Inhalation Solution for 18 days due to unavailability, and there was no documentation that the practitioner was notified or that an alternative treatment was provided. Additionally, the resident refused multiple doses of Novolog insulin and Oxycodone over several days, but there was no evidence that the practitioner was informed of these repeated refusals or that alternative treatments were considered, as required by facility policy. Interviews with the resident and spouse confirmed that the resident was not offered alternative options when medications were unavailable or refused. The resident had a history of only using sliding scale insulin at home and refused Oxycodone in the morning due to side effects impacting participation in therapy and social visits. The DON confirmed that the resident did not receive the prescribed medications as ordered and that the necessary notifications and documentation were not completed.
Failure to Implement and Monitor Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and monitor fall prevention interventions as outlined in the care plan for a resident identified as high risk for falls. Despite documented falls and a care plan that included specific interventions such as the use of an anti-roll back device on the wheelchair and a routine toileting schedule, staff interviews revealed that these interventions were not consistently communicated or followed. Nurse aides were unaware of the routine toileting plan, and the resident continued to toilet independently without the scheduled assistance intended to reduce fall risk. The care plan had been updated to address the resident's needs after each fall, but the interventions were not effectively put into practice or monitored by staff. The resident had a history of weakness, difficulty walking, and was assessed as high risk for falls on multiple occasions. Event documentation showed the resident experienced falls while attempting to use the bathroom independently, including one incident where an unlocked wheelchair brake contributed to the fall. Although the care plan was revised to address these risks, including scheduled toileting and equipment adjustments, staff interviews and the DON's confirmation indicated a lack of awareness and implementation of these interventions, resulting in continued risk for the resident.
Failure to Offer and Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine or provided with education on the benefits and risks of the vaccine, as required by facility policy. The policy specified that residents should be given the opportunity to receive immunizations, have their immunization status reviewed upon admission and on an ongoing basis, and receive documented education about the vaccines for which they are eligible. Documentation should include written consent or declination, and administration or referral for vaccination. In this case, the resident was admitted with a history of heart failure, heart disease, and mild cognitive impairment, and was being treated for an upper respiratory infection. Review of the resident's records showed that the most recent COVID-19 booster was received several months prior to admission, and there was no documentation of consent or declination for a new COVID-19 vaccine. The Infection Preventionist confirmed that the resident was not offered a COVID-19 vaccine booster at admission or since, resulting in the resident not being current on COVID-19 vaccination.
Failure to Monitor and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to properly evaluate, monitor, and document pressure ulcers for a resident who was at risk for skin breakdown. Upon admission, the resident was assessed as being at risk for pressure ulcer development but had no existing ulcers. The resident was dependent on staff for most activities of daily living and had multiple diagnoses, including hip fracture, diabetes, and end stage renal disease. Despite the facility's policy requiring systematic assessment and documentation, the resident developed a stage 2 pressure ulcer on the right heel, which was not consistently measured or assessed as required. There were significant gaps in documentation, with weeks passing between wound measurements and incomplete assessments of wound characteristics. The resident subsequently developed a pressure ulcer on the left heel, but treatment for this new ulcer was delayed. The documentation continued to lack regular measurements and comprehensive assessments, making it difficult to determine whether the wounds were healing or deteriorating. The right heel ulcer progressed to a stage 3 ulcer with signs of infection, including increased drainage, foul odor, and a larger wound area. Despite the worsening condition, there were still missing measurements and incomplete documentation of the wound's status. Additionally, a dietary recommendation for a nutritional supplement to aid in wound healing was made, but there was no evidence in the medical record that this intervention was implemented. The resident's condition continued to decline, requiring multiple changes in wound care orders and eventually leading to hospitalization for further evaluation. Throughout the course of care, the facility staff failed to ensure weekly assessments, proper documentation, and timely interventions as outlined in their own policies, resulting in the development and worsening of pressure ulcers.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to identify causal factors and revise or develop fall interventions to prevent ongoing falls for three residents, leading to repeated incidents. Resident 6, who was severely cognitively impaired and required assistance with daily activities, experienced multiple falls without long-term interventions being implemented. Despite having an order for a pull tab alarm, observations revealed that the alarm was often not in place or functioning, and staff failed to secure it to the resident. Interviews with staff confirmed that the necessary interventions were not consistently implemented to prevent future falls. Resident 25, who had severe cognitive impairment and required assistance with daily activities, also experienced multiple falls without long-term interventions being implemented. The resident had a personal alarm to alert staff of ambulation attempts, but incident reports indicated that no additional interventions were identified to prevent ongoing falls. Interviews with the Director of Nursing confirmed that interventions were not implemented to prevent future falls for this resident. Resident 79, who had a history of a hip fracture and required substantial assistance with daily activities, experienced several falls without causal factors being identified or interventions being revised. Despite having a pull tab alarm and a silent fall alarm, incident reports revealed that these alarms were not always in place or functioning. Interviews confirmed that no investigations were conducted to determine why the alarms malfunctioned, and no new interventions were developed to prevent further falls.
Failure to Document Discontinued Medications
Penalty
Summary
The facility failed to ensure proper accounting and documentation for medications that were discontinued and awaiting destruction for four residents. The facility's policy on medication disposition, revised on 8/1/23, required that discontinued medications be immediately removed from the resident's supply, stored securely, and documented with specific details before being returned to the pharmacy or destroyed. However, during an observation of the medication storage room, it was found that a locked cabinet drawer contained five medications without any labeling or documentation, indicating a lack of compliance with the policy. Interviews with LPN-H and RN Consultant-P confirmed that the medications were awaiting destruction but lacked the necessary documentation. The medications involved included Erythromycin ophthalmic ointment and Moxifloxacin solution for Resident 6, Naphcon A ophthalmic drops for Resident 8, Ativan for Resident 17, and Lorazepam for Resident 83. The absence of documentation for these medications put them at risk of potential loss or theft, as there was no record of the residents' names, medication details, or quantities, which was required by the facility's policy.
Failure to Address Repeat Grievances and Ensure Resident Care
Penalty
Summary
The facility failed to address repeat grievances and ensure sustainable resolutions for concerns related to the care and activities provided to Resident 21. The grievances documented by the resident's family included issues such as incomplete oral care, lack of use of towels and washcloths, an unplugged fall alarm, and inadequate toileting before breakfast. Despite initial resolutions, these concerns persisted, indicating a lack of effective follow-up and resolution. Further grievances were raised by the family regarding insufficient assistance with meals, which was particularly concerning given the resident's weight loss. The family also reported finding a room tray from the previous evening left uncovered, suggesting neglect in meal assistance. Additionally, the resident's care plan included 1:1 activities, which were not consistently provided, as documented in the facility's records. Interviews with the resident's family and facility staff confirmed ongoing issues with the provision of care, including assistance with food and fluids, toileting, oral care, and repositioning. Despite previous staff education and counseling, there was no evidence of additional 1:1 activities being provided, highlighting a continued deficiency in addressing the family's concerns and ensuring the resident's care needs were met.
Failure to Notify Family of Resident's Condition Changes
Penalty
Summary
The facility failed to notify the family or responsible party of Resident 21 about significant changes in the resident's condition, specifically regarding weight loss and the initiation of nutritional interventions. The resident, who had diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, and depression, experienced a substantial weight loss of 14 pounds over two months. Despite notifying the resident's primary care physician about the weight loss and starting a nutritional supplement called Magic Cup, there was no evidence that the family or responsible party was informed of these changes. Further review of Resident 21's medical records revealed additional failures in communication. The family or responsible party was not notified about a change in the resident's diet to soft, bite-sized food, the initiation of Arginaid for wound healing, the discontinuation of Magic Cup due to supplier issues, or its subsequent reintroduction. Interviews with the resident's family and the Director of Nursing confirmed these lapses in communication, highlighting the facility's failure to adhere to its policy of notifying family members of significant changes in a resident's condition.
Latest citations in Nebraska
Surveyors found that the facility 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 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 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 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 multiple open wounds, a PICC line, and an active MRSA infection was not managed under the facility’s Enhanced Barrier Precautions (EBP) policy, which requires gown and glove use and door signage for residents with wounds, indwelling devices, or MDROs during high-contact care. Observations showed no EBP signage or gowns available at the room, and an LPN performed wound care using only gloves without a gown, later confirming that EBP should have been used but was not.
Surveyors found that medications were not stored securely as required by facility policy and regulations. A container of Gavilyte-G solution labeled for a resident was left on a bathroom sink, and a clear plastic bag containing multiple medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, was found on a dresser in another resident’s room. The second resident was cognitively intact per BIMS, required extensive assistance with ADLs, was at risk for pressure ulcers, and had two venous ulcers. An LPN and the Wound and Infection Nurse confirmed these medications should not have been stored in these unsecured locations and should have been kept locked.
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.
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.
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 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.
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 Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy during care of a resident with multiple wounds, an indwelling device, and an active MDRO infection. The facility’s EBP policy dated 01-2024 states that residents with wounds or indwelling medical devices, regardless of MDRO status, and residents known to be infected or colonized with an MDRO, are to be placed on EBP with signage on the door and targeted gown and glove use during high-contact activities, including wound care. EBP is required for activities such as dressing, bathing, hygiene, changing linens and briefs, toileting assistance, device care, and any wound care requiring a dressing. Record review showed that the resident was cognitively intact, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had multiple wounds including venous ulcers, open wounds on both buttocks, a left BKA incision, several unstageable pressure ulcers on the right lower extremity, a PICC line in the right upper arm, and an active MRSA infection. Observations on separate days revealed there was no EBP signage on the resident’s door and no gowns available inside or outside the room. During observed wound care, an LPN used gloves but did not wear a gown, and later confirmed that EBP had not been utilized and should have been during the wound care encounter.
Medications Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were stored safely and securely in accordance with its policy and regulatory requirements. The facility’s policy on centralized medication storage, revised 8/2024, stated that medications are to be stored safely, securely, and properly, accessible only to authorized personnel. During an observation on 3/17/26 at 8:14 AM, surveyors found a container of Gavilyte-G solution, labeled by the pharmacy for Resident 3, sitting on the bathroom sink in Resident 3’s bathroom with approximately one inch of solution remaining. In an interview on 3/16/26 at 10:47 AM, the Wound and Infection Nurse confirmed that the Gavilyte-G container should not have been stored on the resident’s bathroom sink. The facility also failed to secure multiple medications in the room of Resident 2. Resident 2’s MDS dated 01-04-2026 showed the resident was admitted on a prior date, had a BIMS score of 13 indicating cognitive intactness, required extensive assistance with toileting, bathing, dressing, hygiene, bed mobility, and transfers, was at risk of developing a pressure ulcer, and had two venous ulcers. On 03-16-2026, an observation revealed a clear plastic bag containing medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, sitting on the dresser in Resident 2’s room. In an interview on the same date, LPN D confirmed that these medications were on the dresser and acknowledged that medications are supposed to be kept locked up.
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.
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