Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 - Millard during CMS and state inspections, most recent first.
Failure to Monitor Weight Loss and Nutrition Needs: The facility did not identify or respond to significant weight loss for multiple residents and did not obtain required weights for residents at nutritional risk. One resident with malnutrition and dysphagia had ongoing weight loss despite supplement orders, with fortified foods not actually provided and no weekly weights or reweights documented. Another resident with vascular dementia and a pressure ulcer lost substantial weight, had a requested reweigh not completed, and had snacks and fluids left out of reach. Additional residents had delayed supplement initiation or missing weight monitoring despite documented nutritional risk and weight loss.
Multiple care process failures were cited across nursing, nutrition, pharmacy, restorative, and QAPI oversight. A resident who required feeding assistance waited an extended period for breakfast and help eating on two observed occasions, while other residents had missed bowel monitoring, missing blood glucose documentation, delayed CPAP orders, incomplete physician visits, unaddressed pharmacy recommendations, and failures in restorative, weight-monitoring, and infection-control practices. The DON and other staff confirmed several of these lapses.
QAPI Program Failed to Identify Survey Deficiencies: The facility’s QAPI process did not identify or address multiple survey findings, including failures involving AIMS monitoring, MDS coding, meal assistance, bowel and glucose monitoring, wound care, restorative programs, weight loss, CPAP orders, physician visits, pharmacist recommendations, med security, facility assessment, transfer agreement, and infection control. The QAPI Coordinator stated the issues were usually brought to the committee after the survey and then assigned for follow-up.
The facility failed to review and update its facility assessment with input from the MD and DON. Record review showed the only name or title documented as involved in completing the assessment was the administrator, and the ADM stated the assessment was completed one-to-one with corporate level staff.
Missing Hospital Transfer Agreement: Record review showed no evidence of a transfer agreement between the facility and a Medicare- or Medicaid-certified hospital, and the ADM confirmed the facility did not have a hospital transfer agreement. The issue affected the facility census of 74 residents.
The facility failed to ensure that 4 sampled residents received the required initial face-to-face physician visit. Records showed that residents admitted with conditions including fractures, chronic renal failure, and other complex diagnoses were seen by APRNs/APRNs rather than a physician for the initial comprehensive assessment, and the DON confirmed the visits were completed by APRNs and that she was unaware Medicare A residents required the initial provider assessment to be done by a physician.
Staff failed to follow infection control practices during respiratory equipment care, medication administration, and wound care. A resident’s nebulizer equipment was repeatedly observed assembled, unlabeled, and stored without a barrier; another resident’s CPAP mask was left on the bedside table without a barrier and lacked cleaning/tubing change orders until later. Staff also used poor hand hygiene and glove technique during med pass and eye care, and wound care for a resident on EBP was performed without using the required precautions.
Failure to monitor bowel movements and blood glucose. A resident with Alzheimer’s disease and severe cognitive impairment had repeated days with no bowel movement charting and did not receive the ordered bowel protocol medications despite standing bowel orders. Another resident with diabetes had ordered BID blood sugar checks, but evening glucose readings were not documented for several days, and the DON confirmed the missing documentation and that the MAR had no place to record the reading.
Failure to implement pressure relieving boots for a resident with pressure ulcers. A resident with TBI, hemiplegia, limited ROM, and memory problems had a stage 3 pressure ulcer to the right foot and later developed a new DTI to the right foot near the toe. The care plan called for a pressure relieving/reducing device, but the TAR initially had no boot order, and later documentation showed no use of the Prevalon boots; when observed in bed, the boots were in the wheelchair. The DON confirmed the boots were not initiated until after the stage 3 ulcer developed.
Delayed Funeral Home Notification After Resident Death: A resident with DNR status was found unresponsive on the bathroom floor, death was confirmed by two nurses, and post-mortem care was completed. Staff notified the physician and family, but the funeral home was not contacted until about eight hours later, after the family had already provided the funeral home name and number to the RN.
A resident admitted with anxiety disorder and depression was receiving scheduled quetiapine, but the facility did not complete the required AIMS assessment on admission. The consultant pharmacist noted the antipsychotic order and recommended an AIMS, and the DON confirmed the assessment was not done as required.
Inaccurate MDS Mood Coding: A resident with major depressive disorder had a PHQ-2 to 9 evaluation showing a score of zero, but the quarterly MDS recorded a score of 16, which reflects moderately severe depression. The SSC confirmed the evaluation was completed but not locked and acknowledged the MDS mood score was coded inaccurately.
A resident with severe cognitive impairment and multiple spinal and pain-related diagnoses was supposed to receive eating assistance, but observations showed repeated delays between tray delivery and staff help. Breakfast and lunch were left without timely feeding support, including one instance where an LPN did not assist until 55 minutes after the tray arrived. Staff confirmed the resident needed help with eating and that the delay was not the facility expectation for an assisted diner.
A resident with intact cognition and assistance needs for transfers, toileting, dressing, bathing, and bed mobility did not receive the restorative ambulation and bilateral LE ROM program recommended by PT. The resident said exercise programs stopped after a hallway move and did not recall being offered restorative services or refusing them. The restorative aid and PTA both reported they were unaware of the recommendation, and no further information was provided by the facility.
A resident with OSA had a CPAP order for bedtime use, but the order listing did not include CPAP settings. The resident was cognitively intact and also required oxygen and a non-invasive mechanical ventilator. A CPAP machine was observed at the bedside, and the DON confirmed the settings were not obtained until later and should have been obtained when the CPAP was ordered.
Failure to Follow Up on Consultant Pharmacist Medication Review Recommendations: The facility did not follow up on repeated consultant pharmacist recommendations for two residents. One resident with anxiety, depression, and antipsychotic and alprazolam use had ongoing recommendations for AIMS assessments, antipsychotic documentation, and prednisone diagnosis support, while another cognitively intact resident on an antipsychotic had repeated recommendations for AIMS assessment and daily target behavior monitoring. The DON confirmed the recommendations were not followed up on.
Unsecured medications were left on top of a locked med cart during med pass for a resident. An MA prepared the resident’s meds, locked the cart, then walked away with the meds while the medication cards for several ordered drugs remained unsecured on the cart until the MA noticed and returned to secure them.
The facility failed to secure treatment carts on the 200 and 500 halls, leaving them unlocked and unattended with insulin stored inside. Observations confirmed the carts were not locked, and interviews with RNs acknowledged the oversight. Facility policy requires medications to be stored in locked areas, accessible only to authorized personnel.
The facility failed to perform required neurological checks after falls for two residents. One resident had an unwitnessed fall, with incomplete neurological evaluations recorded in the EHR. Another resident also experienced an unwitnessed fall, with only vital signs logged and insufficient Neuro Check entries. The facility's policy mandates regular neurological evaluations after such incidents, but these were not conducted as required.
The facility failed to implement fall interventions for two residents, both of whom had experienced falls. Despite care plans requiring call lights to be secured with Velcro, observations revealed that this intervention was not followed. Staff confirmed the oversight, highlighting a deficiency in maintaining a safe environment.
Facility staff failed to maintain safe water temperatures in resident handwashing sinks, with temperatures recorded significantly above the recommended range, posing a risk of hot water burns. The Maintenance Director and Administrator confirmed the use of an incorrect thermometer, leading to inaccurate readings and non-compliance with the facility's water management policy.
A resident was transferred to the hospital after a fall, but the facility staff failed to provide a Transfer Discharge notification as required by policy. The oversight was confirmed by the Facility Administrator, and the facility's policy mandates written notification to the resident and their representative, even in emergency transfers.
Facility staff failed to ensure a resident's drug regimen was free from unnecessary duplicate medication orders. The resident, moderately cognitively impaired, had multiple orders for Acetaminophen, including 500 mg every 6 hours as needed, 500 mg four times a day, and 650 mg every 4 hours as needed, all with a maximum daily limit of 3,000 mg. The DON confirmed these orders were duplicate therapy.
Failure to Monitor Weight Loss and Provide Adequate Nutrition
Penalty
Summary
The facility failed to provide enough food and fluids to maintain residents’ health by not identifying significant weight loss, not implementing interventions to prevent further weight loss, and not obtaining required weights for multiple residents. The report cites 175 NAC 12-006.09(J)(i)(1) and 12-006.09(J)(iii) and identifies deficiencies for Residents 1, 26, 40, and 62. Facility policy required initial weights within 24 hours of admission, weekly weights for residents at nutritional risk, and re-weighing when weight varied by more than 3 percent. Resident 26 had diagnoses including hemiplegia, traumatic subdural hematoma, unspecified protein-calorie malnutrition, depression, and hypertension, and was assessed as cognitively severely impaired. The resident had a significant weight loss from 159.0 pounds to 150.2 pounds in less than 30 days, then continued to lose weight to 143.2 pounds, 137.0 pounds, 134.6 pounds, and 123.7 pounds over the following months. The record showed no weekly weights or reweights were obtained, and no evaluation or additional interventions were documented despite the ongoing loss. The RD noted a 5% weight loss and recommended increasing the nutritional supplement, but the record review found the resident had already been receiving that supplement twice daily, fortified foods were not actually ordered or provided, and staff confirmed fortified foods had not been received. Resident 40 had diagnoses including melena, hemorrhage of anus and rectum, ulcerative proctitis, bilateral paralytic syndrome following cerebral infarction, vascular dementia, and a stage 3 sacral pressure ulcer. The resident’s weight dropped from 263.5 pounds to 234.5 pounds in less than one month, and the weight loss was not planned for on the CCP. A reweigh was requested, but no additional weights were found in the EMR and the ordered reweigh had not been obtained. Resident 40 required total assistance with eating, yet observations showed snacks left out of reach and no water pitcher or cup available. Food and fluid intake documentation also showed multiple days with missing meal or snack documentation. Resident 62 had dementia and chronic kidney disease stage 4, required supervision with eating, and had a nutritional problem on the CCP with a goal of consuming more than 50% of meals. The resident had prior significant weight loss documented, and the RD recommended a Boost Plus supplement after a 90-day weight loss, but the supplement was not initiated until weeks later. The MAR initially lacked the supplement order, and the record showed additional weight loss from 168 pounds to 162 pounds. Resident 1 had protein-calorie malnutrition and dysphagia, with a documented significant weight loss of 12.32% over 180 days, but there were no weight measurements from 04/26/2026 until 05/20/2026 and no evidence that weights were attempted during that period.
Multiple care process failures across nursing, nutrition, pharmacy, and QAPI oversight
Penalty
Summary
The facility failed to administer its resources effectively and efficiently as reflected by multiple deficiencies involving nursing, dietary, pharmacy, restorative, and administrative oversight. The administrator job description identified responsibility for overall leadership, regulatory compliance, documentation, and QAPI, while the DON was responsible for maintaining standards of resident care and monitoring nursing operations. The dietitian was responsible for nutrition interventions and medical nutrition therapy. Despite these roles, the facility had deficiencies cited for failure to timely notify a funeral home, complete an AIMS evaluation, accurately code an MDS mood score, and maintain several care processes for residents. Resident 95 did not receive timely dining assistance on two observed occasions. On one occasion, the heated breakfast tray cart was placed in the kitchen area of the unit at 8:55 AM, the nurse aide began delivering room trays at 9:40 AM, the resident did not receive the tray until 10:00 AM, and assistance with eating did not begin until 10:15 AM. On another occasion, the breakfast cart reached the unit at 9:00 AM, trays began being delivered at 9:05 AM, breakfast was delivered last to the resident at 9:35 AM, and an LPN entered the room at 9:55 AM to assist with eating. The ST confirmed the resident required assistance with eating, the LPN confirmed the resident had been waiting almost an hour for breakfast, and the DON confirmed that waiting 55 minutes or longer for assistance eating was not the facility expectation for an assisted diner. The facility also failed to monitor bowel movements and blood glucose as ordered. Resident 2’s bowel movement log showed no bowel movement except for a small one on 5/7/26, and the DON confirmed bowel protocol medications were not given and should have been. Resident 87’s blood sugar summary for 05/01/26 through 05/07/26 lacked evening readings for 05/02/26, 05/03/26, and 05/04/26, and the DON confirmed the missing documentation and stated there was no place on the medical record to document the reading. Additional deficiencies included failure to identify causal factors and implement interventions for wound healing and pressure ulcer prevention for Resident 26, failure to implement restorative ambulation and range-of-motion programs for Residents 42 and 26, failure to identify significant weight loss and monitor meal intakes for Residents 26, 40, 62, and 1, failure to obtain CPAP orders for Resident 4 in a timely manner, failure to ensure initial physician visits for Residents 6, 8, 42, and 95, failure to follow up on consultant pharmacist recommendations for Residents 3 and 62, failure to secure medication cards during medication administration, failure to update the facility assessment with input from the Medical Director and DON, failure to maintain a transfer agreement with a hospital, failure to have QAPI identify and address the cited deficiencies, and failure to handle linen, perform hand hygiene with glove changes, clean CPAP equipment, and label/store nebulizer equipment to prevent cross contamination.
QAPI Program Failed to Identify Survey Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI program identified and addressed deficient practices found during the annual survey. The QAPI plan, dated March 24, 2026, described a committee led by the location administrator with support from the QAPI Coordinator, and stated that the committee meets at least quarterly to address identified quality concerns. A separate undated QAA committee sheet stated the QAPI committee meets every 4 weeks. During interview, the QAPI Coordinator confirmed they were not aware of the issues identified by the survey team before the survey and stated the Facility Administrator informed them after the survey was completed. The annual survey identified multiple deficiencies affecting residents and facility systems, including failure to perform an AIMS evaluation for antipsychotic use, inaccurate MDS mood coding, delayed meal assistance, failure to monitor bowel movements and blood glucose per order, failure to identify causal factors and interventions for wound healing, failure to implement therapy-recommended ambulation and restorative ROM programs, failure to identify and address significant weight loss, failure to obtain and follow CPAP orders, failure to ensure physician visits occurred as required, and failure to follow up on pharmacist recommendations. The survey also found medications were not secured in the medication cart during administration. Additional deficiencies included ineffective administration, failure to review and update the facility assessment with input from the Medical Director and DON, absence of a transfer agreement with a hospital, and infection control failures involving enhanced barrier precautions, hand hygiene, CPAP equipment handling, nebulizer labeling and storage, and linen handling. The QAPI Coordinator stated issues are typically presented during the monthly QAPI meeting, responsibilities are delegated to committee members, and follow-up occurs at the next QAPI meeting.
Facility Assessment Completed Without Required Leadership Input
Penalty
Summary
The facility failed to review and update its facility assessment with input from the Medical Director and the Director of Nursing. Record review of the facility assessment dated [DATE] showed that the only name or title recorded as involved in completing the assessment was the facility administrator. The assessment also stated that, to ensure required thoroughness, the facility must involve nursing home leadership, including a member of the governing body, the medical director, the administrator, and the director of nursing, as well as direct care staff such as RNs, LPNs, CNAs, or other representatives of direct care staff, and must solicit and consider input from residents, resident representatives, and family members. During an interview on 05/26/2026 at 12:22 PM, the Administrator stated the facility assessment was completed one-to-one with corporate level staff.
Missing Hospital Transfer Agreement
Penalty
Summary
The facility failed to have a transfer agreement with at least one Medicare- or Medicaid-certified hospital to ensure residents could be moved quickly when medical care was needed. Record review showed no evidence of a transfer agreement between the facility and a hospital. During interview, the Administrator stated the facility did not have a hospital transfer agreement. The facility census was 74 residents.
Failure to Ensure Initial Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by a physician for the initial comprehensive visit for 4 of 4 sampled residents. The record review and interviews showed that Resident 95, admitted with an unstable burst fracture of T7-T8 and covered by Medicare A, did not receive an initial physician visit; the admission visit was completed by an APRN instead, and the DON confirmed she did not know Medicare A residents require the initial provider assessment to be conducted by a physician. Resident 8, admitted following a left periprosthetic femur fracture and also covered by Medicare A, likewise did not receive an initial physician visit, and all provider visits documented in the record were completed by an APRN. Resident 6 was admitted with diagnoses including hypokalemia, chronic atrial fibrillation, end stage renal disease, type 2 diabetes mellitus, and dependence on renal dialysis; the admission and 5-day MDS identified stage five chronic renal failure as the primary medical condition. The record contained an APRN-completed medication reconciliation, hospital follow-up, and history and physical on the day of admission, but no evidence that a physician completed the initial comprehensive visit. Resident 42's record showed multiple practitioner visits by an Advanced Practice Nurse Practitioner after admission, and the resident stated he had not seen a physician since admission; the DON confirmed this. The facility policy stated the attending physician would see the resident every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with certain non-physician practitioners allowed for every other required visit after the initial visit.
Infection Control Breaches With Respiratory Equipment, Medication Handling, and PPE Use
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program as evidenced by multiple observations of unsafe handling of respiratory equipment, medication administration practices, and use of personal protective equipment. Review of facility policies showed expectations for hand hygiene, glove use, cleaning and storage of nebulizer equipment, and handling of soiled items, but survey observations found staff actions that did not follow those practices. Resident 45, who had a BIMS score of 5 indicating cognitive impairment, received DuoNeb nebulizer treatments three times daily. During repeated observations, the resident’s nebulizer mouthpiece and medication cup were seen fully assembled and laying on a chair next to the bed with drops of fluid visible in the cup, no barrier between the equipment and the surface, and no label on the tubing to show when it was placed into use. The equipment remained in that condition across multiple observations over several days. During medication administration to Resident 10, a medication aide used the same gloves throughout multiple tasks, touched medication cards, cart drawers, multiple medication bottles, the narcotic book, scissors, a pen, and the resident’s room door, and then administered medications while still wearing the soiled gloves. The aide confirmed these actions created an infection control breach with several opportunities for cross contamination. For Resident 15, a medication aide entered the room without hand hygiene before donning gloves, wiped the resident’s eyes with a washcloth, changed gloves without hand hygiene, and then administered eye drops and medications; the aide confirmed this was a breach of infection control. Resident 15’s nebulizer mask and undated tubing were also observed lying directly on the bedside table without a barrier, and the aide confirmed the items should have been dated and stored in a plastic bag when not in use. For Resident 4, who was assessed as cognitively intact and required extensive assistance with bathing, lower body dressing, hygiene, bed mobility, toileting, and transfers, staff performed wound care while an Enhanced Barrier Precautions sign was posted and PPE was available. Although hand hygiene and gloves were used, staff handled the resident’s bed linens and clothing during the procedure, and the Clinical Education Specialist confirmed EBP was not used during the wound care and should have been. Resident 4 also had a CPAP order for bedtime use, but the record lacked orders for cleaning the CPAP mask and tubing changes until later, and observations showed the CPAP mask laying on the bedside table without a barrier. The DON confirmed the cleaning and tubing change orders were not obtained until later and that the CPAP mask was not stored in a manner to prevent cross contamination.
Failure to Monitor Bowel Movements and Blood Glucose
Penalty
Summary
The facility failed to monitor bowel movements and follow the ordered bowel protocol for Resident 2. Resident 2 had a diagnosis of Alzheimer’s disease, a BIMS score of 5 indicating severe cognitive impairment, and required assistance with hygiene, bed mobility, transfers, toileting, bathing, and dressing. The bowel movement log showed multiple days with no charting and repeated entries of no bowel movement, with only one small bowel movement documented before a later medium bowel movement. Resident 2 had standing bowel-related orders for Miralax, Senna, and a bowel protocol that included prune juice on day 2 without a bowel movement, Milk of Magnesia on day 3, a bisacodyl suppository on day 4, and a fleet enema with provider notification on day 5, but the record showed the prn bowel protocol medications were not given from 05-01-2026 through 05-13-2026. The DON confirmed the resident had not had a bowel movement other than the small one and that the prn bowel protocol medications should have been given. The facility also failed to document blood glucose readings for Resident 87 as ordered. Resident 87 was admitted with a diagnosis of diabetes mellitus and had an order for Tresiba insulin with a morning blood sugar reading area on the medication record, along with an order for blood sugar checks twice daily for morning and evening medication passes. The blood sugar summary showed no evening blood sugar documentation for three consecutive days, and progress notes for that period did not include those blood sugar levels. The DON confirmed the lack of documentation for the evening readings and stated there was no place on the medication record to document the reading.
Failure to Implement Pressure Relieving Boots for a Resident with Foot Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for Resident 26. The resident’s MDS dated 04-28-2026 documented short-term and long-term memory problems, limited assistance needs for bed mobility and transfers, extensive assistance needs for toileting, bathing, and upper body dressing, total assistance for lower body dressing, a traumatic brain injury, hemiplegia, limited ROM on one side, risk for pressure ulcer development, and a stage 3 pressure ulcer. The care plan revised on 03-19-2026 identified skin integrity impairment related to localized edema and protein-calorie malnutrition and included a pressure ulcer to the right side of the right foot and the right heel, with interventions to monitor the wound, refer to restorative nursing, and provide a pressure relieving/reducing device and/or skin protective device, but it did not specify what device to use, for what area, or how often. Record review showed a new stage 3 pressure ulcer to the right foot on 01-13-2026, and the TARs for November and December 2025 had no order for pressure relieving boots. A TAR entry dated 01-14-2026 later ordered Prevalon boots to both lower extremities, to be worn at all times in bed as the resident allowed. Despite this, the EMR task record from 04-27-2026 through 05-26-2026 showed no documentation of Prevalon boot use, and on 05-26-2026 the resident was observed in bed without the boots, which were found in the wheelchair. The resident also developed a new pressure ulcer to the right foot near the toe, documented as a DTI on 03-04-2026. The DON confirmed on 05-26-2026 that the facility had not initiated pressure relieving boots until after the resident developed the stage 3 pressure ulcer to the right foot.
Delayed Funeral Home Notification After Resident Death
Penalty
Summary
The facility failed to timely notify the selected funeral home of needed services for one resident who died in the facility. Resident 88 was admitted to the facility, had a DNR code status, and was later found on the bathroom floor unresponsive. Death was confirmed by two nurses, three staff members assisted the resident back to bed with a mechanical lift, and post-mortem care was completed. Facility staff notified the physician and family after the death was confirmed. The resident’s family member reported that after the family left the facility, the family informed RN-J of the funeral home name and telephone number. Facility records showed the funeral home was not called to assume care until approximately eight hours later, at 6:39 AM. Interviews with an LPN and the DON confirmed the expected process was to notify the physician, review the record for funeral home information, and call the funeral home after post-mortem care and any grieving period, but the family member stated the delay was not dignified or respectful to the decedent.
Failure to Complete AIMS for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to complete an abnormal involuntary movement scale (AIMS) evaluation for a resident who was receiving a scheduled antipsychotic medication. The facility policy stated that when a resident is admitted on psychotropic medications or returns from hospitalization on new psychotropic medications, a registered nurse must complete the AIMS if the medication is an antipsychotic. Record review showed the resident was admitted with diagnoses of anxiety disorder and depression and was receiving quetiapine on a scheduled basis only. The consultant pharmacist documented in multiple medication regimen reviews that the resident had been admitted with an order for quetiapine and recommended completing an AIMS immediately and at least every 6 months going forward. Review of the resident's electronic health record showed no evidence that an AIMS assessment was completed prior to the survey date. During interview, the DON confirmed the resident was admitted with an antipsychotic medication order and that an AIMS assessment was not completed on admission and should have been completed.
Inaccurate MDS Mood Coding
Penalty
Summary
The facility failed to accurately code the mood score on the Minimum Data Set for one resident. The resident was admitted on 01/12/2024 and had a diagnosis of major depressive disorder. A quarterly MDS dated [DATE] documented a PHQ-2 to 9 total severity score of 16, which the MDS manual identifies as moderately severe depression. Record review also showed an undated PHQ-2 to 9 evaluation for the resident with a total severity score of zero. During an interview on 05/20/2026, the Social Services Coordinator confirmed the evaluation was completed on 03/10/2026 and that the score was zero. The coordinator also confirmed the evaluation had not been locked and stated they believed it would not transfer correctly to the MDS if not locked. The coordinator confirmed the MDS showed a PHQ-2 to 9 score of 16 and acknowledged the MDS mood score was coded inaccurately.
Delayed Dining Assistance for a Resident Needing Feeding Help
Penalty
Summary
The facility failed to ensure that a resident who was supposed to receive eating assistance was fed in a timely manner. Resident 95 was admitted with diagnoses including an unstable burst fracture of T7-T8, a wedge compression fracture of L3, spinal stenosis, obesity, cognitive communication deficit, acute pain due to trauma, major depressive disorder, and a history of falling. The resident’s BCAT score was 12, indicating severe cognitive impairment, and the care plan identified the resident as needing assistance with eating. Observations showed the resident’s meal trays were delivered to the unit and then remained without timely feeding assistance. On one occasion, the resident was observed in the room with the lunch tray on the bedside table and no staff assisting. On another occasion, breakfast was delivered at 10:00 AM and the resident had not received assistance by 10:15 AM. On 5/26/2026, breakfast was delivered to the resident at 9:35 AM, but an LPN did not enter to assist with eating until 9:55 AM, resulting in a 55-minute delay from tray arrival to feeding. Later that same day, lunch was delivered at 1:07 PM and the resident did not receive the meal until 1:55 PM. Staff interviews confirmed the resident was supposed to have eating assistance, that waiting almost an hour was not ideal, and that waiting 55 minutes or longer to be fed was not the facility expectation for an assisted diner.
Failure to Provide Recommended Ambulation and ROM Program
Penalty
Summary
The facility failed to implement an ambulation program for Resident 42 as recommended by therapy and as desired by the resident. Resident 42’s MDS dated 03-11-2026 showed a BIMS score of 14, indicating cognitive intactness, and documented that the resident required limited assistance with toileting, transfers, and lower body dressing, as well as extensive assistance with bathing and bed mobility. The resident was admitted to the facility on an unspecified date. Resident 42’s PT discharge summary dated 03-20-2026 recommended a restorative ambulation program for the resident to ambulate with a 4-wheeled walker, follow with wheelchair, and CGA, along with a restorative ROM program for both lower extremities. During interview, Resident 42 stated that when moved from the 500 hallway to the 100 hallway, all exercise programs stopped and the resident did not remember being offered a restorative program or refusing to participate. The restorative aid stated the program had not been provided because they were not informed of the recommendation, and the PTA stated they had no knowledge of a restorative program for Resident 42. By 05-26-2026 at 6:00 PM, the facility had not provided any further information regarding a restorative program for the resident.
CPAP Settings Not Obtained or Documented
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for one resident who had an order for CPAP at bedtime and removal in the morning for obstructive sleep apnea. Record review showed the resident was cognitively intact with a BIMS score of 14 and required assistance with dressing, bathing, hygiene, bed mobility, toileting, and transfers, and also required oxygen and a non-invasive mechanical ventilator. The EMR contained the CPAP order, but the resident’s order listing did not include CPAP settings. During observation, a Res Med Air Sense 10 auto set CPAP machine was seen on the resident’s bedside table. The DON confirmed that CPAP machine settings were not obtained until after the order was written and stated they should have been obtained when the CPAP was ordered.
Failure to Follow Up on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that monthly consultant pharmacist drug regimen review recommendations were followed up and documented for 2 sampled residents. Facility policy required drug irregularities to be reported to the medical director and attending physician and for someone to ensure the reports were acted upon within 30 calendar days of the review. Record review showed that Resident 6, who was admitted with diagnoses of anxiety disorder and depression and was receiving a scheduled antipsychotic medication, had repeated pharmacist recommendations to complete an AIMS assessment, complete antipsychotic medication documentation, request a duration of therapy for alprazolam, and later obtain a diagnosis to support continued prednisone use. The EHR contained no evidence that these recommendations were completed. Resident 62, who had a BIMS score of 15, required varying levels of assistance with activities of daily living, and was taking an antipsychotic medication, also had repeated pharmacist recommendations for an AIMS assessment and daily target behavior monitoring. The consultant pharmacist made these recommendations across multiple monthly reviews, but record review found no evidence that the follow-up actions were completed. During interviews, the DON confirmed that the pharmacy recommendations for both residents were not followed up on and should have been.
Unsecured Medications Left on Cart During Administration
Penalty
Summary
Medication storage was not maintained securely during medication administration for one resident. During an observation of medication administration, the medication aide prepared medications for Resident 10, locked the medication cart, and then left the medication cards containing Finasteride 5 mg, Amlodipine Besylate 10 mg, Sertraline HCL 50 mg, Carvedilol 6.25 mg, and Sevelamer Carbonate 800 mg on top of the cart. The medication aide walked away from the cart with the prepared medications and reached the resident’s door before noticing the cards were still unsecured. The aide returned to the cart, unlocked it, and secured the medication cards before continuing to the resident’s room. During interview, the medication aide confirmed the medications had been left on top of the cart and stated they should have been secured in the cart before walking away.
Unsecured Treatment Carts with Insulin
Penalty
Summary
The facility failed to ensure the security of treatment carts on the 200 and 500 halls, which were left unlocked and unattended. During an observation, it was noted that the treatment cart on the 200 Hall was unlocked, and an interview with a Registered Nurse (RN) confirmed that insulin, a medication used to treat diabetes, was stored in the cart and that it should have been locked when unattended. Similarly, another observation revealed an unlocked treatment cart on the 500 Hall, and an interview with another RN confirmed the presence of insulin in the cart and acknowledged that it should have been secured. The facility's policy on medication storage, dated March 29, 2024, mandates that medications be stored in a locked cart, drawer, or cupboard, with access limited to the person passing medications and the director of nursing services or their designee.
Failure to Perform Neurological Checks After Falls
Penalty
Summary
The facility failed to perform neurological checks after falls for two residents, as required by their policy. Resident 1 experienced an unwitnessed fall, and the Neuro Vital Sign Sheet Report indicated that neurological evaluations should be conducted every 30 minutes for four sets, then every 8 hours for the next three days. However, the records showed only vital signs were logged, and the Neuro Check assessments in the Electronic Health Record (EHR) had only two entries on the day of the fall and one the following day. Similarly, Resident 3 had an unwitnessed fall, and the NVSSR also showed only vital signs logged, with only two Neuro Check entries recorded on the day of the fall. The facility's policy on Neurological Evaluation-Rehab/Skilled requires establishing a baseline neurological status for comparison and monitoring changes, especially after unwitnessed falls or suspected head injuries. An interview with the Director of Nursing confirmed that the Neuro Check entries in the EHR should match the vital signs on the NVSSR and acknowledged that the evaluations were not completed at the appropriate intervals for both residents. This failure to adhere to the policy resulted in incomplete neurological assessments following the falls.
Failure to Implement Fall Interventions for Residents
Penalty
Summary
The facility failed to implement fall interventions for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident 3, who has severe cognitive impairment as indicated by a BIMS score of 4, required moderate assistance with toileting, bathing, and lower body dressing, and supervision with transfers. Despite a fall on December 25, 2024, the intervention to secure the call light to the bed with Velcro was not implemented, as observed on February 20, 2025, during two separate observations. This was confirmed by RN D, who acknowledged that the call light was not secured. Similarly, Resident 4, with moderate cognitive impairment and requiring maximum assistance with bathing and moderate assistance with personal hygiene and bed mobility, also experienced a fall on December 25, 2024. The care plan intervention to secure the call light with Velcro was not followed, as observed on February 20, 2025, when the call light was found lying on the bed instead of being secured. This was confirmed by Nurse Aid E. The facility's policy on fall reduction emphasizes the importance of communicating fall risk factors and implementing interventions, which was not adhered to in these cases.
Unsafe Water Temperatures in Resident Sinks
Penalty
Summary
The facility staff failed to maintain safe water temperatures in resident handwashing sinks, leading to the potential risk of hot water burns for six residents out of a total census of 62. Observations conducted on November 18, 2024, revealed that the water temperatures in the sinks of several residents were significantly above the recommended safe range of 110-115 degrees Fahrenheit. Specifically, the water temperature for one resident was recorded at 128 degrees Fahrenheit, while others had temperatures ranging from 122.3 to 130.7 degrees Fahrenheit. During an interview, the Maintenance Director, Administrator, and Maintenance Technician Assistant confirmed that the thermometer used for measuring water temperatures was incorrect, leading to inaccurate readings. The facility's policy on plumbing systems and water management emphasizes the importance of maintaining water temperatures within a safe range to ensure resident safety and comfort. However, the failure to use a properly calibrated thermometer and adhere to the recommended procedures resulted in the deficiency observed by the surveyors.
Failure to Provide Transfer Discharge Notification
Penalty
Summary
The facility staff failed to provide a Transfer Discharge notification for a resident who was sent to the hospital following a fall. The resident, identified as Resident 18, was transferred to the hospital on July 5, 2024, but there was no evidence in the medical records, including progress notes, faxes, demographic sheets, and practitioner orders, that a Transfer Discharge notice was provided to the resident or their responsible party. This oversight was confirmed during an interview with the Facility Administrator on November 20, 2024. The facility's Discharge and Transfer Policy, reviewed and revised on January 3, 2024, outlines the requirement to notify the resident and their representative of the transfer or discharge in writing, in a language and manner they understand. The policy specifies that even in cases of emergency transfers to an acute care center, a notice of transfer must be provided as soon as practicable. The responsibility for completing the Notification of Transfer or Discharge falls to the social worker or designated individual, or the charge nurse if the transfer occurs when social services are not present.
Duplicate Medication Orders for a Resident
Penalty
Summary
Facility staff failed to ensure that a resident's drug regimen was free from unnecessary duplicate medication orders. A review of the electronic health record (EHR) for a resident, who was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12, revealed multiple orders for Acetaminophen. The resident had diagnoses including adult failure to thrive, bipolar disorder, anxiety disorder, history of falling, chronic kidney disease stage 3, and legal blindness. The EHR showed three separate orders for Acetaminophen: 500 mg every 6 hours as needed, 500 mg four times a day, and 650 mg every 4 hours as needed, all with a maximum daily limit of 3,000 mg. An interview with the Director of Nursing confirmed these orders constituted duplicate therapy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 414 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookestone Village | 1.5 mi | ★★★★★ | 10 | 0 |
| Hillcrest Millard Llc | 1.7 mi | ★★★★★ | 12 | 0 |
| Newport House | 2.1 mi | ★★★★★ | 8 | 0 |
| The Banyan At Montclair | 2.3 mi | ★★★★★ | 23 | 0 |
| Rose Blumkin Jewish Home | 3.7 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.