Good Samaritan Society - Beatrice

The facility failed to follow the meatloaf recipe during meal preparation, this had the potential to affect all residents that eat food served from the kitchen. The facility census was 60 at the time of the survey. An observation on 01/22/2026 at 11:16 AM revealed Lead [NAME] (LC) beginning to prepare meatloaf to be served the following day. LC removed 20 lbs. (pounds) of ground beef from the walk in refrigerator, applied gloves, removed the ground beef from the outer wrap, removed gloves and washed hands with soap and water. LC then referred to recipe.A record review of the meatloaf recipe with a copyright date of 2025 revealed the ingredients needed to make 70 servings:Liquid eggs: 2 3/4 cups Milk: 1 QT (quart) 3 TBS (tablespoon) Ground beef: 17.5 lbs.Tomato paste 1 lbs. 1 ozGarlic minced 8.5 oz (ounce)Salt 1 Tbs. 1 tsp. (teaspoon)Onion 1 lbs. 1ozBreadcrumbs 2 lbs.Pepper: 3/4 tsp Directions:1. In mixer bowl, combine eggs and milk with paddle at medium speed 1-2 minutes or until combined.2. Add beef, tomato paste, garlic, salt, pepper, onions and breadcrumbs to egg mixture. Mix for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, interviews and record reviews, the facility failed to maintain and serve foods at a safe and appetizing temperature to prevent the potential for food borne illnesses on unit 1. This had the potential to affect all 16 residents on unit 1 who eat from the kitchen.Findings:An observation on 01/26/2026 at 11:25 AM revealed a [NAME] (C-B) transferring an insulated food cart from the main kitchen to the 100's dining room. The cart was filled with stainless steel pans of the different hot food items to be served for lunch. C-B placed each pan on the stream table, covering the pans with a lid.C-B then took the temperature of each hot food item using the facility's thermometer which revealed:The Breaded Chicken was 150 degrees FahrenheitThe Pureed Chicken was 115 degrees FahrenheitThe Potato Casserole was 160 degrees FahrenheitThe Un-breaded chicken was 140 degrees FahrenheitThe Peas were 140 degrees FahrenheitThe Cauliflower was 140 degrees FahrenheitC-B then went to the small unit kitchen to obtain the drinks for each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.007.04(D) Based on observation, interview, and record review the facility failed to ensure the ventilation (the provision of fresh air to a room, building, etc.) systems were operational in seven resident bathrooms (rooms 120, 301, 303, 305, 308, 309, and 313) out of 24 resident rooms sampled. The facility census was 60. Findings are: Observations on the initial tour on 1.21.2026 at 9:30 AM revealed the bathroom ventilation was not functioning in seven resident rooms (rooms 120, 301, 303, 305, 308, 309, and 313). Observations during a facility tour on 1.26.2026 at 10:40 AM with Water Management (WM) revealed the bathroom ventilation was not functioning in seven resident rooms (room [ROOM NUMBER], 301, 303, 305, 308, 309, and 313). In an interview on 1.26.2026 at 10:40 AM with the WM, it was confirmed the bathroom ventilation was not functioning in seven resident rooms (room [ROOM NUMBER], 301, 303, 305, 308, 309, and 313) and it should be. WM confirmed the company that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 175 NAC 12-006.09(G)(i)Based on record review and interviews, the facility failed to complete a discharge summary for Resident 67(A) after a medical appointment with a direct admission to the hospital. Resident 69 (B) was transferred to hospital and did not return to facility. This affected 2 out of 2 residents with a closed record review. The facility reported a census of 60.Findings are: A Record review of Resident 67's hospital Discharge summary dated [DATE] revealed a primary diagnoses of sepsis (an extreme, life-threatening response to an infection), severe thrombocytopenia (a condition where the blood has very few platelets, causing prolonged bleeding), cirrhosis of the liver with ascites (permanent scaring of the liver causing a buildup of fluid in the abdomen). Record review of Resident 67's admission Record revealed an admission date to the facility of 10/16/2025. Record reviews of Resident 67's Electronic Medical Record (EMAR) revealed no documentation of a transfer notice or a discharge summary that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(vi)(3)(g)Based on record reviews, observations, and interviews, the facility failed to obtain a doctor's order for a continuous positive airway pressure machine (CPAP, a bedside device that uses mild air pressure to keep airways open during sleep) for one (Resident 2) of one sampled resident. The facility census at the time of the survey was 60. Findings are:Observations of Resident 2's room on 01/21/2026 at 12:42 PM revealed a CPAP machine on the bedside table with a CPAP mask in the drawer and the water chamber 1/4 full of water. Record review of Resident 2's admission Record revealed an admission date to the facility on [DATE] with a diagnosis of obstructive sleep apnea (a sleep disorder where the airway becomes blocked or narrowed resulting in a brief loss of breathing). Record review of Resident 2's order summary revealed no order for pressure settings for the CPAP machine. Record review of Resident 2's Minimum Data Set (MDS, a federally mandated comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18Based on record reviews, observations, and interviews, the facility failed to follow infection control practices during catheter care for 2 Residents (Resident 4 and Resident 12) out of 2 observed for catheters, and during wound care for 2 Residents (Resident 12 and Resident 19) out of 5 observed for wound care. The facility census was 60.Findings are: A record review of the facility's Hand Hygiene policy last reviewed 11/13/2025 revealed that when using alcohol-based hand rub (ABHR) for hand hygiene (HH- a general term that applies to either handwashing or applying hand sanitizer to prevent the spread of disease causing organisms) the staff member should apply enough ABHR to one palm, then rub hands together, covering all surfaces of the hands and fingers until hands are dry, which should take 15 to 20 seconds. When washing the hands with soap and water, the staff member should wet their hands and apply soap, then rub hands together briskly, covering all surfaces of the hands, fingers, and wrists for at least 15 to 20 seconds. The policy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 12-006.11E Based on observations, record review and interviews; the facility failed to change gloves and perform hand hygiene for 20 seconds to prevent potential food born illness. This had the potential to affect all 60 residents who served food from the kitchen. The facility identified a census of 60. Findings are: A record review of the policy: Hand Hygiene, dated 03/29/2022, revealed the following: Policy: Hand hygiene should be performed after glove removal. Procedure: HCW will use waterless alcohol-based sanitizer or soap and water to clean their hands: After removing gloves regardless of task completed. Washing with soap and water: -Wet hands first with tepid water, apply amount of soap to hands as recommended by the manufacturer. -Rub hands together briskly for at least 15-20 seconds covering all the surfaces of the ands, fingers and wrists (CDC). -Rinse hands with water and dry thoroughly with a disposable towel or warm-air hand dryer if disposable towel not available. An observation on 9/19/24 at 10:49 AM while in the kitchen with Lead [NAME]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 1-005.06(D) Based on record review, observations, and interviews; the facility failed to change gloves and complete hand hygiene during wound care and catheter care for 2 (Resident 8 and 208) out of 5 sampled residents. The facility census was 60. Findings are: A. Record review of Resident 208's admission Record revealed admitted on [DATE]. Record review of Resident 208's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 9/2/24 revealed in Section C: BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) scored 15. In Section H: indwelling catheter. In Section M: at risk for pressure ulcer, uses pressure reducing devices used in bed and w/c, 3 total number of venous and arterial ulcers present, application of nonsurgical dressings (with or without topical medications) other than to feet, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12 006.09(H)(vi)(3)a-i) Based on observation, record reviews and interviews; the facility failed to keep Oxygen tubing nasal cannula (piece of the oxygen tubing which is inserted into the nose to deliver oxygen) off the floor and to date the tubing for 1 (Resident 39) of 1 sampled residents. The facility census was 60. Finds are: Record review of Resident 39's admission Record revealed admission date was 12/4/23. Record review of Resident 39's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/21/24 revealed BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 15. Observation on 9/18/24 at 10:40 AM Resident 39's O2 (oxygen) tubing was undated and hanging over the oxygen concentrator with the nasal cannula touching the floor. Interview on 9/18/24 at 10:40 AM with Resident 39 revealed Resident 39 wears O2 at night and as needed. Observation on 9/19/24 at 2:00 PM O2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.12(A)(i-vi) Based on record review and interviews, the facility failed to provide a stop date for the use of as needed antianxiety medication and failed to monitor specific target behaviors for antipsychotic medications and implement non-pharmacological interventions( is a healthcare intervention that doesn't primarily rely on medications) for 4 (Resident 29, 19, 212, and 32) with the sampled size of 5. The facility census was 60. Findings are: A. A record review of a facility policy entitled: Psychotropic Medications-Rehab/Skilled dated 12/06/23 included the following information: Purpose: -To evaluate behavior interventions and alternative before using psychotropic medications. -To eliminate unnecessary psychotropic medications. - Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: without adequate monitoring. -While the use of PRN (as needed) psychotropic medications is not encouraged, if a PRN physician's order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to follow physician's orders related to notification of blood sugar results for 1 (Resident 163) of 1 sampled resident. The facility identified a census of 62. Findings Are: A record review of the undated demographic information revealed the facility had admitted Resident 163 on 9/18/23 with a primary diagnoses of unspecified intracapsular fracture of the left femur (thigh bone) and unspecified Dementia. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 9/22/23 revealed Resident 163 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 01 which indicated resident was severely cognitlvey impaired. A record review of the Order Summary list ran on 10/12/23 revealed Resident 163 had the following orders related to Diabetes Mellitus (DM-a diseases that affect how…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D8b Based on record review and interview; the facility failed to provide bathing weekly for 1 (Resident 4) of 2 sampled residents. The facility identified a census of 62. Findings are: A record review of form Sanford Policy for Rehab/Skilled and Long Term Care Activities of Daily Living-R/S, LTC reviewed and revised 11/29/22; revealed the purpose was to provide resident with appropriate treatment and services to maintain or improve ability in activities of daily living for the well-being of mind, body and soul. The policy identifiied residents were to recieve a bath at least weekly. Record review of Resident 4's undated facesheet revealed Resident 4 was admitted [DATE]. The facesheet revealed Resident 4 had the following diagnoses: Chronic Obstructive Pulmonary Disease, Diabetes Mellitus with Diabetic Polyneuropathy, and Morbid (severe) obesity. A record review of Resident 4's MDS (Minimum Data Set is a standardized assessment tool that measures health status in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to document consistent assessment of characteristics or wound measurements which affected 1 (Resident 40) of 1 sampled resident for pressure ulcer. The facility had a census of 62. Findings are: A record review of Resident 40's admission Record dated 12/15/2022 revealed, Resident 40 was admitted on [DATE] with diagnoses of: pressure ulcer (PU) (injury to skin from prolonged pressure) of sacral region, stage 4, morbid (severe) obesity due to excess calories, nutritional deficiency, reduced mobility and venous insufficiency (poor blood flow). A record review of the MDS (Minimum Data Set) (a tool used to measure a residents health status) dated 9/8/2023 under Section C, Brief Interview for Mental Status (BIMS) (a tool used o identify the cognitive condition of a resident) had a score of 15 which indicated the resident is cognitively intact. A record review of Resident 40's Care Plan dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17d Based on observations, record review and interview; the facility staff failed to provide handwashing to prevent cross contamination before medication administration for 1 (Resident 6) of 1 sampled resident. The facility census was 62. Findings are: Record review of Resident 6's admission Record dated 9/29/2023 revealed Resident 6 was admitted on [DATE] with diagnoses of: unspecified severe protein-calorie malnutrition, encounter for attention to gastrostomy (a surgical opening into the stomach), abnormal weight loss, nausea, and vomiting. An observation on 10/16/2023 at 11:00 AM of medication administration through gastrostomy tube (GT) for Resident 6 revealed LPN-A performed hand hygiene (HH) at the bathroom sink by first wetting their hands. Then applied soap and lathered their hands with soap for 7 seconds and then rinsed hands under the water. Record review of Hand Hygiene policy dated 3/29/2022 under section Procedure-Washing with soap and water/liquid…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.