Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Hastings Village during CMS and state inspections, most recent first.
Food Storage, Sanitation, and Dietary Hygiene Deficiencies: Surveyors found multiple TCS foods in kitchen refrigerators and freezers that were opened or prepared but lacked required use-by dates, including chicken salad and an unlabeled bowl of ice cream. They also observed food debris behind movable stoves and heavy debris in a food warmer door seal, and a Dietary Aide preparing food while wearing artificial fingernails, which the RD confirmed is not allowed when working with exposed food.
The facility failed to complete required communicable disease screening for one new employee and had incomplete screening forms for four other staff members. Staff were observed cleaning reusable bed pans with a vinegar-and-water or spray solution while visible soil remained, a nurse aide providing care had long artificial nails, and oxygen equipment for a resident with COPD and respiratory failure was found unlabeled, undated, or left with another resident’s blue supply bag attached; additional cleaned concentrators in storage also still had used blue bags.
Loose corridor handrails were observed in multiple areas, including the entrance corridor, near a bathing room, by an activity room, across from a dining room, and outside resident rooms. The MD acknowledged awareness of some loose handrails and said he was unaware of others; the safety inspection record for railings/grab bars in the lobby/entrance and hallways was left blank.
Expired medications and medical supplies were found in medication storage areas, including Vacuette drawing needles, lancets, alginate dressings, Remedy Cream, purple top specimen tubes, and Bisacodyl suppositories. The DON confirmed the items were expired and acknowledged the facility is required to monitor medications and supplies to ensure they are not outdated.
Meals Served Late in Dining Rooms: Meal service did not begin on time in the 100 Avenue and 400 Avenue dining rooms based on the facility’s posted meal schedule. Observations showed breakfast and lunch were repeatedly delayed, with the last residents not served until well after the scheduled times. MA-J stated they could not both care for residents and deliver meals, so kitchen staff usually did it, and the DM confirmed dietary aides were also responsible for serving residents and that the meals were late.
The facility failed to provide daily housekeeping for two residents as required by the Resident Agreement and housekeeping policy. Housekeeping coverage was only scheduled Monday through Friday, and staff confirmed no weekend housekeeping was provided. One resident reported a soiled window that limited the view outside, and staff observed buildup on the window. Another resident’s room and bathroom had strong urine odors, and staff acknowledged that some residents need additional bathroom cleaning to prevent lingering odors.
The facility failed to notify the State Ombudsman of resident transfers and discharges and did not provide a written reason for a hospital transfer to a resident or the resident representative. A resident was transferred to the hospital and later returned, but records showed no Ombudsman notifications had been sent for months, and staff confirmed they only called families and did not provide written transfer documentation.
A resident did not receive required quarterly care conferences after MDS assessments. The resident said care plan meetings were not held every 3 months and could not recall the last one. The chart had no care conference progress notes after two MDS assessments, and the SSD confirmed the conferences did not occur even though the facility said residents and representatives are notified and meeting notes are documented in the record.
Failure to maintain function and provide scheduled bathing. A resident reported decline after therapy ended, with staff no longer using the sit-to-stand lift and instead using a full body lift, which changed toileting from the toilet to a bed pan and coincided with increased incontinence and reduced self-care abilities. Facility staff confirmed there was no restorative nursing program. The same resident also reported wanting two baths weekly but often receiving only one or none; the care plan did not reflect the updated preference, documentation showed only weekly bathing, and staff confirmed a missed bath due to staffing issues and that the resident had gone more than a week without a bath.
A resident with a sacral pressure ulcer received wound care using a tap-water-moistened washcloth placed on the wound before a foam dressing was applied, even though the DON stated wounds should be cleansed with a wound cleanser or soap and water. The resident also had a specialty mattress in place, but staff were unsure of the proper setting and check frequency, and the EMHR contained no provider orders for the mattress setting or how often it should be verified.
Perineal care was not provided according to standards for two residents. One NA wiped the upper inner thighs without separating the labia or cleansing the urethral and vaginal area, and another NA used the same premoistened wipe more than once and did not cleanse the front perineal area. Both NAs confirmed the care was incomplete, and the DON confirmed the expected method for peri care.
A resident admitted with a PEG tube, cancer, malnutrition, and other serious diagnoses did not have an admission weight obtained as required. The facility’s policy called for initial vitals, height, and weight on admission, but the first recorded weight was not taken until the next day after the DON discovered the omission. The DON and FA both confirmed that an admission weight should have been completed.
Medication Administration Error Rate Exceeded Limit: The facility had a 7.61% med error rate, with two insulin administration errors involving two residents. An LPN and an RN both failed to prime insulin pens correctly by holding them upright, and both failed to hold the pen in place long enough during injection to ensure the full dose was delivered. In both cases, the residents did not eat within 15 minutes after receiving rapid-acting insulin, and the DON confirmed these actions were medication errors.
Insulin Pen Administration Errors: Staff failed to administer rapid-acting insulin correctly for two residents. An LPN and an RN did not prime insulin pens with the needle pointed upward, did not hold the needle in place long enough during injection, and the residents did not eat within 15 minutes of receiving Novolog or insulin lispro. The DON confirmed these actions were medication errors.
The facility failed to maintain sanitary conditions in the kitchen and properly label and date leftover foods, risking foodborne illnesses for residents. Observations revealed expired and unlabeled food items, and unsanitary conditions in the kitchen. Additionally, meals served to residents in their rooms were not handled properly, with trays left unattended for hours, compromising food safety. Two residents were directly affected by these deficiencies.
The facility, licensed for 175 beds, failed to employ a qualified full-time social worker. The Social Services Director, responsible for all department duties, lacks the necessary qualifications, having only completed a 10-hour online certification for smaller facilities. A resident's POA reported communication issues with the social services department.
A resident did not receive their scheduled weekly bath due to a malfunctioning bath chair and time constraints expressed by the bath aide. The resident, who is cognitively intact, preferred a whirlpool bath, which was not provided on the scheduled date. Staff interviews revealed confusion about bathing responsibilities and unclear documentation practices.
A facility failed to ensure staff wore gowns and gloves during high contact care for a resident with an indwelling urinary catheter, as required by Enhanced Barrier Precautions (EBP). During an observed transfer, two nurse aides handled the resident and urinary catheter without protective equipment, despite the resident's care plan indicating the need for EBP. Interviews confirmed the requirement for gown and glove use, and the aides admitted to the lapse due to being rushed.
Food Storage, Sanitation, and Dietary Hygiene Deficiencies
Penalty
Summary
The facility failed to follow the 2022 FDA food code for storing, preparing, distributing, and serving food. During record review, the facility’s policy on date marking required time temperature control for safety (TCS) foods to be date-marked when received, when opened, and when removed from freezer into refrigeration, and required opened TCS foods and ready-to-eat TCS foods held in refrigeration to have a clear open date and use-by date. On 7/14/26 at 9:00 AM, surveyors observed several stand-up refrigerator/freezers labeled 100, 400, and cook fridge containing prepared and opened food items with an open date but no use-by date, and all use-by dates were blank. Additional kitchen observations found a tub of chicken salad in the walk-in refrigerator with an open date of 7/3/26, and an uncovered dished-up bowl of ice cream in the walk-in freezer with no date or label. The stove and ovens on caster wheels were moved and food debris was found on the floor between the wall and stoves. A tall food warmer in use for lunch holding warm food trays had thick food debris and dust in the crease between the door and seal. On 7/14/26 at 2:05 PM, a Dietary Aide was observed preparing foods and drinks for dinner service while wearing artificial fingernails. The Dietary Manager stated not knowing the aide had artificial fingernails, and the Registered Dietician confirmed dietary employees may not wear artificial fingernails when working with exposed food.
Infection Prevention and Control Failures with Staff Screening, Bed Pans, Nails, and Oxygen Equipment
Penalty
Summary
The facility failed to complete required pre-employment communicable disease screening for one housekeeping supervisor, and four additional staff files contained communicable disease screening forms that were incomplete. The forms for the nurse aides, registered nurse, and dietary aide were signed by the employees, but the sections for communicable disease review and immunization review were not marked complete, and the lines for the form completion date and reviewer signature were left blank. The facility administrator confirmed that the screening for the housekeeping supervisor was not completed and that the other screening forms were not reviewed as required. The facility also failed to keep reusable bedside bed pans in a sanitary condition for two residents. For one resident, a bed pan was observed hanging in a clear plastic bag in the bathroom with visible brown particles and an odor of vinegar and urine. A nurse aide stated that after use, the bed pan was rinsed with a vinegar and water solution and emptied into the toilet, but that all soiling did not always come out and the bed pans were not sure how often replaced. For another resident, the bed pan was sprayed with a solution, swished, emptied, and then returned to a clear plastic bag, but visible light brown thick substance remained on the back edge and lip of the bed pan. The DON stated that the bed pans were unclean and should be thoroughly cleaned between uses until changed, and that the vinegar and water solution did not properly cleanse them. The facility further failed to ensure that direct care staff did not have artificial nails during resident care. A nurse aide assisting two residents with bed pan use was observed with long pointed bright pink fingernails on all fingers of both hands. The infection preventionist confirmed that the facility discouraged direct care staff from having long false fingernails, and the nurse aide acknowledged that the false nails were discouraged while working and providing care. The facility also failed to properly clean and manage oxygen equipment for one resident with lung cancer, brain metastases, COPD, chronic respiratory failure, shortness of breath, and generalized weakness. In the resident’s room, oxygen tubing was observed without a label, a blue oxygen supply bag had another resident’s initials and the wrong room number, and a portable oxygen cylinder with tubing attached was not labeled or dated. Later observations showed the tubing had been dated and labeled, but the blue bag remained on the concentrator with the wrong room number and another resident’s initials. Staff interviews indicated uncertainty about how often tubing and bags were changed, and the infection preventionist confirmed that the blue bag was not supposed to be in that room and should have been discarded. In the storage room, three of four cleaned oxygen concentrators still had used blue bags attached, and the infection control nurse removed them after the observation.
Loose Corridor Handrails
Penalty
Summary
Firmly secured handrails were not maintained in resident corridors, as multiple handrails were found loose during observations and walkthroughs with the Maintenance Director and Housekeeping Supervisor. At the front corridor near the building entrance, a several-foot-long rounded handrail was loose and drywall was falling from around the edges where screws and attachments were affixed to the wall. Additional loose handrails were observed beside the bathing room on the 100 hall, beside and across from the activity room in an open corridor area, across from the smaller dining room used by residents on the 400 halls, and outside the rooms of two residents. The Maintenance Director stated he was aware the handrail beside the bathing room on the 100 hall was loose, and he also acknowledged the front corridor handrail was loose with drywall falling out of the wall. He stated he was not aware that the handrails beside and across from the activity room, across from the smaller dining room, or outside the two resident rooms were loose. A record review of the facility's safety inspection documentation showed instructions to inspect the entire operational location quarterly and to immediately schedule and/or repair required repairs, but the inspection form for railings/grab bars in the lobby/entrance and hallways was left blank with no information entered.
Expired Medications and Medical Supplies Found in Medication Rooms
Penalty
Summary
The facility failed to ensure that medications and medical supplies were not expired. Record review showed the facility policy titled "Medications: Acquisition, Receiving, Dispensing, and Storage" dated 3/30/26 required routine checks for expired medications and disposal in accordance with state/pharmacy regulations. The facility census was 52. During observation, surveyors found multiple expired items in medication storage areas. In the 100 medication storage room, a box of Vacuette Drawing Needles had expired on 5/19/26, an unopened box of Accucheck Safe-T-Pro Plus lancets had expired on 2/28/25, alginate dressings included packages expired on 9/1/24 and 7/1/25, and tubes of Remedy Cream included some expired on 1/2025, 7/2025, and 11/2025. In the 400 medication room, an opened package of purple top specimen tubes had expired on 3/1/25, and a bag with two Bisacodyl suppositories in the refrigerator had expired on 1/2025. The DON confirmed each of these items was expired and stated the facility is required to monitor medications and medical supplies to ensure they are not outdated.
Meals Served Late in Dining Rooms
Penalty
Summary
The facility failed to serve meals in a timely manner based on its posted meal times, affecting residents who ate in the dining rooms. The posted schedule listed breakfast at 7:30 AM, lunch at 11:30 AM, and the evening meal at 5:30 PM, with dining room locations identified as 100 Avenue and 400 Avenue. During observations, meal service in the 100 Avenue dining room had not started at 11:57 AM on 7/13/26, and the last resident was not served lunch until 12:45 PM. On 7/14/26, breakfast had not started in the 100 Avenue dining room at 8:00 AM, and meal service had not started in the 400 Avenue dining room at 8:10 AM. Further observations showed breakfast in the 400 Avenue dining room was not fully served until 8:55 AM on 7/14/26, and lunch in that dining room had not started at 11:50 AM and was not fully served until 12:48 PM. On 7/15/26, breakfast was not fully served until 8:35 AM in the 400 Avenue dining room and 8:37 AM in the 100 Avenue dining room. MA-J stated on 7/14/26 that they were responsible for delivering meals but could not care for residents and deliver meals at the same time, so kitchen staff typically did this and it took longer than anticipated. The Dietary Manager confirmed that the dietary aides who serve meals were also responsible for serving residents and acknowledged the listed meals were late being served.
Daily Housekeeping Not Provided for Two Residents
Penalty
Summary
The facility failed to provide daily housekeeping for two residents, including Resident 18 and Resident 25, as required by the Resident Agreement and the facility’s housekeeping policy. The policy stated that standard or light cleaning should occur on a daily basis in occupied rooms, and the Resident Handbook stated that each room would be cleaned daily and replenished with paper supplies by housekeeping staff. However, the housekeeping calendar showed that only Monday through Friday were scheduled for housekeeping coverage, with 100-hall cleaned on Mondays, Wednesdays, and Fridays and 400-hall cleaned on Tuesdays and Thursdays, and the housekeeping supervisor and housekeeper confirmed that no housekeeping services were done on weekends because no additional housekeepers had been hired. Resident 25 reported that soiling on the window made it difficult to view nature outside and was unsure if or when the window would be cleaned. An observation with the housekeeping supervisor and maintenance director found Resident 25’s outdoor window had buildup of soiling and scaling from outdoors. Resident 18 was observed with strong urine odors in the room and bathroom, and the housekeeping supervisor stated that some residents need additional cleaning in bathrooms as necessary to prevent lingering odors. The report also noted that windows were not scheduled to be cleaned and that outdoor windows were cleaned in springtime.
Failure to Notify Ombudsman and Provide Written Transfer Reason
Penalty
Summary
The facility failed to ensure that the State Ombudsman was notified of resident transfers and discharges, and failed to provide a written copy of the reason for transfer to the hospital to the resident or the resident representative. Resident 14 was transferred to the hospital and later returned to the facility, and the record review identified that no Ombudsman notifications had been sent in the past 6 months. The Social Services Director confirmed that no information had been sent to the Ombudsman since hire in May 2026 and was unable to locate any other notifications since 2022. The Social Services Director also stated that written notifications were not given at the time of transfers or discharges, although families were called to be informed. The Facility Administrator confirmed that no documentation related to Ombudsman notification had been sent and that the Ombudsman had not been notified of Resident 14’s hospital transfer. The Administrator also confirmed that no written reason for the transfer was provided to the resident or the resident representative.
Missed Care Conferences After MDS Assessments
Penalty
Summary
The facility failed to ensure that care conferences were provided for a resident as required after comprehensive assessments. Record review showed that the resident had a quarterly MDS assessment on 10/14/25 with a BIMS score of 15 and required moderate assistance with lower body dressing, followed by an annual MDS assessment on 1/12/26 with a BIMS score of 14 and independence with lower body dressing. The resident told surveyors that care plan meetings did not occur every 3 months and could not remember when the last care plan meeting was held. The facility Social Services Director stated that residents are notified of upcoming care plan meetings and that family or representatives are notified by phone, with meeting notes documented in a progress note under care conference. However, the resident’s medical record contained no progress note for a care conference after either the 10/14/25 MDS or the 1/12/26 MDS. The Social Services Director confirmed that there was no documentation that care conferences were completed for those assessments and confirmed that the care conferences did not occur, despite the requirement that care conferences be provided at least quarterly.
Failure to Maintain Function and Provide Scheduled Bathing
Penalty
Summary
The facility failed to provide necessary care and services to maintain a resident’s level of function and failed to complete routine bathing for that resident. Resident 6 stated that after therapy services ended, staff no longer used the sit-to-stand lift for transfers and instead used a full body lift, which led to the resident using a bed pan rather than being transferred to the toilet. The resident also stated that there were no exercises or programs provided after therapy to help prevent decline in transfer ability or continence. The record showed that the resident had previously been able to transfer with a sit-to-stand lift, propel a wheelchair independently for 150 feet, and had been only occasionally incontinent of bladder and continent of bowel, but later assessments documented partial to moderate assistance with personal hygiene and wheelchair propulsion and frequent bladder and bowel incontinence. Facility staff confirmed that there was no restorative nursing program in place. The PTA stated that when residents were discharged from therapy, the therapy department did not make recommendations for restorative nursing services because the facility did not have such a program. A nurse aide confirmed that Resident 6 had declined in function, including needing a full body lift and using a bed pan instead of the toilet. The DON also confirmed that the facility did not have a restorative nursing program or any program to support health maintenance activities to help prevent decline in function, and acknowledged that Resident 6 had declined in mood, personal hygiene ability, wheelchair self-propulsion, and continence. The facility also failed to provide bathing as preferred and documented. Resident 6 stated a preference for two baths per week but reported often receiving only one bath weekly and sometimes none at all. A progress note documented that the resident raised this concern during a care conference and that the care plan was changed, but the care plan reviewed later still reflected only one whirlpool bath weekly and did not reflect the resident’s stated preference for two baths weekly. Point of care documentation showed weekly baths on several dates, with no documentation of twice-weekly bathing and no bath documented after the last recorded bath. Staff reported that a scheduled bath was missed because of staffing issues, and the DON confirmed that the resident had not been bathed since the last recorded bath and had gone more than a week without bathing.
Inadequate wound cleansing and specialty mattress management
Penalty
Summary
The facility failed to provide care in a manner to promote healing of a pressure-related skin injury for one resident with a sacral pressure ulcer. During wound care, an LPN used a washcloth moistened with tap water from the resident’s bathroom sink, rang out the excess water, and placed the tap-water-moistened washcloth on the resident’s sacrum before applying a 4 inch by 4 inch bordered foam dressing. The LPN stated she was following the resident’s order, which directed the wound to be cleansed with water and patted dry with gauze before covering it with foam dressing. The DON later confirmed that wounds should be cleansed with a wound cleanser or soap and water, and that the cleansing directions should have been clarified with the provider to ensure they were up to current clinical standards of practice. The same resident was observed with a specialty mattress in place, and the control box at the foot of the bed showed the setting at different positions during observations, including 275, 225, and between those marks. The LPN stated she was not sure what the mattress control box should be set at or how often it should be checked to ensure the setting was correct and the mattress was functioning properly. Review of the resident’s EMHR found no provider orders stating what the specialty mattress should be set at or the frequency for checking the setting and function. The DON stated she was unsure of the mattress specifications and confirmed there should have been directions in the resident’s orders for the mattress setting and how often it should be checked.
Perineal Care Not Provided per Standards
Penalty
Summary
The facility failed to provide perineal care according to professional standards of practice for 2 residents. Record review showed the facility policy required separating the labia and cleansing from front to back with a disposable wipe, and the Nebraska ICAP UTI perineal care procedure also directed cleansing the labia, urethra, and vaginal opening from front to back using a clean area of the washcloth for each stroke. During observation, one nurse aide provided perineal care to a female resident by wiping the upper inner thighs and center area with a moistened cloth, but did not separate the resident's legs or labia and did not cleanse the inner labia, urethra, or vaginal opening. In a second observation, another nurse aide wiped between a resident's legs from front to back using the same premoistened wipe more than once, then applied the incontinence product, but did not cleanse the front perineal area by separating the labia and cleansing the meatus and vaginal opening. Both nurse aides confirmed the care was not done as required, and the DON confirmed the expected method for perineal care.
Missing Admission Weight for Resident with PEG Tube and Malnutrition
Penalty
Summary
The facility failed to ensure that an admission weight was obtained for Resident 67 when the resident was admitted. The facility policy dated 6/2/26 stated that initial admission documentation included taking vital signs, weight, and height and documenting them in the electronic medical record. Record review showed that Resident 67 was admitted on [DATE], but there was no weight taken at the time of admission and no recorded weights in the EMR on 7/12/2026. The first recorded weight for the resident was not taken until 7/13/2026 at 11:21 AM by the DON. Resident 67’s baseline care plan dated 7/8/2026 identified the resident as at risk for altered fluid balance, ineffective tissue perfusion, falls, and malnutrition, and noted the need for enhanced barrier precautions related to a PEG tube. The resident’s diagnoses included achalasia of the cardia, malignant neoplasm of the right bronchus or lung, secondary malignant neoplasm of the brain, moderate protein calorie malnutrition, celiac disease, iron deficiency anemia, nausea, vomiting, and generalized weakness. The DON stated that admission procedures include obtaining vital signs, height, weight, and an initial assessment, and confirmed that the first weight was completed only after the missing weight was discovered. The Facility Administrator also confirmed that residents are to have an admission weight when they admit to the facility.
Medication Administration Error Rate Exceeded Limit
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, with a reported error rate of 7.61% based on 27 medication administrations and 2 errors. The deficiency involved two residents, both of whom received rapid-acting insulin, and the survey findings documented errors in insulin pen priming, injection technique, and timing of meal intake after insulin administration. For one resident with diabetes and long-term insulin use, the order was for 3 units of rapid-acting insulin subcutaneously three times daily with meals. During observation, an LPN removed the cap from a Novolog FlexPen, wiped the top, attached a needle, and primed the pen with 2 units while holding it horizontally rather than with the needle pointing upward and without observing for a drop of insulin. The LPN then dialed the ordered 3-unit dose and administered the insulin in the resident’s abdomen, but did not hold the needle in place for at least 10 seconds after injection. After the injection, the resident was taken to the dining room and did not eat or drink anything for 18 minutes after the insulin was given. For another resident with diabetes, the order was for insulin lispro 5 units subcutaneously before lunch. During observation, an RN removed the cap from a lispro KwikPen, disinfected the top, attached a needle, and primed the pen with 2 units while holding it horizontally rather than with the needle pointed upward. The RN then administered the ordered dose in the resident’s abdomen and held the needle in place for only 3 seconds before removing it. The resident was assisted to the dining room after the injection and did not eat or drink anything for 18 minutes after the insulin was administered. The DON confirmed that incorrect priming and failure to hold the pen in place long enough to ensure the full dose was delivered were medication errors, and also confirmed that rapid-acting insulins Novolog and lispro require administration within 15 minutes or less of a meal.
Insulin Pen Administration Errors
Penalty
Summary
The facility failed to ensure that staff administered rapid-acting insulin in a manner that prevented significant medication administration errors for two residents. The deficiency involved insulin pen preparation and administration for one resident with diabetes and long-term insulin use, and another resident with diabetes who had an order for insulin lispro before lunch. In both cases, surveyors observed staff preparing and giving insulin in a way that did not follow the manufacturer instructions or the facility policy. For one resident, an LPN reviewed the order for 3 units of Novolog with meals, removed the cap from the insulin pen, wiped the top, attached a needle, and primed the pen by dialing 2 units and pressing the plunger while holding the pen horizontally. The LPN did not hold the pen with the needle pointing upward or observe for a drop of insulin during priming. The LPN then administered the ordered dose but removed the needle immediately instead of holding it in place for at least 10 seconds. After the injection, the resident was taken to the dining room, and no food or drink was provided or directed immediately after the insulin was given. The resident did not eat or drink anything for 18 minutes after the insulin administration. For the second resident, an RN reviewed the order for 5 units of insulin lispro before lunch, removed the cap from the KwikPen, disinfected the top, attached a needle, and primed the pen by dialing 2 units and pressing the dose knob while holding the pen horizontally. The RN did not hold the pen with the needle pointing upward during priming. The RN then administered the insulin and held the needle in place for 3 seconds before removing it. The resident was assisted to the dining room after the injection and did not eat or drink anything for 18 minutes after the insulin was administered. The DON confirmed that the pen should be primed with 2 units, that rapid-acting insulins such as Novolog and lispro should be administered within 15 minutes or less of a meal, and that the pen should be held in place for 10 seconds during administration; the DON also confirmed that failure to prime correctly and failure to hold the pen in place long enough are medication errors.
Sanitation and Food Safety Deficiencies in Kitchen and Room Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and properly label and date leftover foods, which could potentially lead to foodborne illnesses for all residents consuming meals prepared in the kitchen. Observations revealed several items in the dietary department that were either past their use-by dates or lacked proper labeling. For instance, a container of coleslaw and potato salad were found with expired use-by dates, and several containers in the refrigerator were unmarked, leading to their disposal. Additionally, the kitchen area, including the walk-in freezer, was found to be unsanitary, with food items and debris on the floor. The facility also failed to ensure that meals served to residents in their rooms were handled in a manner that prevented foodborne illness. Resident 34 was observed with a breakfast tray left untouched for several hours, with the resident lying flat in bed, indicating a lack of timely assistance or monitoring. Despite being able to feed themselves, the resident did not consume the meal until much later, raising concerns about the food's safety due to prolonged exposure at room temperature. Similarly, Resident 16, who requires supervision for eating, was left with a meal tray in their room for an extended period without consuming any food. The resident was observed lying on their side, with the meal tray untouched for several hours, indicating a lack of appropriate supervision and timely removal of the meal tray. The Dietary Manager confirmed that the food would not be safe to eat due to the potential for foodborne illness, highlighting the facility's failure to comply with food safety standards.
Facility Lacks Qualified Full-Time Social Worker for 175-Bed Capacity
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite having a licensed bed count of 175, which exceeds the threshold of 120 beds that necessitates such a position. At the time of the survey, the facility had a census of 37 residents. The Social Services Director (SSD), who is responsible for all duties within the department, lacks the required qualifications for the role. The SSD transitioned from the kitchen and activities department and obtained an online certification as a social services designee, which was a 10-hour program designed for facilities with 120 beds or fewer. The facility's job description for a social worker requires a bachelor's degree in social work, which the SSD does not possess. Additionally, a resident's Power of Attorney expressed concerns about the lack of communication and availability of the social services department, indicating potential gaps in service provision.
Failure to Provide Scheduled Bath for Resident
Penalty
Summary
The facility failed to provide a scheduled weekly bath for Resident 5, as required by their care plan. Resident 5, who is cognitively intact with a BIMS score of 14/15, reported not receiving a bath during the week of 02/26/2025. The resident was informed that the bath chair was not working, and despite expressing a preference for a shower, the bath aide stated they did not have time to provide one. The resident's care plan indicated a preference for a weekly whirlpool bath, and the records showed that a whirlpool bath was provided on previous dates, but not on 02/26/2025. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for resident care and bathing schedules. The scheduling of staff responsible for baths was determined during morning huddles and was not documented. On 02/26/2025, there was confusion among staff about who was responsible for bathing Resident 5, and the charting for that day indicated that the bathing activity did not occur. Staff members were also unclear about the meaning of 'non-applicable' in the charting for the type of bath given, indicating a lack of understanding or training regarding documentation procedures.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to Enhanced Barrier Precautions (EBP) during high contact resident care activities, specifically for Resident 33, who has an indwelling urinary catheter. The facility's policy requires staff to wear gowns and gloves during such activities to prevent the transfer of Multi-Drug Resistant Organisms (MDROs). However, during an observation, Nurse Aide-E and Nurse Aide-B did not wear the required protective equipment while transferring Resident 33, who is dependent on staff for transfers and other personal care activities. Resident 33's care plan, dated 3/3/25, indicated the need for EBP due to the presence of an indwelling urinary catheter. Despite this, during a transfer observed on 3/4/25, the nurse aides handled the resident and the urinary catheter without wearing gowns or gloves. This included removing the call light, blanket, and urinary catheter bag, as well as attaching the lift sling and repositioning the resident, all with bare hands. The urinary catheter tubing was noted to contain cloudy urine, suggesting a potential infection risk. Interviews with the nurse aides and the facility's Infection Preventionist confirmed the requirement for gown and glove use during high contact care activities for residents on EBP. The aides acknowledged the lapse, attributing it to being rushed, and confirmed that they normally adhere to the EBP requirements. The Infection Preventionist also confirmed the necessity of wearing protective equipment during such activities and mentioned providing on-the-spot training when non-compliance is observed.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Hastings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harvard Rest Haven | 14.9 mi | ★★★★★ | 14 | 0 |
| Accura Healthcare Of Kenesaw | 15.4 mi | ★★★★★ | 5 | 1 |
| Adept Nursing & Rehab Of Blue Hill | 18 mi | ★★★★★ | 0 | 0 |
| Eventide Prairie Commons Care Center | 21.1 mi | ★★★★★ | 1 | 0 |
| Emerald Nursing & Rehab Lakeview | 21.1 mi | ★★★★★ | 19 | 1 |
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