Good Samaritan Society - St John's
Inspection history, citations, penalties and survey trends for this long-term care facility in Kearney, Nebraska.
- Location
- 3410 Central Avenue, Kearney, Nebraska 68847
- CMS Provider Number
- 285189
- Inspections on file
- 19
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Good Samaritan Society - St John's during CMS and state inspections, most recent first.
A resident with ongoing respiratory symptoms received multiple nebulizer treatments for wheezing and cough, but the facility failed to complete required assessments and did not consistently follow physician orders. Documentation showed that medication aides, rather than licensed nurses, often monitored the effectiveness of treatments, and the facility did not use its change in condition evaluation process as required. Staff interviews confirmed that appropriate follow-up assessments were not performed.
A resident with advanced dementia, recent falls, and a lumbar fracture was admitted without timely completion of a fall risk assessment or baseline care plan. Despite being placed on alarms and moved closer to the nurses' station, individualized fall prevention interventions were not documented or communicated as required. The resident subsequently experienced an unwitnessed fall, sustaining an abrasion, and staff confirmed that care planning was not completed within the expected timeframe.
The facility failed to ensure complete and reviewed healthcare documentation for new hires, affecting all sampled employees. Records showed incomplete Medical History Questionnaires, missing or unreviewed Tuberculosis Screening Questionnaires, and incomplete Hepatitis B forms. Interviews confirmed these deficiencies, indicating a systemic issue in handling new hire healthcare documentation.
The facility's laundry area, including the ante room, storage room, and dirty laundry area, was found to be unsanitary during an inspection. Observations revealed dusty floors, debris, and improperly stored items, including water-damaged cardboard boxes and a soap scum-covered sink. Interviews with the Facility Administrator and Infection Control Preventionist indicated that the area was rarely inspected, and the Housekeeping/Laundry Supervisor had not addressed the cleanliness issues despite being instructed to do so. These conditions had the potential to affect all laundry staff and residents.
The facility failed to provide necessary bathing assistance to residents, affecting four out of five sampled individuals. A resident with a fractured pelvis had not received a bath since early December, while another resident at risk for skin breakdown had only two baths in December. A hospice care resident had no recorded baths in the previous 30 days, and another resident with a suprapubic catheter also lacked documented showers. Staffing issues and the termination of the bath aide contributed to the deficiency, as confirmed by the Facility Administrator.
The facility failed to maintain a clean and safe environment for residents, as evidenced by soiled wheelchairs and unclean bathrooms. Observations revealed that wheelchairs were not regularly cleaned, with visible debris on wheels and frames. Bathrooms had soiled exhaust vents and toilets, and sinks with drainage issues. These deficiencies were confirmed by the Facility Administrator, who acknowledged the need for cleaning and maintenance.
A facility failed to involve a resident and their representative in quarterly care plan meetings as required. Despite policies mandating invitations and documentation, there was no record of the resident or their family being invited to or attending care plan meetings throughout the year. The Social Services Director confirmed the absence of documentation regarding the resident's participation in these meetings.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss due to the facility's failure to monitor and address nutritional needs. Despite a care plan including a modified diet and supplements, the facility did not effectively communicate weight changes or provide consistent nutritional support, leading to continued weight loss.
A resident with severe cognitive impairment was prescribed Amitriptyline for shingles pain, but continued its use without a documented indication or monitoring. The facility's policy requires drug regimens to be free from unnecessary drugs, yet the resident's care plan lacked documentation of the antidepressant use or related interventions.
A facility failed to follow physician orders for bowel protocols for a resident with severe cognitive impairment and constipation. Despite the resident not having a bowel movement for several days, the prescribed interventions, including medications and physician communication, were not carried out as per the facility's policy.
Failure to Follow Physician Orders and Complete Required Assessments for Resident with Respiratory Issues
Penalty
Summary
The facility failed to follow physician orders and ensure appropriate follow-up assessments for a resident experiencing respiratory issues. Record reviews showed that the facility's policy required thorough evaluation and documentation when a resident had a change in condition, including the use of a Change in Condition Evaluation (CICE) form and communication with providers. However, for the resident in question, there was no evidence that a CICE was completed despite multiple episodes of wheezing and cough, and repeated administration of Ipratropium-Albuterol Inhalation Solution both as scheduled and as needed. Documentation revealed that the resident received several PRN and scheduled nebulizer treatments for wheezing and cough, with varying effectiveness noted by different staff members, including medication aides and nurses. There were instances where the effectiveness of the medication was not properly assessed or documented, and in some cases, medication aides, rather than licensed nurses, were monitoring the efficacy of the treatments. Communication with the physician was documented regarding the resident's worsening symptoms, but there was no evidence that follow-up assessments or changes in treatment were consistently implemented as directed. Interviews with staff, including an LPN and the Director of Nursing Services, confirmed that assessments were not completed as required and that medication aides should not have been responsible for monitoring the effectiveness of the nebulizer treatments. The DNS acknowledged that more could have been done by the nursing staff in response to the resident's change in condition, and that the facility did not adhere to its own policies or physician orders regarding assessment and follow-up care.
Failure to Timely Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to implement a timely and appropriate plan of care to prevent potential injuries for a resident with significant fall risk factors. Upon admission, the resident had a history of multiple recent falls, advanced dementia, and a lumbar fracture, and was unable to communicate effectively. Although the facility's fall prevention policy required completion of a fall risk assessment and baseline care plan (BCP) upon admission, no Falls Tool UDA assessment was completed, and the BCP was not available in the care plan binder at the time of review. The resident was placed on alarms at the request of a family member, and staff were instructed to move the resident closer to the nurses' station, but these interventions were not documented in a timely care plan. The resident was monitored for various health conditions, but the lack of a completed BCP and fall risk assessment meant that individualized interventions to prevent accidents were not formally established or communicated to staff. Subsequently, the resident was found on the floor after an unwitnessed fall, resulting in an abrasion to the right eyebrow. Interviews with staff confirmed that the BCP was not completed within the expected timeframe, and the Director of Nursing acknowledged that interventions were not implemented in a timely manner to prevent accidents for this resident.
Incomplete Employee Healthcare Documentation
Penalty
Summary
The facility failed to ensure that employee healthcare questionnaires were completed, reviewed, and maintained prior to the hire dates for all five sampled employees. This deficiency was identified through record reviews and interviews with the Facility Administrator (FA). The General Orientation Packet (GOP) provided to new hires included several required documents, such as the Medical History Questionnaire, Employee/Candidate Tuberculosis Screening Questionnaire, Hepatitis B Consent and Immunization Form, and Hepatitis B Vaccination Declination. However, the records for the sampled employees showed incomplete documentation and lack of review by facility staff. For instance, the employment file for the Minimum Data Set (MDS) Nurse contained only a Communicable Disease Screening document, with no evidence of review by facility staff. Similarly, the Facility Driver's file had a Tuberculosis Screening Questionnaire reviewed by the Infection Control Preventionist, but no other healthcare information. Other employees, such as Cook-K and Nurse Aide (NA)-L, had incomplete Medical History Questionnaires and missing or incomplete Hepatitis B forms. The Maintenance Technician's file also lacked completed documentation. Interviews with the FA confirmed these deficiencies in the personnel files, indicating a systemic issue in the facility's process for handling new hire healthcare documentation.
Unsanitary Conditions in Laundry Area
Penalty
Summary
The facility failed to maintain a sanitary environment in the laundry area, which included the ante room, storage room, and dirty laundry area. During an initial observation tour, it was noted that the ante room contained dusty floors with dirt debris, brownish gray fuzzy matter, and paper trash. Items such as blankets, cardboard boxes, and a metal mouse trap were improperly stored, contributing to the unsanitary conditions. The storage room had a large framed print covered in grey fuzzy substance, and the floor was littered with debris, paper, and overflowing cardboard boxes. In the dirty laundry area, soiled clothing was sorted into containers, but the area was cluttered with water-damaged cardboard boxes, a soap scum-covered sink, and a linen scale and vent covered in grey fuzzy substance. Interviews with the Facility Administrator (FA) and Infection Control Preventionist (IP) revealed that the laundry area was rarely inspected by the IP, and the lack of cleanliness and infection control had been overlooked. The FA acknowledged that the Housekeeping/Laundry Supervisor (EVS) had been instructed multiple times to clean the area but had not done so until the day of the inspection. The unsanitary conditions in the laundry department had the potential to affect all laundry staff and residents, with a current facility census of 44.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to ensure that residents who required assistance with bathing were provided with the necessary care, affecting four out of five sampled residents. Resident 1, who was cognitively intact and required assistance due to a fractured pelvis, had not received a bath since early December, despite expressing a desire for a whirlpool bath. The resident's family intervened, leading to a bath being provided on January 1, 2025. Resident 20, who was at risk for skin breakdown due to morbid obesity, had only received two baths in December and expressed fear of showering alone due to flooding issues in the bathroom. Nursing staff confirmed a lack of training in using the whirlpool bath. Resident 252, admitted for hospice care, required assistance with activities of daily living, including bathing, but had no recorded baths in the previous 30 days. The resident used shower wipes instead of bathing due to early dressing changes and required assistance with oxygen management during showers. Observations revealed signs of inadequate hygiene, such as yellow crusted exudate on the resident's leg. Resident 203, who required assistance with bathing due to a suprapubic catheter, also had no recorded showers in the 30-day look-back period. Observations showed the resident in a soiled hospital gown with unshaven facial hair and food residue around the mouth. The Facility Administrator acknowledged the issue, citing staffing concerns and the termination of the bath aide as contributing factors to the deficiency. The lack of proper charting and documentation for bathing tasks was confirmed, indicating a systemic issue in providing adequate hygiene care for residents. The deficiency highlights a failure to adhere to the facility's policy and procedure for bathing, which aims to promote cleanliness, comfort, and safety for residents.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to ensure that resident equipment was cleaned and maintained, affecting the residents' right to a dignified existence. Observations revealed that wheelchairs used by several residents were soiled with various types of debris, including tan, gray, and brown crusty substances. These observations were confirmed by the Facility Administrator (FA), who acknowledged that the wheelchairs needed cleaning. Interviews with nurse aides revealed that wheelchairs were rarely cleaned and were not on a regular cleaning schedule, despite the expectation that the night shift was supposed to clean them weekly or biweekly. In addition to the issues with wheelchair cleanliness, the facility also failed to maintain a clean and safe environment in residents' bathrooms. Observations showed that bathroom exhaust vents were soiled with fluffy gray debris, and toilets had missing caulking and were soiled with brown and yellow debris. These conditions were confirmed by the FA, who acknowledged the need for cleaning and maintenance in these areas. Furthermore, the facility did not address issues with bathroom sinks, where water was observed to rise and drain slowly, indicating a problem with the drainage system. This was observed in the bathrooms of multiple residents, and the FA confirmed that the drains were not functioning properly and needed to be fixed. These deficiencies highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents, as required by regulations.
Failure to Involve Resident and Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided the opportunity to participate in quarterly care plan reviews as required. Specifically, Resident 29, who had a Power of Attorney (POA) for healthcare, was not invited to participate in care plan meetings throughout 2024. The facility's policy mandates that residents and their representatives be invited to care plan meetings at least two weeks in advance, and any absence of invitation must be documented in the medical record. However, there was no documentation of Resident 29 or their family being invited to or attending care plan meetings, nor was there any explanation for their absence. Interviews and record reviews revealed that the facility's Social Services Director confirmed the lack of documentation regarding Resident 29's participation in care plan meetings. Despite a care plan conference being scheduled in August 2024, there was no follow-up documentation indicating that the meeting occurred or that the resident or family participated. This oversight persisted throughout the year, with no records of care plan meetings or invitations being extended to Resident 29 or their representative, leading to a deficiency in the facility's compliance with care planning requirements.
Failure to Address Resident's Weight Loss
Penalty
Summary
The facility failed to adequately monitor and address ongoing weight loss for a resident with severe cognitive impairment and multiple health issues, including dementia, type 2 diabetes, GERD, and dysphagia. The resident, who was admitted with a weight of 150 lbs, experienced a significant weight loss of 16% over six months, dropping to 125 lbs. Despite the facility's policy to weigh residents at nutritional risk weekly and notify relevant parties of significant weight changes, the resident's weight loss was not effectively managed or communicated to the physician. The care plan for the resident included interventions such as a texture-modified diet, fortified foods, and nutritional supplements like Boost. However, the facility's dietary offerings were limited, and the interdisciplinary team, including the registered dietician, did not review the resident's case regularly, believing no further actions were necessary. This lack of ongoing assessment and intervention contributed to the resident's continued weight loss. Interviews with facility staff revealed gaps in communication and implementation of the care plan. The dietary manager and registered dietician did not communicate the resident's weight loss to the physician, and the facility staff failed to provide mid-day snacks to the resident. Additionally, the resident's intake of nutritional supplements varied, and staff did not consistently encourage consumption. These inactions and oversights led to the deficiency in maintaining the resident's nutritional status.
Lack of Clinical Rationale and Monitoring for Antidepressant Use
Penalty
Summary
The facility failed to provide a clinical rationale and monitoring for the use of psychotropic medication for a resident, identified as Resident 27. The facility's policy on psychotropic medications, dated 12/30/2024, mandates that each resident's drug regimen must be free from unnecessary drugs, defined as those used without adequate indications or monitoring. A review of Resident 27's records revealed that the resident was taking Amitriptyline, an antidepressant, without a documented indication for its use. The medication was initially prescribed for pain associated with shingles, a condition that typically resolves within a few weeks, yet the resident continued to take the medication without a current diagnosis related to depression or any other documented indication. Further examination of Resident 27's records showed that the resident had a severe cognitive impairment, as indicated by a BIMS score of 00/15, and the PHQ-2 to 9 was not completed due to no response from the resident. The resident's care plan did not reflect the use of the antidepressant or any related interventions, and there was no order in place for monitoring the medication's use. Interviews with facility staff, including the Quality Assurance Coordinator and MDS, confirmed the lack of indication and monitoring for the continued use of Amitriptyline, highlighting a deficiency in adhering to the facility's policy and regulatory requirements for medication management.
Failure to Follow Bowel Protocols for a Resident
Penalty
Summary
The facility failed to adhere to physician orders regarding bowel protocols for Resident 38, who was admitted with diagnoses of constipation and communication deficit. The resident, who had severe cognitive impairment and required substantial assistance for activities of daily living, did not receive the prescribed bowel management interventions. According to the facility's policy, specific steps were to be taken on days 3, 4, and 5 without a bowel movement, including administering Milk of Magnesia, Senna, Dulcolax, and prune juice, and contacting the physician if no bowel movement occurred by day 5. However, a review of the Medication Administration Record for December 2024 showed that these medications were not administered, and there was no communication with the physician for further guidance. The deficiency was identified through record reviews and interviews, revealing that the facility did not initiate the bowel protocols as ordered for Resident 38 during December 2024. The Quality Assurance Coordinator confirmed that the protocols were not followed, resulting in the resident experiencing extended periods without a bowel movement. This oversight highlights a failure in the facility's adherence to established bowel management protocols, as evidenced by the lack of documentation and communication regarding the resident's bowel care needs.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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