Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - St Luke's Village during CMS and state inspections, most recent first.
Unmeasured Chicken Portions Served: A dietary cook served BBQ chicken to multiple residents using tongs and unmeasured portions instead of verifying the menu-stated 3 oz serving. The cook confirmed the chicken pieces were not all the same size and that no weighing or measured scoop was used, and the DM confirmed the protein portions were not measured to match the recipe.
Medication administration errors exceeded the allowed rate, with surveyors finding a 20% error rate based on 25 observations. An RN failed to prime and properly hold an insulin pen for a resident receiving Humalog, a MA contaminated and gave ophthalmic drops too close together for a resident with dry eyes, another MA administered budesonide-formoterol without the ordered rinse-and-spit step, and tamsulosin was given at the wrong time instead of after the evening meal.
A medication aide failed to perform hand hygiene during a medication pass for multiple residents, including before and after administering meds, after handling a resident’s belongings and trash, and after moving between resident rooms. The aide prepared, carried, and administered medications without using ABHS or soap and water between residents, and only used hand hygiene once during the entire pass. The DON, regional educator, and IP confirmed that hand hygiene is expected for all staff, including float staff.
Failure to document non-pharmacological interventions before PRN psychotropic use. A resident with cerebral infarction, generalized weakness, and severely impaired cognitive skills had PRN lorazepam/Ativan orders for anxiety or restlessness, with specific non-pharm interventions listed in the order. On three administrations, the EMHR lacked documentation in PCC or POC of the resident’s behaviors, mood, symptoms, and responses to interventions before the medication was given, and the DON confirmed the documentation was missing.
Incomplete CAA Documentation for Two Residents: The facility failed to complete required CAA documentation for two residents after their MDSs triggered multiple care areas. For both residents, the analysis of findings lacked narrative describing the relationship between risk factors and confounding problems, and the care plan considerations sections repeatedly listed Visual Functions without an overall objective, impact statement, or rationale. The MDSC confirmed the CAAs were not completed as outlined in facility policy.
A resident with cerebral infarction, generalized weakness, impaired cognition, and prior Foley catheter use had a care plan that still reflected an indwelling catheter and EBP after the catheter was removed and the provider said not to replace it. Observations showed no Foley catheter, no EBP signage, and no isolation PPE, and the MDSC and DON confirmed the care plan was not accurate or up to date.
Failure to Hold BP Medication Outside Ordered Parameters: A resident with an order for carvedilol to be held when BP was below set limits received doses despite documented diastolic readings below the ordered threshold on multiple occasions. The MA stated the medication should be held and not signed as given when BP is outside parameters, and the DON confirmed the medication was administered when it should have been held.
Failure to provide bowel management for a dependent resident. A resident with cerebral infarction, generalized weakness, severe cognitive impairment, and bowel incontinence had no documented BM for multiple consecutive days on two separate occasions. Although PRN orders for Milk of Magnesia and bisacodyl suppository were in place, the MAR and progress notes showed no documented administration of the laxative during one episode and no documented bowel interventions during either episode; the DON confirmed the lack of documented BM.
Failure to Provide Pre-Dialysis Breakfast: A resident with ESRD receiving hemodialysis three times weekly was supposed to receive nourishment before leaving for dialysis, and the care plan also directed that a meal be sent with the resident. However, the resident repeatedly left before breakfast was provided, stated that staff did not offer breakfast before dialysis, and staff gave inconsistent accounts about whether any nourishment was being given. The DON confirmed the resident was to receive a pre-dialysis meal, but the facility had no documentation showing that it was provided.
A resident who was non-verbal, dependent for care, and reliant on a PEG tube did not receive ordered Dilantin doses on multiple occasions due to the medication being unavailable, and there was no documentation that the alternative Phenytoin was administered or that the physician was notified within 24 hours as required. The resident was later hospitalized for a seizure with low Dilantin levels, and facility records and interviews confirmed the lack of medication administration and required notifications.
A resident with Down's Syndrome, non-verbal status, and full PEG-tube dependence did not receive prescribed Dilantin and Phenytoin due to pharmacy supply issues, with multiple missed doses and inadequate documentation in the MAR. The pharmacy confirmed the medications were unavailable for several days, and there was no timely physician notification as required by policy. The resident was later hospitalized for a seizure with low Dilantin levels.
The facility did not employ a full-time RD, and the DM lacked the necessary qualifications, affecting all 41 residents consuming food prepared in the facility's kitchen.
A facility failed to ensure proper infection control during laundry delivery, as a laundry aide did not perform hand hygiene between delivering clean laundry and handling potentially soiled hangers. This was observed across multiple rooms, involving 21 residents, and was inconsistent with the facility's policy, posing a potential risk for cross-contamination.
A facility failed to ensure a RN completed their initial orientation within the required 30 days of hire, as per policy. Discrepancies in the RN's start date were noted, and it was confirmed that essential training on emergency procedures and abuse and neglect was completed well beyond the 30-day requirement. This oversight had the potential to affect all 41 residents.
A resident with dementia and a history of falls suffered a fall resulting in a major injury, which was not reported to the state or regulatory agency as required by the facility's policy. The resident, who required substantial assistance and used a wheelchair, returned from the hospital with sutures. The DON confirmed the failure to report the incident.
A facility failed to accurately complete the MDS for a resident regarding psychotropic medication use. The resident, with a primary diagnosis of hemiplegia and a BIMS score indicating no cognitive impairment, was receiving several mood-affecting medications. However, the MDS inaccurately reported that no antipsychotic medications were received. The DON confirmed the error and noted the absence of a specific MDS policy, relying instead on the RAI manual.
The facility failed to develop care plans with measurable goals and interventions for two residents with dementia, leading to deficiencies in addressing their care and treatment needs. One resident, with dementia, had no goals or interventions related to their antipsychotic medication, while another resident, cognitively intact, lacked a care plan addressing their antipsychotic and antidepressant medications. Staff confirmed the absence of specific target behaviors and interventions in the care plans.
A resident with heart failure, who had expressed a desire for CPR, was found unresponsive and not provided with life-saving measures by the nursing staff. Despite the absence of a DNR order and the resident's documented wishes, CPR was not initiated, leading to a deficiency in care.
A facility failed to provide proper bowel care management for a resident with severe cognitive impairment and chronic respiratory failure. Despite a care plan outlining interventions for constipation, no bowel movements were documented for five days, and no PRN medications were administered. The DON confirmed the absence of a bowel protocol policy and that staff did not follow the facility's expectations for bowel management.
A resident with urinary retention and incontinence experienced multiple falls while attempting to reach the bathroom independently. The facility failed to implement a scheduled toileting plan or update the care plan with interventions to prevent these falls, despite the resident's cognitive awareness and need for assistance.
The facility failed to ensure timely physician visits for two residents, as required by federal guidelines. One resident was not seen every 30 days during the initial 90-day period, and another was not seen every 60 days thereafter. The deficiency was confirmed by the DON and Administrator.
A resident's medication administration was not in accordance with facility policy, as the medication cassette label did not match the MAR. The discrepancy arose because the provider sent the order directly to the pharmacy, bypassing the facility, resulting in the MAR not being updated. The issue was confirmed by the DON and a pharmacist, who noted inconsistencies in the order communication process.
A facility failed to properly document and monitor behaviors to support the use of psychotropic medications for a resident with hemiplegia and no cognitive impairment. The resident was on multiple psychotropic medications, but the Treatment Administration Record showed incomplete documentation. Despite observed behaviors, there were no correlating progress notes, and a Gradual Dose Reduction was declined without clinical rationale. The Director of Nursing confirmed the lack of documentation and rationale, indicating a deficiency in medication management.
Unmeasured Chicken Portions Served
Penalty
Summary
The facility failed to ensure that the amount of protein served at a meal matched the portion stated on the facility-supplied menu for 32 of 36 residents. A facility document titled Dining Manager BBQ Chicken Thigh dated 2026 listed the portion description as 3 ounces of boneless chicken thigh. During meal service observation on 04/09/2026 from 11:40 AM through 12:15 PM, Dietary Cook-D used red-handled tongs to place a single piece of cooked chicken on the plates of multiple residents, including Residents 1, 5, 6, 10 through 18, 20, 21, 23, 25, 27, 29 through 32, 35, 37, 38, 46, and 47. The chicken pieces were not weighed before being served, and the residents were served the piece as placed on the plate. During the same meal service observation, Cook-D also used red-handled tongs to scoop pieces of cut-up chicken onto the plates of Residents 3, 7, 26, 34, 36, and 39 without using a measured scoop or otherwise measuring the portion. In interview, Cook-D confirmed that the chicken pieces were not all the same size and stated they did not weigh the chicken or use a measured scoop, so they did not know how much chicken/protein each resident received. The Dietary Manager later confirmed that Cook-D did not weigh or measure the chicken/protein served and should have ensured each resident received the recipe-stated 3-ounce portion.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with surveyors identifying an actual medication error rate of 20% based on 25 observations. Record review showed the facility’s policy required medication administration according to the prescriber’s order and the six rights, including correct medication, dose, resident, route, time, and documentation. The cited observations involved multiple medication administration errors by staff members during routine medication passes. For one resident with orders for Humalog KwikPen insulin, an RN administered a total of 19 units after a blood sugar reading of 295, but did not prime the insulin pen with 2 units before administration and did not hold the pen in place for the required time after injecting the dose. The RN confirmed the needle was not primed and stated the pen had not been held in place for 6 seconds after administration. Facility policy and the insulin pen instructions both required priming before each injection and holding the pen in place long enough to deliver the full dose. For another resident receiving two ophthalmic medications, a Medication Aide administered the eye drops too close together, touching the resident’s eyelashes and eye area with the dropper tip and not forming the lower eyelid pocket described in the facility procedure. The aide also gave the second eye drop about 1 minute after the first instead of waiting 5 minutes. The aide confirmed not knowing the eye drops were supposed to be separated by 5 minutes and acknowledged the bottle had touched the eyelashes, which could contaminate the bottle. Additional observations showed a Medication Aide administering budesonide-formoterol to a resident while the resident was ambulating in the hallway, and the resident did not rinse and spit after inhalation as ordered. Another resident received tamsulosin before the ordered after-meal evening time. The Medication Aide later confirmed the tamsulosin had been given at the wrong time and stated they did not always read the entire medication order. The Regional Educator confirmed the expected practices for insulin pen use, eye drop administration, budesonide inhalation, and following physician orders as written.
Hand Hygiene Not Performed During Medication Pass
Penalty
Summary
The facility failed to ensure hand hygiene was completed during medication administration between residents. During observation of a medication pass, a medication aide prepared and administered medications to multiple residents without performing hand hygiene before or after each resident encounter, despite the facility policy requiring hand hygiene before preparing or administering medications, after glove removal, and when entering or exiting a patient room. The observed medication pass included multiple instances in which the medication aide handled medications, entered resident rooms, and moved from one resident to the next without using alcohol-based hand sanitizer or soap and water. The aide prepared and gave medications to one resident, then moved on to the next resident without hand hygiene; handled crushed medications, pudding, inhalers, water cups, and medication carts without sanitizing hands between residents; and at one point went outside the facility while carrying medications and water, then returned and continued the pass without hand hygiene. The aide also assisted a resident with a wheelchair foot pedal and handled a trash can in a resident room without performing hand hygiene afterward. The report identified eight sampled residents affected by these observations. The medication aide stated that hand hygiene was only used once during the entire medication pass, after removing and replacing a resident's sock during a foot assessment. The aide confirmed that hand hygiene should occur at the start and completion of each resident's medication pass and acknowledged not using alcohol-based hand sanitizer or soap and water throughout the observed medication administration. The DON and regional educator confirmed that float staff are expected to use hand hygiene like all other staff, and the infection preventionist stated that hand hygiene is important to reduce infections.
Failure to Document Non-Pharmacological Interventions Before PRN Psychotropic Use
Penalty
Summary
The facility failed to document non-pharmacological interventions used before administering as-needed psychotropic medication for Resident 19. The resident was admitted with diagnoses of cerebral infarction and generalized muscle weakness, and the MDS dated 03/27/2026 showed short- and long-term memory problems, severely impaired cognitive skills for daily decision making, partial to moderate assistance needed with eating, and dependence on staff for transfers and toilet use. The facility policy titled Psychotropic Medications required documentation in PCC or POC of the resident’s mood, symptoms, or behaviors causing distress or endangerment and the responses to interventions used before giving a non-emergency psychotropic medication. Resident 19 had physician orders for lorazepam/Ativan every 4 hours as needed for anxiety or restlessness, with target behaviors listed as increased restlessness and calling out for help despite needs being met, and with non-pharmacological interventions identified as repositioning, offering toileting, offering a snack or drink, providing one-on-one hand holding, and taking the resident for a wheelchair ride outside if weather permitted. EMHR review showed the medication was administered on three occasions, and each time there was no documentation in PCC or POC of the resident’s observed mood, symptoms, or behaviors and no documentation of the interventions used before administration. The DON confirmed during interview that the required documentation was not present for those administrations and should have been.
Incomplete CAA Documentation for Two Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) for 2 sampled residents, Resident 9 and Resident 19, as required by the facility policy titled Minimum Data Set 3.0 Resident Assessment Instrument. The policy stated that the analysis of findings should include a narrative describing the relationship between the resident’s risk factors, complications, and confounding problems, and that the Care Plan Considerations section should indicate yes or no with a rationale for whether the care area would be addressed in the care plan. The record review showed that the CAAs for both residents did not contain the required narrative analysis or the required rationale in the care plan considerations section. For Resident 9, the comprehensive MDS dated 03/18/2026 triggered CAAs for Visual Function, Functional Abilities, Urinary Incontinence, Psychosocial Well-Being, Falls, Nutritional Status, Dental Care, Pressure Ulcer/Injury, and Psychotropic Drug Use. Review of the CAA worksheets showed that each of these areas lacked descriptive narrative in the analysis of findings section. Each also documented that Visual Functions would be addressed on the care plan, but there was no overall objective and no description of the impact or rationale for that decision. The MDSC signed the CAAs as completed on 03/20/2026. During interview on 04/13/2026, the MDSC confirmed that Resident 9’s CAAs were not completed as outlined in the facility policy and should have been. For Resident 19, the comprehensive MDS triggered CAAs for Cognitive Loss/Dementia, Visual Function, Communication, Functional Abilities, Urinary Incontinence, Psychosocial Well-Being, Activities, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, Pressure Ulcer/Injury, and Pain. Review of the CAA worksheets showed the same pattern: no descriptive narrative in the analysis of findings section for each triggered area, and the care plan considerations section repeatedly stated that Visual Functions would be addressed on the care plan without an overall objective, impact statement, or rationale. The CAAs were signed as completed by the MDSC, with one area signed by the Dietary Manager. During interview on 04/13/2026, the MDSC confirmed that Resident 19’s CAAs were not completed as outlined in the facility policy and should have been.
Care plan not updated after Foley catheter removal
Penalty
Summary
The facility failed to review and revise Resident 19’s care plan when the resident’s care needs changed. Resident 19 was admitted with diagnoses of cerebral infarction and generalized muscle weakness, and the comprehensive MDS showed short- and long-term memory problems, severely impaired cognitive skills for daily decision making, partial to moderate assistance needed with eating, dependence for transfers and toilet use, and an indwelling urinary catheter. The care plan included Enhanced Barrier Precautions related to the Foley catheter, a skin integrity focus with an intervention to watch the placement of the Foley catheter drain tube, and an activities of daily living self-performance deficit with catheter care interventions. On 04/03/2026, documentation showed Resident 19 removed the indwelling Foley catheter, and the provider was notified and directed that the catheter not be replaced at that time. Subsequent observations on 04/08/2026 and 04/09/2026 showed no visible evidence of a Foley catheter, no signage indicating Enhanced Barrier Precautions, and no isolation PPE in or outside the room. RN-B confirmed the resident no longer had a Foley catheter and was no longer on EBP, and the MDS Coordinator confirmed the care plan was not accurate or up to date because it still reflected the Foley catheter and EBP. The DON also confirmed the care plan should have reflected the resident’s current care needs.
Failure to Hold Blood Pressure Medication Outside Ordered Parameters
Penalty
Summary
The facility failed to follow a provider order to hold carvedilol when the resident’s blood pressure was outside the ordered parameters for one resident. Resident 9 had an order for carvedilol 12.5 mg twice daily, with instructions to hold the medication if systolic blood pressure was less than 100 or diastolic blood pressure was less than 55. Review of the MAR showed multiple instances in February and March 2026 where carvedilol was documented as administered even though the resident’s diastolic blood pressure was below 55, including readings of 107/53, 107/54, 102/52, 129/35, and 132/52. During interview, the medication aide stated that blood pressure is checked before giving the medication and that the medication is held and not signed as given if the blood pressure is not above the ordered parameters. The medication aide confirmed the resident should not receive carvedilol if either the systolic was not greater than 100 or the diastolic was not greater than 55. The DON also confirmed that the carvedilol should have been held and not administered when the resident’s blood pressure was outside the provider’s ordered parameters, and that the resident received the medication when it should not have been given.
Failure to Provide Bowel Management for a Dependent Resident
Penalty
Summary
The facility failed to provide care and services to promote regular bowel movements for Resident 19. The resident was admitted with a diagnosis of cerebral infarction and generalized muscle weakness, and the MDS documented short- and long-term memory problems, severely impaired cognitive skills for daily decision making, dependence on staff for transfers and toilet use, partial to moderate assistance with eating, and that the resident was always incontinent of bowel. A facility bowel protocol directed staff to take escalating interventions when bowel movements were absent over several days, including prune juice, Milk of Magnesia, a suppository, and an enema. Record review showed that Resident 19 had no documented bowel movement for six consecutive days in late March 2026 and five consecutive days in early April 2026. During both periods, the MAR showed that Milk of Magnesia was ordered as needed for constipation, but it was not signed as administered on the days without bowel movements, and the bisacodyl suppository was only documented as administered once during the March episode and not during the April episode. Progress notes for both time periods contained no documentation of a bowel movement or any intervention to promote one. In interview, the DON confirmed that Resident 19 went without a documented bowel movement during the identified periods.
Failure to Provide Pre-Dialysis Breakfast
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis was provided appropriate nourishment before dialysis trips. Resident 3 had end stage renal disease and received hemodialysis three times weekly on Monday, Wednesday, and Friday with a chair time of 7:00 AM for about 4 hours. The resident’s care plan directed that a meal be sent to dialysis on dialysis days, and the facility’s dialysis coordination agreement stated that residents should be prepared to spend an extended length of time at the dialysis center and have received proper nourishment before coming to the dialysis center. Record review showed that breakfast was repeatedly documented as “Resident Not Available” on multiple dialysis mornings, while the resident ate breakfast on non-dialysis days. The resident stated that they left for dialysis around 7:15 AM, did not get breakfast before leaving, and that staff did not ask whether they wanted breakfast before dialysis. The resident also stated they would like breakfast before leaving for dialysis. On one non-dialysis morning, the resident was observed eating and finished 100% of the breakfast meal, showing that the resident did eat breakfast when it was provided at the facility. Interviews with staff showed inconsistent understanding of whether breakfast was being provided before dialysis. A nurse aide was unsure if the resident got breakfast before leaving, the transportation driver thought the resident ate before dialysis, and the RN stated that nourishment was probably provided by night staff, like toast, with early morning medications. The dietary manager confirmed the resident did not receive the breakfast meal prior to leaving for dialysis, and the DON confirmed the resident was to be provided a pre-dialysis meal but the facility did not have documentation of pre-dialysis meals provided to the resident.
Failure to Administer Ordered Anticonvulsant Medication and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for a resident who was non-verbal, had Down's Syndrome, was dependent for all care needs, and relied on a PEG tube for nutrition and medication administration. The resident had physician orders for Dilantin Oral Suspension to be given twice daily via PEG tube, and for Phenytoin Oral Tablet to be given via PEG tube every 12 hours as needed if the liquid Dilantin was unavailable. Record reviews revealed that there were multiple instances in March and April where Dilantin was not administered as ordered, with documentation on the Medication Administration Record (MAR) indicating 'drug not available' or referencing nurse notes, and with no documentation that Phenytoin was administered as an alternative during these periods. Communication with the pharmacy confirmed that neither Dilantin nor Phenytoin was available for several days, and there was no evidence that the physician was notified within 24 hours of the medication being unavailable, as required by facility policy. Progress notes and MARs lacked documentation of administration or physician notification for the missed doses. The resident was subsequently hospitalized due to a seizure, with hospital records indicating low Dilantin levels and a new order to increase the medication. Interviews with the DON and Administrator confirmed the lack of documentation for medication administration and physician notification during the periods when the medication was unavailable. Facility policy required provider notification and completion of a SAFE Event Report for medication errors, but these actions were not documented as completed.
Failure to Provide and Document Essential Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure that pharmacy services provided necessary medications for a resident with Down's Syndrome, who was non-verbal, dependent for all care needs, and fully reliant on PEG-tube feedings. The resident was prescribed Dilantin Oral Suspension to be administered twice daily via PEG-tube, with Phenytoin Oral Tablet as an alternative if the liquid form was unavailable. Review of the Medication Administration Record (MAR) and progress notes revealed multiple instances in March and April where Dilantin was not available or not administered, and there was a lack of documentation for both Dilantin and Phenytoin on several dates. Communication records showed that the pharmacy confirmed Dilantin and Phenytoin were not available for delivery over several days. Although a nurse contacted the pharmacy regarding the medication shortage, there was no evidence that the physician was notified within 24 hours as required by facility policy. Additionally, there was insufficient documentation in the MAR and progress notes regarding the administration or non-administration of the medications during the identified periods. The resident was subsequently hospitalized due to a seizure, with hospital records indicating low Dilantin levels and a new order to increase the medication dosage. Facility interviews confirmed the absence of documentation for medication administration and the lack of timely physician notification about the unavailability of the prescribed medications.
Non-Compliance in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to ensure compliance with regulatory requirements for food and nutrition services staffing. Specifically, the facility did not employ a full-time Registered Dietitian (RD) and the Director of Food and Nutritional Services, referred to as the Dietary Manager (DM), did not possess the necessary educational degree or certification. The DM had completed 270 contact hours in a nutrition and food service professional training program, but there was no evidence of certification from this training. An interview with the DM confirmed the lack of required qualifications, and an interview with the RD confirmed their part-time status and the DM's non-compliance with educational requirements. This deficiency had the potential to affect all 41 residents consuming food prepared in the facility's kitchen.
Inadequate Hand Hygiene During Laundry Delivery
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the delivery of laundry services. Observations revealed that a laundry aide, identified as LA-L, did not perform hand hygiene between delivering clean laundry to residents' rooms and handling potentially soiled hangers. The aide was seen pushing a covered cart, retrieving clothing items from the cart, and entering multiple residents' rooms to deliver these items. Upon exiting the rooms, the aide collected empty hangers and placed them back into the covered cart without performing hand hygiene, as required by the facility's policy. This deficiency was observed across multiple rooms and involved 21 residents, indicating a systemic issue in the facility's infection control practices. The facility's policy mandates that clean linen carts be covered at all times and that hand hygiene be performed between laundry passes to prevent cross-contamination. However, the aide's actions were inconsistent with these requirements, as confirmed by the facility administrator during an interview. The failure to adhere to these infection prevention procedures posed a potential risk for cross-contamination among the residents.
Failure to Complete Staff Orientation Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a staff member, specifically a Registered Nurse (RN), completed their initial orientation within the required 30 days of hire, as per the facility's policy. The orientation policy, dated July 21, 2023, mandates completion within 30 days of the employee's start date. However, records show discrepancies in the RN's start date, with one document listing it as June 25, 2024, and another as May 31, 2025. Despite these inconsistencies, it was confirmed through interviews with the Director of Nursing Services and the facility Administrator that the RN did not complete the orientation within the stipulated timeframe. The orientation included essential training on emergency procedures and abuse and neglect, which were completed on September 18, 2024, well beyond the 30-day requirement. This oversight had the potential to affect all 41 residents residing in the facility.
Failure to Report Resident Fall with Major Injury
Penalty
Summary
The facility failed to report an accident with a major injury within the required time frames for a resident. The resident, who was admitted with diagnoses of dementia, a history of falls, and atrial fibrillation, suffered a fall and was taken to the hospital for care. Upon returning to the facility on the same day, the resident had sutures to the right hand. Despite the facility's policy on Fall Prevention and Management, which mandates reporting such incidents to the state and regulatory agency, the incident was not reported. The resident's quarterly Minimum Data Set (MDS) indicated moderate cognitive impairment, requiring substantial assistance with daily activities and using a wheelchair for mobility. The Director of Nursing Services confirmed that the facility did not adhere to its policy or regulatory guidelines by failing to report the fall with injury. This oversight was identified through record review, observation, and interview during the survey process.
Inaccurate MDS Assessment for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident regarding the use of psychotropic medications. Specifically, the MDS for a resident with a primary diagnosis of hemiplegia and a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, inaccurately reported the use of antipsychotic medications. The resident was receiving several medications affecting mood and behavior, including Clonazepam, Escitalopram Oxalate, Mirtazapine, and Olanzapine, yet the MDS section N0450 was incorrectly coded to indicate that no antipsychotic medications were received. The Director of Nursing (DON) confirmed the coding error upon review of the MDS and acknowledged that the facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) manual. The RAI manual requires that assessments accurately reflect the resident's status, as per federal regulations. This deficiency was identified through record review and an interview with the DON, highlighting a lapse in the facility's assessment process.
Deficiency in Care Plan Development for Residents with Dementia
Penalty
Summary
The facility failed to develop care plans with measurable goals and interventions for two residents with dementia, leading to deficiencies in addressing their care and treatment needs. Resident 31, admitted with dementia, was found to have no measurable goals or interventions related to their antipsychotic medication on their care plan. Interviews with staff, including a nurse aide and an LPN, confirmed that specific target behaviors were not documented in the resident's treatment administration record or care plan, despite the resident exhibiting repetitive behaviors. Similarly, Resident 35, who was cognitively intact and admitted with type 2 diabetes, hypertension, and urinary retention, also lacked a care plan with measurable goals or interventions for their antipsychotic and antidepressant medications. Staff interviews revealed that the resident displayed impatience and short-tempered behavior when waiting for assistance, yet these behaviors were not addressed in the care plan. The Director of Nursing Services confirmed the absence of specific target behaviors and interventions in the care plans for both residents.
Failure to Initiate CPR for Resident Requesting Resuscitation
Penalty
Summary
The facility failed to provide life-saving measures to a resident who had expressed a desire for cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Resident 39, who was admitted with acute on chronic diastolic heart failure, had documented wishes for CPR to be performed. However, when the resident was found unresponsive, cool to the touch, and with blue discoloration around the mouth, CPR was not initiated by the nursing staff on duty. The incident occurred when two Nursing Assistants (NAs) reported to the Registered Nurse (RN) on duty that Resident 39 was unresponsive. The RN, who was occupied with another deceased resident's family and mortician, delayed attending to Resident 39. Upon checking the resident, the RN found no pulse and noted the resident's cold extremities and discoloration. Despite the resident's documented wishes for CPR, the RN did not initiate resuscitation efforts and instead contacted the Director of Nursing Services (DNS) to discuss the situation. The DNS confirmed that the staff was not re-educated on the facility's CPR policy following the incident. The facility's policy mandates the initiation of CPR unless there is a valid Do Not Resuscitate (DNR) order or obvious signs of clinical death, neither of which applied to Resident 39. The failure to perform CPR was a deviation from the resident's expressed wishes and the facility's policy, resulting in a deficiency in the standard of care provided.
Failure in Bowel Care Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure proper bowel care management for a resident with severe cognitive impairment and chronic respiratory failure with hypoxia. The resident was at risk of constipation due to decreased mobility and medication side effects. The Comprehensive Care Plan outlined specific interventions to monitor and manage constipation, including observing for signs and symptoms of complications and ensuring a bowel movement at least every three days. However, a review of the resident's records revealed no documented bowel movements for five consecutive days, and no PRN medications for bowel care were administered during this period. An interview with the Director of Nursing (DON) revealed that the facility lacked standing orders or a bowel protocol policy to prevent constipation. The facility's process required the evening nurse to review the bowel report and administer PRN medications if no bowel movement occurred in three days. If PRN medications were unavailable, the nurse was to contact the physician for orders. Despite these expectations, the DON confirmed that staff did not follow the facility's bowel management protocol for the resident, as evidenced by the lack of documentation and administration of PRN medications during the specified timeframe.
Failure to Prevent Falls Due to Inadequate Toileting Interventions
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident, identified as Resident 35, who was admitted with diagnoses including type 2 diabetes, hypertension, and urinary retention. The resident, who was cognitively intact and required supervision for toilet use and transfers, experienced multiple falls while attempting to reach the bathroom independently. Despite these incidents, the resident's care plan lacked any focus or interventions related to urinary incontinence, urinary retention, or falls due to the need to toilet. Interviews with the resident and staff revealed that the resident frequently fell due to the urgency of needing to use the bathroom and not waiting for staff assistance. The staff confirmed that the resident was not on a scheduled toileting plan, which contributed to the falls. The Director of Nursing Services acknowledged that the falls were associated with the resident's toileting needs and confirmed the absence of appropriate interventions in the care plan to address these issues.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits for two residents were conducted within the federal guidelines. According to the facility's policy, physician visits are required every 30 days for the first 90 days after admission and every 60 days thereafter. The policy also allows for a 10-day grace period for visits to be considered timely. However, the records for Resident 35 showed that the resident was not seen by their physician every 30 days during the initial 90-day period. Similarly, Resident 31 was not seen by their physician every 60 days as required. The deficiency was confirmed through interviews with the Director of Nursing Services and the Administrator, who acknowledged the failure to meet the required frequency of physician visits for both residents. The facility's policy also states that if a physician is continually late in completing required visits, the Director of Nursing Services, Administrator, and/or Medical Director should communicate with the physician to address the issue. However, the report does not mention any corrective actions taken to address the deficiency.
Medication Administration Discrepancy
Penalty
Summary
The facility failed to ensure that medications were administered according to its policy for one resident, identified as Resident 28. The facility's policy requires adherence to the Six Rights of medication administration and performing three checks to ensure accuracy. However, an observation revealed that the medication cassette for Resident 28 contained a label for Calcium Carbonate with Vitamin D, which did not match the order on the Medication Administration Record (MAR). The MAR indicated an order for Calcium Carbonate 600 mg tablets, two tablets daily, without mention of Vitamin D3, highlighting a discrepancy between the medication cassette and the MAR. The deficiency was further confirmed through interviews with the Director of Nursing Services and a pharmacist. The Director of Nursing Services acknowledged the mismatch between the medication cassette and the MAR, attributing it to the provider faxing the order directly to the pharmacy without informing the facility. This resulted in the facility not updating the MAR to reflect the new order. The pharmacist also noted inconsistencies in the process of receiving medication orders, with some physicians sending orders directly to the pharmacy, leading to changes in medication cassettes without corresponding updates to the facility's records.
Deficiency in Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper behavior monitoring and documentation to support the use of psychotropic medications for Resident 13, who was admitted with a primary diagnosis of hemiplegia and no cognitive impairment. Resident 13 was receiving multiple psychotropic medications, including Clonazepam, Escitalopram Oxalate, Mirtazapine, and Olanzapine, which required behavior monitoring. However, the Treatment Administration Record (TAR) for November 2024 through January 2025 showed numerous instances where documentation was incomplete or marked as not applicable, with several opportunities left blank or documented as zero without correlating progress notes. The facility's policy on behavior management required documentation of ongoing and repetitive behaviors by CNAs and social services or nursing staff. Despite this, there were multiple instances where target behaviors such as sad statements about the resident's spouse's death and self-isolation were not documented in progress notes, even when they were observed. Interviews with staff confirmed that Resident 13 exhibited these behaviors but had been attending more activities and meals outside of their room, indicating some improvement. Additionally, a Gradual Dose Reduction (GDR) form signed by the physician on December 19, 2024, declined a dose reduction for the antipsychotic medications without providing a clinical rationale. The Director of Nursing Services confirmed the lack of documentation to support the continued use of psychotropic medications and the absence of a clinical rationale for not attempting a dose reduction, highlighting a deficiency in the facility's medication management and documentation practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kearney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mother Hull Home | 1.5 mi | ★★★★★ | 14 | 0 |
| Good Samaritan Society - St John's | 1.5 mi | ★★★★★ | 18 | 0 |
| Mt Carmel Home - Keens Memorial | 2.1 mi | ★★★★★ | 9 | 0 |
| Brookestone Gardens | 3.7 mi | ★★★★★ | 8 | 0 |
| Bethany Home, Inc | 15.4 mi | ★★★★★ | 0 | 0 |
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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 July 2026) and official state health department websites.