Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Shepherd Lutheran Home during CMS and state inspections, most recent first.
Unsafe transfers and resident safety measures were not followed for multiple residents. A resident with severe cognitive impairment and transfer dependence was moved with a defective sit-to-stand lift that had a broken leg strap buckle, and the Administrator confirmed the equipment should not have been used. Another resident with cognitive impairment and mobility limitations was lowered to the floor during an attempted transfer when the resident could not bear weight, resulting in a fracture. A third resident’s fall mat was observed folded against the wall instead of placed beside the bed as directed in the Kardex, and the DON confirmed it was not in the required position.
Posted nurse staffing information was missing required details, including the facility census, the total hours worked per discipline per shift, and the total hours worked for each shift. Observation of the posted staffing sheets and review of 30 days of documentation showed the same omissions, and the DON confirmed that the census and hour calculations were not included or documented.
Hand hygiene was not completed during food prep and resident dining assistance. The DM handled food, removed gloves, and continued prep tasks without cleaning hands between glove changes or after touching items such as trash, counters, and the dish area. In the dining room, an NA assisted two residents with tray setup, clothing protectors, and feeding while touching their necks and clothing without performing hand hygiene before or after resident contact.
Facility Assessment Missing Staffing and Contingency Planning Details: The facility failed to include specific staffing needs per unit and shift, a plan to support recruitment and retention of direct care staff, and a contingency plan for events that could affect resident care without activating the emergency plan. The Facility Assessment also lacked a total calculation of hours worked per shift and a list of personnel in house to meet resident needs, and the DON/Administrator confirmed these omissions during interview.
Failure to notify the PCP of significant weight gain: A resident had an order for daily weights and PCP notification for any gain over 5 lbs, but several weights were missed and multiple weight increases above the threshold were documented without provider notification in the EHR. The IP confirmed the missed weights and the lack of PCP notification.
A resident with stroke and morbid obesity had an order for oxygen at 1-2 L/min via NC, but the comprehensive care plan did not include any oxygen focus area or interventions. Staff observations showed the oxygen concentrator on while the NC was lying on the bed sheet, and the resident and DON both confirmed the resident used oxygen at night; the DON later acknowledged the oxygen was not on the care plan.
Failure to Follow Orders for Urinalysis, Oxygen Notifications, and Daily Weights: The facility did not follow a practitioner order for a UA/C&S for one resident with a suprapubic catheter and cognitive impairment, did not notify the PCP for another resident’s repeated O2 sats below 90% while on O2, and did not obtain ordered daily weights or notify the PCP of 5-lb-or-greater weight gains for a third resident. The DON and IP confirmed the missed orders and missing notifications.
The facility had significant medication errors for two residents. One resident’s Eliquis was documented as given and then changed to not available during a med pass, and the MAR showed multiple missed doses. Another resident had multiple omitted doses of Lantus Solos, levothyroxine, mirtazapine, and olanzapine, with some doses documented as refused; the DON stated nurses should attempt administration three times before charting an omission.
Staff failed to ensure privacy during wound care for a resident with severe cognitive impairment and multiple complex wounds, including MASD and Stage 3 pressure injuries. During wound treatment to the hips, the resident’s bed was positioned without a privacy curtain in place, while the roommate sat nearby eating breakfast and was able to view the resident’s exposed buttocks and all care provided. The roommate made a comment about the resident’s body, and the RN and resident laughed before the RN covered the resident, with the RN later confirming that the missing curtain for several weeks allowed the roommate to see all personal and wound care and constituted a breach of privacy and dignity.
Two residents with existing pressure injuries and complex medical conditions were found lying on pressure-relieving air mattresses that were not calibrated to their documented weights, despite care plan interventions and orders requiring proper inflation and monitoring. One resident with severe cognitive impairment, multiple open wounds, MASD, and several Stage 3 and unstageable pressure injuries had a weight of about 154 lbs, but the mattress was set to 180 lbs. Another resident with moderate cognitive impairment, diabetes, neuropathy, and a Stage 3 pressure injury to the right buttock weighed about 197 lbs, yet the mattress was set at the maximum setting of 380 lbs. An RN confirmed in both cases that the mattresses should have been set according to each resident’s weight and that incorrect settings could contribute to skin breakdown.
Staff failed to follow infection control and hand hygiene practices during wound care for three residents with Stage 3 and other complex pressure injuries. An RN allowed a resident’s brief and blanket to contact an open hip wound, did not change gloves between touching soiled items and cleansing the wound, and applied triad paste after the wound had been exposed to the blanket without re-cleaning. For another resident with a buttock pressure injury, an RN allowed wound paste to contact the brief and then handled a clean foam dressing with a contaminated glove before applying it. For a third resident with a Stage 3 buttock wound with undermining, an LPN cleansed the wound and then, without changing gloves, applied peri-wound paste and Gentelle Blue foam while repeatedly allowing the buttocks to close over the wound and dressing, creating repeated opportunities for cross contamination.
Surveyors observed that dietary staff failed to follow proper hand hygiene and gloving procedures, including inadequate hand washing and donning gloves without cleaning hands after touching contaminated surfaces. The kitchen environment was also found to be unsanitary, with rust, food and grease buildup, dirty floors, and soiled ventilation covers. The Dietary Manager confirmed these issues, and cleaning logs did not address the specific concerns identified. All residents consumed food prepared in this environment.
Staff failed to maintain infection control standards by storing resident care supplies in areas with water damage and visible mold, not changing a resident's oxygen tubing as ordered, and not using required PPE during high-contact care activities for a resident on enhanced barrier precautions. These actions resulted in multiple deficiencies related to infection prevention.
The facility did not repair ongoing roof leaks, leading to water damage and mold-like spots in the therapy gym, offices, and other areas. Despite management being aware and a partial patch repair being made, no further action was taken, and the damage persisted, potentially affecting all residents.
A deficiency was identified when surveyors found that the ventilation systems in the bathrooms of 20 occupied rooms on two halls were not operational, as demonstrated by a lack of air draw during testing. The Maintenance Director and Environmental Services Account Manager both confirmed there was no documentation of recent operational checks for these ventilation systems.
A resident repeatedly refused multiple prescribed medications for various health conditions, but the facility did not notify the medical practitioner or family as required by policy. The DON confirmed that the practitioner was not informed, and documentation of these refusals was incomplete.
A resident with multiple psychiatric and neurological diagnoses was continued on a PRN lorazepam order for six months without the required clinical rationale documented by the provider, despite facility policy and pharmacist recommendation specifying the need for such documentation. The DON confirmed the absence of the necessary rationale in the resident's record.
A resident with severe cognitive impairment and total dependence on staff was involved in a resident-to-resident abuse incident that was not reported to APS within the required 24-hour timeframe. Facility staff failed to immediately notify administration of the incident, resulting in delayed reporting despite established policy and prior staff education.
A resident with multiple medical and psychiatric diagnoses was transferred to an acute care hospital on two occasions without receiving written notification of the specific reason for transfer, as required by facility policy. The bed-hold agreements provided did not include the reason for transfer, and the Social Services Designee confirmed that this information was not communicated in writing to the resident or their representative.
A resident admitted with multiple diagnoses and significant care needs did not have a comprehensive care plan developed within the required timeframe after the MDS assessment. The care plan failed to address several identified areas, including cognition/dementia, communication, urinary incontinence, psychosocial, and dental needs, as confirmed by the MDS Coordinator.
Surveyors identified that the facility's medication error rate was 8%, exceeding the regulatory limit. Two residents were affected: one received rapid-acting insulin without a meal or snack, and another was given polyethylene glycol from a container labeled for a different resident. These errors were observed during medication administration by an RN and an LPN.
A nurse administered rapid-acting insulin to a resident without providing a meal or snack, and breakfast was not served until more than an hour later, contrary to facility policy requiring insulin to be given immediately before meals or with food.
The facility failed to ensure that the designated infection preventionist was certified, potentially affecting all residents. The Infection Preventionist admitted they were not currently certified but expected to complete the certification by May 2024. The Facility Administrator confirmed the lack of a certified Infection Preventionist.
A resident with a suprapubic catheter was observed multiple times with the catheter bag improperly positioned, touching the floor and a trash can, leading to potential cross-contamination. The DON confirmed the issue and acknowledged the need for proper positioning.
A resident with Alzheimer's disease experienced significant weight loss and severe malnutrition, but the facility failed to notify the responsible party. Despite adjustments in medication and nutritional supplements by the physician, the lack of communication was confirmed by the Director of Nursing.
Unsafe Transfers and Inadequate Resident Safety Measures
Penalty
Summary
The facility failed to implement interventions to prevent accidents for three residents. The deficiency involved unsafe transfers, failure to use required equipment, and failure to keep a fall mat in place as identified in resident care plans and facility policies. The report cited policies requiring safe resident handling, use of mechanical lifts when appropriate, monitoring of falls, and adequate supervision based on assessed needs and environmental hazards. Resident 57 had diagnoses including osteoarthritis, left hip pain, bilateral trochanteric bursitis, and osteoporosis, and the MDS showed moderate cognitive impairment with dependence on staff for transfers and lower body ADLs. The care plan required two staff assist for transfers, and therapy was evaluating transfers and weakness. On 5/2/26, Resident 57 was lowered to the floor after staff attempted to transfer the resident to bed when the resident was unable to bear weight. The resident complained of ankle pain, was sent for evaluation, and the hospital reported an acute right ankle fracture and a fracture to the top of the foot. The DON confirmed the resident’s transfer status was two assists and confirmed the causative factor was not completing the two-assist transfer. Resident 37 had diagnoses of cerebral infarction, Alzheimer’s disease, disorientation, dementia, muscle weakness, gait and mobility abnormalities, and unsteadiness on feet. The MDS showed severe cognitive impairment and dependence on staff for all ADLs except eating, with bilateral lower extremity limited range of motion. The care plan required two staff for transfers. During observation, two nursing assistants used sit-to-stand lift number 4 to transfer the resident even though the leg strap buckle was broken and could not be fastened; one staff member attempted to tie the strap and the transfer continued. The Administrator confirmed the lift was defective and should not have been used. Resident 55 had severe cognitive impairment and required assistance with multiple ADLs, including sitting-to-standing transfers. The bedside Kardex directed staff to assist the resident out of bed and place a fall mat on the left side of the bed when the resident was in bed. However, observations showed the resident in bed with the fall mat folded against the wall rather than on the floor beside the bed, and the DON confirmed the mat was not in the required position.
Posted Nurse Staffing Information Missing Required Details
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information included the required facility census, the total number of hours worked per discipline per shift, and the total number of hours worked for each shift. The facility census was 62. Record review of an undated facility policy titled "Posting Direct Care Daily Staffing Numbers" stated that the daily posting should include the facility name, current date, resident census at the beginning of the shift, the 24-hour shift schedule, the shift being posted, the type and category of nursing staff working during that shift, the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and unlicensed nursing staff working for the posted shift. Observation on 05/19/26 at 3:20 PM and 05/20/26 at 3:25 PM showed that the posted nursing staffing information for 05/18/26, 05/19/26, and 05/20/26 did not contain the facility census, a calculation of the number of hours worked per discipline per shift, or the total number of hours worked per shift and daily. Review of 30 days of posted nurse staffing documentation from 04/18/26 through 05/20/26 showed the same omissions. During interview on 05/21/2026 at 8:34 AM, the DON confirmed that the facility census was not included on the past 30 days of posted nurse staffing information and that no calculation of hours worked per discipline or total hours worked had been completed or documented.
Hand Hygiene Not Performed During Food Prep and Resident Dining Assistance
Penalty
Summary
The facility failed to ensure hand hygiene was completed between residents during dining service and failed to perform hand hygiene when indicated during food preparation. During meal preparation, the Dietary Manager completed hand hygiene, put on gloves, and handled individually wrapped pork chops, but then removed soiled gloves and did not perform hand hygiene before touching clean baking sheets, lining the sheets with parchment paper, opening more pork chops, discarding trash, washing the counter with a sanitizer washcloth, going to the dish area, retrieving potato salad from the walk-in, and opening the potato salad containers. The Dietary Manager later confirmed that hand hygiene was not completed between glove changes and should have been. During dining service, a Nursing Assistant entered the dining room and assisted Resident 58 with setting up the meal tray and applying a clothing protector while touching the resident's neck and clothing without performing hand hygiene. The Nursing Assistant then approached Resident 62 and applied a clothing protector while touching the resident's neck and clothing before sitting beside the resident to assist with eating. No hand hygiene was performed before or after contact with Resident 58, or before contact with Resident 62. The DON confirmed the Nursing Assistant should have completed hand hygiene before and after resident contact in the dining room.
Facility Assessment Missing Staffing and Contingency Planning Details
Penalty
Summary
The facility failed to ensure that its facility assessment included information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for events that do not require activation of the facility emergency plan but still have the potential to affect resident care. The report states that the facility census was 62 residents, and the deficiency had the potential to affect all residents who resided in the facility. A record review of the facility’s undated Facility Assessment policy showed that the assessment was intended to address resident population, staff competencies and skill sets, physical environment, equipment and services, cultural, ethnic, and religious factors, and facility resources, and to inform staffing decisions, including specific staffing needs per unit and each shift, recruitment and retention planning, and contingency planning for non-emergency events. However, the Facility Assessment dated [DATE] contained no information related to specific staffing needs per unit and each shift, no total calculation of hours worked per shift, no plan for staff development or retention, and no contingency plan for events that could affect residents without activating the emergency plan. During interview on 05/21/2026 at 7:20 AM, the Administrator confirmed that the assessment did not include specific staffing needs per unit per shift, did not list specific personnel in house to meet resident needs, did not cover staffing levels with numbers of staff needed for each shift, and did not include recruitment, retention, or contingency planning.
Failure to Notify PCP of Significant Weight Gain
Penalty
Summary
The facility failed to notify the resident’s PCP of a weight gain greater than 5 pounds for Resident 7, despite an order to obtain daily weights and report any gain over 5 pounds. Record review showed multiple missed weight checks in April and May 2026, including on 4/9, 4/15, 4/16, 4/22, 4/23, 4/25, 4/29, 4/30, 5/1, 5/6, and 5/14. The resident’s EHR also showed no provider notification for several documented weight increases over the ordered threshold. Resident 7’s record showed weight gains of 7 pounds on 4/7/2026, 7.2 pounds on 4/24/2026, 5.4 pounds on 4/28/2026, and 8.2 pounds on 5/10/2026, with no notification to the PCP documented in the EHR. During interview, the Infection Preventionist confirmed the missed weights and confirmed there was no provider notification in the resident’s record regarding the 5-pound-or-greater weight gain.
Failure to Include Oxygen Interventions in Care Plan
Penalty
Summary
The facility failed to add oxygen interventions to the comprehensive care plan for Resident 22. The resident was admitted with diagnoses of cerebral infarction (stroke) and morbid obesity, had a BIMS score of 14 indicating cognitive awareness, and required varying levels of assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, bathing, footwear, bed mobility, and transfers. The resident also had a physician order for oxygen at 1-2 liters per minute via nasal cannula, with instructions to notify the PCP if oxygen saturations were less than 90%. The care plan report with an admission date of 11/10/2025 did not include a focus area or interventions for oxygen. Observations showed the oxygen concentrator was on while the nasal cannula was lying on the bed sheet, and the resident was not in the room during multiple observations. In interview, the resident stated oxygen was worn only at night, and the DON confirmed the resident was on oxygen at night and later acknowledged that oxygen was not on the care plan and should have been.
Failure to Follow Orders for Urinalysis, Oxygen Notifications, and Daily Weights
Penalty
Summary
The facility failed to follow a practitioner order for a urinalysis screen/culture for a resident with vascular dementia, moderate cognitive impairment, acute and chronic respiratory failure with hypoxia, neurogenic bladder with suprapubic catheter, and hypertension. The order was written on 5/23/26 at 3:00 PM, but the urinalysis was not obtained until 5/25/26 at 12:56 PM. The DON confirmed in interview that the order was not followed as written and should have been. The facility also failed to follow a physician order for oxygen monitoring for a resident with diagnoses of cerebral infarction and morbid obesity who was receiving oxygen at 1-2 liters per minute via nasal cannula. The resident’s MDS showed a BIMS of 14 and required assistance with multiple activities of daily living. The physician order required notification of the PCP if oxygen saturations were less than 90%, but the resident had multiple documented oxygen saturation readings below 90%, including readings of 84%, 88%, 77%, 87%, 89%, 82%, 86%, 84%, 78%, and 89%. The resident’s progress notes and uploaded files did not show that the PCP had been notified of these low oxygen saturation levels, and the DON confirmed that notification had not been done. The facility further failed to obtain daily weights and notify the PCP of weight gains of 5 pounds or more for a resident whose practitioner ordered daily weights and PCP notification for weight gain greater than 5 pounds. The MAR/TAR showed multiple dates when weights were not obtained, including 4/9/26, 4/15/26, 4/16/26, 4/22/26, 4/23/26, 4/25/26, 4/29/26, 4/30/26, 5/1/26, 5/6/26, and 5/14/26. The EHR also showed no provider notification for weight increases of 7 pounds, 7.2 pounds, 5.4 pounds, and 8.2 pounds. The IP confirmed the missed weights and confirmed there was no notification to the provider regarding the 5-pound-or-greater weight gains.
Significant medication errors involving omitted and misdocumented doses
Penalty
Summary
The facility failed to prevent significant medication errors for 2 of 13 residents sampled. The cited deficiency involved medications that were not administered as ordered and, in one case, documentation that was changed after the fact. Facility policy stated that when a medication is unavailable, nursing staff are to verify availability, contact the pharmacy, use the eBox when applicable, notify the provider if the medication remains unavailable, and document actions taken. Another facility policy stated that medication omission is a medication error and includes medication not given in accordance with the prescriber’s order. For one resident, the record showed an order for Eliquis 5 mg twice daily for atrial fibrillation. During a medication pass, the RN stated the medication was not available and then went back into the EHR and changed the documentation to medication not available. In interview, the RN confirmed she had documented the medication as given and then changed it to not available. The resident’s MAR also showed multiple dates when Eliquis was documented as not available and not given. For the second resident, the record showed orders for Lantus Solos, levothyroxine, mirtazapine, and olanzapine. The MAR showed multiple instances when levothyroxine, Lantus Solos, mirtazapine, and olanzapine were not administered as scheduled, along with some refusals documented for Lantus Solos. The DON stated nurses should attempt to administer a medication three times before charting an omission and should document the three attempts in the progress notes. The IP confirmed the listed medications were not administered on the dates identified.
Failure to Ensure Privacy During Wound Care
Penalty
Summary
Facility staff failed to maintain privacy and confidentiality during personal and medical care for one resident. The resident had been admitted to the facility on an unspecified date and had a BIMS score of 5, indicating severe cognitive impairment. The resident’s care plan and clinical profile documented multiple significant medical conditions, including lymphedema, venous insufficiency, osteoarthritis, rheumatoid arthritis, multiple open wounds on the buttocks and lower extremities, pressure ulcers on both heels, severe protein calorie malnutrition, metabolic encephalopathy, and various staged pressure injuries and moisture-associated skin damage. The resident had physician orders for specific wound care to the right and left posterior hips, including cleansing with saline, application of triad paste and silver alginate, and covering with a silicone superabsorbent dressing. During an observation of wound care performed by an RN, the resident’s bed was in a low position with a fall mat beside it, and the resident was lying on their left side. The room did not have a privacy curtain, and it had been missing for a few weeks. While the RN provided wound care, the resident’s roommate was seated at the side of their own bed eating breakfast and was able to see the resident’s exposed buttocks and all personal and wound care being provided. The roommate commented, “nice butt,” and both the resident and the RN laughed before the RN covered the resident with a blanket. In a subsequent interview, the RN confirmed that the lack of a privacy curtain allowed the roommate to view all aspects of the resident’s care and acknowledged this as a breach of the resident’s privacy and dignity.
Improper Calibration of Pressure-Relieving Air Mattresses for Residents With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pressure-relieving air mattresses were inflated according to residents’ weights, as required by physician orders and care plan interventions. For one resident with severe cognitive impairment and multiple complex medical conditions, including lymphedema, venous insufficiency, osteoarthritis, rheumatoid arthritis, severe protein-calorie malnutrition, metabolic encephalopathy, and numerous open wounds and pressure injuries (including MASD to both buttocks, unstageable and Stage 3 pressure injuries on the heels, legs, hip, and root), the care plan and orders specified use of an air mattress with monitoring to ensure it was inflated and functioning properly. The resident’s weight was documented as 154.3 lbs, but during observation the air mattress was found set at 180 lbs. The RN interviewed confirmed the mattress setting did not match the resident’s weight and acknowledged that the mattress should be calibrated according to the individual’s weight and that an incorrectly set mattress could contribute to skin breakdown. A second resident, who was moderately cognitively impaired and had diagnoses including type 2 diabetes, prior right tibia fracture, spinal stenosis, polyneuritis, arthropathy, and osteoarthritis, had a documented Stage 3 pressure injury to the right buttock. Skin observation notes by the ADON described the wound measurements and identified it as a pressure injury, and the resident’s care plan included an intervention for an air mattress. The resident’s weight was documented as 196.9 lbs. However, during observation, this resident’s pressure-relieving air mattress was found set at the maximum inflation setting of 380 lbs rather than being adjusted to the resident’s actual weight. In both cases, the facility had established care plan interventions and physician orders requiring that the air mattresses be properly inflated and functioning, with specific monitoring instructions. Despite these directives, surveyor observations and staff interviews confirmed that the mattresses for two residents with existing pressure injuries were not calibrated according to their documented weights. The RN acknowledged in each instance that the settings were incorrect and that the mattresses should have been set based on the residents’ weights, and further confirmed that incorrect inflation could contribute to skin breakdown.
Improper Wound Care Technique Leading to Cross Contamination Risk
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented cross contamination for three residents, despite having infection control and hand hygiene policies in place. The facility’s Infection Control Guidelines and Handwashing policy required staff to perform hand hygiene after handling items potentially contaminated with blood, body fluids, secretions, contaminated linens, and after contact with broken skin. These policies also directed staff to use alcohol-based hand rub before and after direct resident contact and when moving from dirty to clean tasks. Observations of wound care for three residents showed that these procedures were not consistently followed, resulting in multiple opportunities for cross contamination of open wounds. For one resident with multiple complex wounds and pressure injuries, including Stage 3 pressure injuries and an unstageable pressure ulcer, an RN performed wound care to the hip area in a manner that allowed the resident’s brief and blanket to come into contact with an open, undressed wound. During the dressing change, the RN removed the old dressing, pulled the brief back up over the open wound, then later pulled it down again without changing gloves between touching the brief and cleansing the wound. The RN also pushed the brief away from the wound and cleansed the wound using the same gloves without performing hand hygiene. After the blanket touched the uncovered wound, the RN re-entered the room wearing gloves, exposed the wound, and applied triad paste with a cotton-tipped applicator without changing gloves, using hand sanitizer, or re-cleaning the wound. The RN confirmed these actions, including entering the room with gloves on, not changing gloves between dirty and clean tasks, and allowing the brief and blanket to touch the open wound, created opportunities for cross contamination. For a second resident with a Stage 3 pressure injury to the right buttock, an RN conducted wound care after donning a gown and gloves and exposing the resident’s buttock. The RN used one gloved hand to reposition the buttock and the other to apply triad paste with a cotton applicator. When the RN needed both hands to peel back the adhesive on the bordered foam dressing, the resident’s wound and triad paste came into contact with the resident’s brief. The RN then used the same gloved hand that had been repositioning the buttock to handle the clean dressing and apply it to the wound. The RN acknowledged that the contact between the wound paste and the brief, and touching the clean dressing with a contaminated glove, provided opportunities for cross contamination and that hand hygiene and glove changes should have occurred before handling the clean dressing. For a third resident with dementia, sarcopenia, and a Stage 3 pressure injury with undermining to the left buttock, an LPN performed wound care using saline, triad paste, Gentelle Blue foam, and a silicone foam dressing. After exposing the resident’s buttocks and placing a chux pad, the LPN cleansed the wound with saline and patted it dry using gloved hands and gauze, but did not change the soiled gloves or perform hand hygiene before proceeding. The LPN then applied triad paste to the peri-wound area and allowed the resident’s buttocks to come together, causing contact between the wound area and the resident’s brief. The LPN separated the buttocks again to place the Gentelle Blue foam into the undermined wound, then released the buttocks, allowing them to close over the dressing, and used both hands to apply the silicone dressing. The LPN confirmed that allowing the buttocks to touch the brief and then close over the dressing, and failing to change gloves after cleaning the wound and before applying paste, created multiple opportunities for cross contamination of the wound.
Deficient Hand Hygiene and Kitchen Sanitation in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and gloving practices in the kitchen, as required by both facility policy and professional standards. Observations revealed that a dietary staff member repeatedly performed hand washing for significantly less than the required 20 seconds, often washing for only 6 to 10 seconds between tasks. The staff member also donned new gloves without performing hand hygiene after touching potentially contaminated surfaces, such as cooler door handles and storage areas, and handled food and food preparation equipment without adequate hand washing. The Dietary Manager confirmed that the observed hand hygiene practices did not meet facility policy and that all residents consumed food prepared in this kitchen. In addition to hand hygiene deficiencies, the facility kitchen was observed to have multiple sanitation concerns. These included the presence of rust on a wire dish rack, torn weather stripping on the serving window, food and grease spatters on kitchen equipment, burned and dried food residues on ovens and backsplashes, and grease and sticky substances on various surfaces. The kitchen also had non-operational ovens, dirty and sticky floors, food particles and dirt in storage and preparation areas, and heavily soiled ventilation covers directly above food preparation areas. These conditions were confirmed by the Dietary Manager during a walkthrough. Review of the facility's cleaning schedules indicated that logs were filled out as required, but the specific sanitation issues identified during the survey were not addressed in these records. The Dietary Manager acknowledged the need for cleaning and maintenance in the areas noted by surveyors but was unsure how long some equipment had been out of service. All 66 residents in the facility were potentially affected, as they consumed food prepared in the kitchen where these deficiencies were observed.
Infection Control Failures in Supply Storage, Oxygen Equipment, and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement effective infection prevention and control measures, resulting in multiple deficiencies. On the second floor, which was unoccupied by residents, surveyors observed 65 boxes of incontinent products, disinfectant cleaner, and other resident care supplies stored in rooms with missing ceiling tiles and visible black spots, which staff identified as mold. Additional observations in the therapy gym and office revealed discolored and damaged ceiling tiles, missing plaster exposing brick, and further black spots attributed to water damage from a leaking roof. Despite management and ownership being notified of the water damage, no repairs had been completed since the initial report, and there was no current plan to address the ongoing leaks or mold-like spots. For one resident, staff failed to follow physician orders and facility policy regarding oxygen tubing changes. The resident's treatment administration record required weekly changes of oxygen tubing, with proper labeling and cleaning of the concentrator. However, observations over several days showed the tubing was not changed as ordered, with dates on the tubing indicating it had not been replaced for at least eight days. The DON confirmed the tubing had not been changed and that the documentation was invalid, indicating a lapse in infection control practices related to respiratory equipment. In another case, staff did not adhere to enhanced barrier precautions for a resident with severe cognitive impairment, an indwelling medical device, and an order for contact precautions due to MRSA. During a transfer from a recliner to a wheelchair and then to bed, staff did not wear the required PPE, only donning gown and gloves after the transfer was completed. Interviews with staff confirmed that they were aware of the need for PPE during high-contact activities but failed to implement these precautions during the observed transfer.
Failure to Repair Roof Leaks Resulting in Water Damage and Mold
Penalty
Summary
The facility failed to repair leaks in the roof, resulting in ongoing water damage in multiple areas, including the therapy gym and offices. Observations revealed discolored, water-stained ceiling tiles with brown and black spots, missing plaster exposing brick, and black spots identified by staff as mold. The east window of the therapy office also had missing plaster, and similar damage was observed in the supply room on the second floor. The facility's own policy requires storage areas to be kept free from trash and debris, but the report focuses on the physical damage and lack of repair. Record reviews showed that the management company was made aware of the roof damage, and a payment was made to a roofing company for a patch repair. However, interviews with the Administrator confirmed that no further repairs had been completed since that time, and there was no current plan to address the ongoing leaks or the mold-like spots. The deficiency had the potential to affect all 66 residents in the facility, as the water damage and mold were present in common and therapy areas.
Non-Operational Ventilation Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure a working ventilation system in 20 out of 28 occupied resident rooms on the 300 and 400 halls. During an environmental inspection, it was found that the ventilation systems in the bathrooms of these rooms did not function, as evidenced by the inability of the vents to draw a tissue square to the surface, indicating non-operation. The Maintenance Director confirmed the lack of ventilation draw in these bathrooms and was unable to provide documentation of the last operational check. Additionally, the Environmental Services Account Manager verified that there was no documentation available regarding recent checks of the ventilation systems' operation.
Failure to Notify Practitioner and Family of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the medical practitioner and family of a resident's repeated refusals to take prescribed medications. Record reviews showed that the resident, who was unable to complete a cognitive assessment, had multiple medications ordered for conditions including pain, heart health, hyperlipidemia, hypertension, depression, GERD, memory support, dementia, and constipation. The Medication Administration Record indicated that the resident refused several medications on numerous occasions throughout the month. Despite these repeated refusals, there was no documentation in the progress notes that the primary medical provider was notified of these events. An interview with the Director of Nursing confirmed that the practitioner was not informed of the resident's medication refusals, which was contrary to facility policy. The policy required documentation of the refusal, including notification of the healthcare practitioner within a timeframe determined by the resident's condition and the potential seriousness of the consequences. The lack of notification and documentation represented a failure to follow established procedures for managing medication refusals.
Lack of Documented Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
Facility staff failed to ensure that a clinical rationale was documented for the continued use of a PRN (as needed) antianxiety medication for one resident. The facility's policy requires that PRN psychotropic medication orders be time-limited, with extensions beyond 14 days only permitted if the prescriber documents a clinical rationale, including effectiveness, ongoing diagnosis, indication, and duration. For the resident in question, who had diagnoses including delirium, major depressive disorder, psychosis, unspecified mood disorder, senile degeneration of the brain, and Alzheimer's disease, a PRN order for lorazepam was continued for six months without the required documentation of rationale by the provider. Record reviews showed that the resident had severe cognitive impairment and was receiving antipsychotic and antidepressant medications, but did not display behaviors according to the MDS. The pharmacist recommended continuation of the PRN lorazepam, and the provider agreed, but failed to document the necessary clinical rationale for its continued use. The DON confirmed during interview that no rationale was documented for the ongoing PRN lorazepam order.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required 24-hour timeframe to Adult Protective Services (APS) for one resident. According to the facility's policy, all staff, residents, and visitors are required to immediately report any incidents or suspected incidents of abuse, neglect, or exploitation. The policy further specifies that staff must notify the charge nurse, department head, or administration immediately, and that the administrator or designee must notify APS within 24 hours if the incident does not result in bodily harm. In this case, an incident involving resident-to-resident abuse occurred, but administration was not notified until several days later, and APS was not contacted until after the 24-hour window had passed. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 6, and was dependent on staff for all activities of daily living. The incident was first identified in a facility investigation initiated by the administrator, which revealed that the event had occurred days prior and that no injury had resulted. The Director of Nursing confirmed that staff did not immediately notify administration as required, despite previous education on the reporting process. As a result, the allegation of abuse was not reported to APS within the mandated timeframe.
Failure to Provide Written Notification of Hospital Transfer Reason
Penalty
Summary
Facility staff failed to provide written notification to a resident and their representative regarding the specific reason for the resident's transfer to an acute care hospital. According to the facility's Bed-hold Agreement policy, a copy of the bed-hold agreement, including the specific reason and basis for the transfer, must be provided to the resident or their representative at the time of transfer. Record review showed that for two separate hospital transfers, the bed-hold agreements were signed by the Social Services Designee but did not include the reason for the transfers. The resident involved had multiple diagnoses, including Influenza A, COPD, chronic respiratory failure, cognitive communication deficit, fracture of the neck of the left femur, iron deficiency anemia, schizophrenia, bipolar disorder, hypertension, and dementia. The resident was assessed as cognitively intact at the time of the deficiency. Interviews with the Social Services Designee confirmed that the required written notification of the reason for transfer was not provided to the resident or their representative, and that the bed-hold agreement was not sent at the time of transfer as required.
Failure to Develop Comprehensive Care Plan Following MDS Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days of completing the Minimum Data Set (MDS) assessment for one resident. According to facility policy, the care plan should be developed within seven days of the required MDS assessment and no more than 21 days after admission. For the resident in question, who was admitted with diagnoses including hypertension, thyroid disorder, cerebral infarction (stroke), and neuropathy, the MDS identified significant care needs such as dependence on staff for toileting, bathing, transfers, wheelchair mobility, dressing, and personal hygiene. Despite the MDS and Care Area Assessments (CAAs) indicating the need for care planning in areas such as cognition/dementia, communication, functional abilities, urinary incontinence, psychosocial, behavior, falls, dental, and pressure ulcers, the comprehensive care plan only addressed transfers under functional abilities. There were no interventions listed for cognition/dementia, communication, urinary incontinence, psychosocial, or dental needs. The MDS Coordinator confirmed these omissions and acknowledged that additional interventions should have been included for the resident's identified needs.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, with an observed error rate of 8% during the survey. In one instance, a registered nurse administered 5 units of rapid-acting insulin subcutaneously to a resident without providing a snack or ensuring the insulin was given immediately prior to a meal. The resident's blood sugar was checked, and the insulin was administered at 7:01 AM, but breakfast was not served until after 8:20 AM, contrary to facility policy that rapid-acting insulin should be given immediately before a meal or with food. In another instance, a licensed practical nurse administered polyethylene glycol to a different resident using a container labeled for another resident. The nurse confirmed that the medication was not labeled for the intended recipient and acknowledged the error. These two medication errors were identified among 25 observed medication administrations, affecting two residents.
Significant Medication Error: Improper Timing of Rapid-Acting Insulin Administration
Penalty
Summary
A registered nurse administered 5 units of rapid-acting insulin lispro to a resident in the morning after giving oral medications with water, but did not provide a snack or meal at the time of injection. Facility policy states that rapid-acting insulin should be injected immediately prior to a meal or concurrent with food. Observation showed that breakfast was not served until over an hour after the insulin was given. The nurse confirmed that the insulin was administered without a snack and acknowledged that rapid-acting insulin should be given within 30 minutes of meals.
Facility Lacks Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated infection preventionist was certified, which had the potential to affect all residents in the facility. A record review of the facility's Infection Control Program revealed that a nurse (RN or LPN) would be designated as the Infection Preventionist and complete the required training. However, during an interview, the designated Infection Preventionist admitted they were not currently certified but expected to complete the certification by May 2024. The Facility Administrator confirmed that the facility did not have a certified Infection Preventionist at the time of the interview.
Improper Positioning of Catheter Bag Leading to Potential Cross-Contamination
Penalty
Summary
The facility failed to position a catheter bag in a manner to prevent potential cross-contamination for one resident observed with a urinary catheter. Resident 20, who had a suprapubic catheter due to neurogenic bladder, was observed multiple times with the catheter bag attached to a trash can, with the back of the bag in contact with the exterior of the trash can and the bottom of the bag touching the floor. This was observed on two consecutive days at different times, indicating a consistent issue with the catheter bag's positioning. Resident 20 had a diagnosis of neuromuscular dysfunction of the bladder and a malignant neoplasm of the renal pelvis and was totally dependent on staff for toileting hygiene. The resident's cognitive status was intact, as indicated by a BIMS score of 13. The Director of Nursing confirmed that the catheter bag's contact with the floor and trash can could cause potential cross-contamination and acknowledged that the catheter bag should be positioned to avoid such contact.
Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify the responsible party of a significant weight loss for a resident diagnosed with Alzheimer's disease. The resident experienced a weight loss of 5% or more in the last month and 10% or more in the last six months. The Registered Dietitian's assessment revealed severe malnutrition, decreased appetite, and a significant decline in meal intakes over the last six days. Despite these findings, there was no evidence in the Electronic Medical Record that the responsible party had been informed of the resident's weight loss or decreased intake. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of notification to the responsible party. The resident's physician had responded to the annual nutrition assessment by adding a diagnosis of severe malnutrition and adjusting the resident's medication and nutritional supplements. However, the failure to communicate these critical changes to the responsible party represents a significant lapse in the facility's duty to keep family members informed about the resident's health status.
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What surveyors actually found near you
We read the 312 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Blair
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crowell Memorial Home | 0.5 mi | ★★★★★ | 3 | 0 |
| Azria Health Longview | 13.6 mi | ★★★★★ | 3 | 0 |
| Accura Healthcare Of Tekamah | 16.1 mi | ★★★★★ | 14 | 0 |
| Quality Living, Inc. | 17.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Omaha | 17.9 mi | ★★★★★ | 24 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.