Good Samaritan Society - St Luke's Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Kearney, Nebraska.
- Location
- 2201 East 32nd Street, Kearney, Nebraska 68847
- CMS Provider Number
- 285192
- Inspections on file
- 18
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Good Samaritan Society - St Luke's Village during CMS and state inspections, most recent first.
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.
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.
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.
Trusted data from CMS and state health departments
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.
Trusted by long-term care providers and associations.
