Good Samaritan Society - Bloomfield

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

months and the child felt that despite being reassured their concerns were addressed, nothing had changed significantly. They had been told the resident would be bathed twice weekly and that lasted about 2 weeks and now the resident had not had a bath for 2 weeks. During an interview on 9/29/25 at 1:10 PM, Resident 5 confirmed having had complained to administrative staff multiple times about being short staffed especially when there are only 2 Nurse Aides (NA's) in the building. This often happened during the day and evening time, and more so on the weekends. Resident 5 reported sometimes having to wait 20 or 30 minutes for help after having activated the call light and was unhappy about the response time to calls for assistance. This forced decisions to get up unassisted in which the resident felt unsafe, however didn't want to be incontinent. In addition, the resident desired 2 baths weekly, however rarely got 2 baths and sometimes went 2 weeks between baths. The resident felt they were not receiving the services paid for. In addition, the resident reported the NA's work very hard and are always kind and caring but having to cover 4 halls with 2 persons is just not enough help and when the resident complained to administration, the administration insisted they did have enough help. Resident 5 felt that had been going on since being admitted to the facility last spring. During an interview on 9/29/25 at 2:30 PM with the Director of Nursing (DON) revealed on all days of the week with the current census of 35, Nurse Aide hours include 3 Nurse Aides (NA's) during day shift (plus an additional NA to provide bathing up to 5 days a week up to 8 hours a day), 2.5 Nurse Aides on the evening shift, and 2 Nurse Aides on the night shift. This would be a total of 60 (+8 hour Bath Aide) hours of NA coverage over 24 hours for the current census of 35. In comparison, a census of 27 residents would include 2 nurse aides on the day shift (plus an additional NA to provide bathing up to 5 days a week up to 8 hours a day), 2 on the evening shift and 2 at night. This would be a total of 46 nurse aid hours + 8 hours NA up to 5 days a week per 24 hours for a census of 27. In review of

the facility staff posting, the DON confirmed the facility was not meeting needed NA staffing levels.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Bloomfield

300 North Second St Bloomfield, NE 68718

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(I) Based on record review and interview; the facility failed to review, revise and/or implement care plan interventions to prevent falls for Resident 1. The sample size was 3 and

the facility census was 35. Findings are:Record review of the facility policy Fall Prevention and Management last reviewed 4/8/25 revealed the following:-staff were to use a proactive approach before a fall occurred which included screening to identify risk factors, care planning appropriate interventions, and communicating fall risks and interventions. Fall Procedure:-after a fall a nurse was to observe the resident and perform a full-body exam to determine if there may be a suspected injury,-if no serious injury, staff were to use a total body lift to transfer the resident off the floor,-when the resident was stable, staff were to investigate the causal factors of the fall,-initial documentation would be in the SAFE Event Report form and if any additional documentation was needed it would be in the Progress Notes, -if any teaching was completed it would be documented in the Progress Notes, -staff would communicate that a fall occurred

during the shift change and daily meetings, and -the residents care plan would be reviewed and revised with any changes and/or new interventions. Record review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 8/25/25 revealed the resident was admitted on [DATE REDACTED], had severe cognitive impairment, had limited range of motion of 1 side for both upper and lower extremities, was dependent on staff for assistance with toileting, and required substantial assistance with dressing and hygiene; and had diagnoses of non-Alzheimer's dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior)), anxiety (an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it), and depression.

Record review of Resident 1's Care Plan with a revision date of 9/15/25 revealed the resident required the assistance of 1 staff member for ambulation, bed mobility, transfers and toileting; had falls on 8/28/25, 8/29/25, 9/8/25, and 2 falls on 9/13/25; and fall interventions that staff were to encourage the resident to participate in activities that promote exercise, ensure the resident has appropriate footwear, and monitor for significant changes in gait, mobility, positioning device, standing/sitting balance, and lower extremity joint function. Record review of the facility forms SAFE Resident Event revealed the following regarding Resident 1 revealed the following:-a fall on 8/28/25 at 8:00 PM revealed no documentation that an intervention to prevent falls had been put into place, -a fall on 8/29/25 at 7:45 PM revealed no documentation that an intervention to prevent falls had been put into place,-a fall on 9/8/25 at 10:45 PM revealed no documentation that an intervention to prevent falls had been put into place, -a fall on 9/13/25 at 8:00 PM revealed no documentation that an intervention to prevent falls had been put into place, -a fall on 9/22/25 at 8:45 PM revealed no documentation that an intervention to prevent falls had been put into place, and-a fall

on 9/27/25 at 7:30 PM revealed no documentation that an intervention to prevent falls had been put into place. An interview with the Director of Nursing on 9/29/25 at 3:30 PM confirmed interventions to prevent future falls were not implemented for falls on 8/28/25, 8/29/25, 9/8/25, 9/13/25, 9/22/25, and 9/27/25 and

the care plan should have been updated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Bloomfield

300 North Second St Bloomfield, NE 68718

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725

only worked on 9/22/25.

Level of Harm - Minimal harm or potential for actual harm

K. An interview on 9/29/25 at 2:00 PM with the Administrator confirmed that there was not a housekeeping schedule and that when ESS-F was working as an NA the maintenance and laundry staff cleaned some resident rooms and halls. The administrator was unsure what rooms were cleaned by maintenance and laundry staff.

Residents Affected - Many

L. An interview on 9/29/25 at 2:15 PM with maintenance staff (G) confirmed that the facility was unsure of what rooms were cleaned from 9/21/25 to 9/27/25 by maintenance and housekeeping staff.

M. Interview with the Administrator on 9/29/25 at 3:09 PM confirmed the facility census had increased from 27 to 35 and they had identified increasing call light response times since the increase in census. The facility was reviewing all admissions on an individual basis to determine if they could meet the needs of the residents. The Administrator was aware the facility was having concerns with call light response times and had started a Performance Improvement Plan to address those concerns. In addition, the facility is trying to hire additional staff but was using agency and pool nursing but had not filled all available shifts.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet