Good Samaritan Society - Bloomfield
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
continuously into a collection bag). During an interview on 11/25/25 at 10:30 AM with Resident 1 and the resident's spouse the following was identified:-11/5/25 the resident had turned their call light on at 7:00 AM.-Nurse Aide (NA)-D had entered the resident's room, turned the call light off and then exited the room.-the resident turned the call light back on and NA-D returned to the room, shut the call light off and then removed the call light from the resident's reach. -it was a common occurrence for staff to remove the resident's call light from reach whether intentional or not as the resident required almost total assistance of x2 staff with cares and cares took a long time to be completed. -the resident and spouse reported the incident to the facility Administrator. The Administrator indicated staff was counseled after the staff member admitted they had done this. Review of facility investigations of potential abuse/neglect from 9/29/25 to 11/24/25 revealed no evidence Resident 1's allegation of potential staff to resident abuse was reported to
the State Agency. In addition, there was no evidence that an investigation was completed by the facility and then submitted within 5 working days. An interview with the Director of Nursing (DON) on 11/24/25 at 11:30 AM confirmed the facility did not report the allegation of potential abuse involving Resident 1, complete and then submit an investigation to the State Agency within the required time frame.
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
11/24/2025
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-Tag F0657
F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(F)(iii)Based on record review and interview; the facility failed to update Resident 1's comprehensive care plan to reflect the resident's preference for getting up in the morning. The sample size was 3 and the facility census was 30. Findings are:Review of Resident 1's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 9/26/25 indicated the resident was admitted [DATE REDACTED] with diagnoses of heart failure, previous stroke, paralysis to one side of his body, sepsis (extreme response to infection leading to widespread inflammation, organ damage and potential organ failure), obstructive uropathy (medical condition where the flow of urine is blocked. causing it to back up and potentially damage the kidneys), anxiety, depression, and diabetes.
The assessment identified the resident's cognition was intact, the resident required total staff assistance with toileting hygiene, dressing, personal hygiene, bed mobility and transfers, was frequently incontinent of bowel and had an indwelling urinary catheter (thin tube inserted into the bladder to drain urine continuously into a collection bag). Review of a Care Conference Progress Note dated 7/9/25 at 11:18 AM revealed the resident and spouse had attended the resident's care plan conference and had identified a preference for
the resident to be up and out of bed at 7:00 AM each morning and to be put to bed at 8:30 PM in the evening. Review of the resident's current Care Plan with a revision date of 11/5/25, revealed the resident had an activity of daily living self-care performance deficit related to a previous stroke with weakness, right side paralysis, and weakness. Interventions included to position the resident up in bed with 2 staff and to use the full sling lift for all transfers. Further review of the resident's care plan revealed no evidence the resident's preferences for what time to get up in the morning or for the time the resident preferred to go to bed at night were identified on the care plan. An interview on 11/24/25 at 1:15 PM with the Director of Nursing confirmed the resident's care plan had not been updated regarding the resident's preferences.
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
11/24/2025
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-Tag F0677
F 0677
the resident out of bed and onto the commode.-the resident was involuntarily incontinent of feces by the time assisted the resident with toileting cares.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
11/24/2025
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-Tag F0725
F 0725
-On 11/5/25 there were 14 times that ranged from 16 minutes to 40 minutes.
Level of Harm - Minimal harm or potential for actual harm
An interview with the Director of Nursing on 11/24/25 at 12:10 PM confirmed that call lights were to be answered in 15 minutes and there were call lights that did not get answered timely in the facility.
Residents Affected - Some
D. Review of the facility's nursing schedule from 10/22/25 to 11/5/25 revealed the following: -On 10/22/25 there were 3 CNA's from 6 AM to 2:30 PM, -On 10/25/25 (Saturday) there were 2 CNA's from 6 AM to 2:30 PM, -On 10/26/25 (Sunday) there were 2 CNA's from 6 AM to 2:30 PM, -On 10/28/25 from 10 PM to 6:30 AM there was 1 CNA for 8 hours and 1 CNA for 4 hours, -On 10/29/25 there were 3 CNA's from 6 AM to 2:30 PM, and -On 11/2/25 there was 1 CNA from 6 PM to 10 PM and 1 CNA from 10PM to 6:30AM.
An interview with the DON on 11/24/25 at 1:15 PM confirmed the following numbers of Certified Nursing Assistants should be scheduled: -Monday through Friday 6 AM to 2:30 PM 4 Certified Nursing Assistants (CNA's), -Saturday and Sunday 6 AM to 2:30 PM 3 CNA's, -from 2:00PM to 10:30 PM there should be 2-3 CNA's, and -from 10:00PM to 6:30 AM 2 CNA's were to be scheduled.
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
11/24/2025
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-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many
-9:49 AM the resident was again attached to the lift with the catheter bag removed from the bed linens and placed on the lift above the resident's head. The resident was transferred into the recliner and the lift was removed with the urinary catheter drainage bag placed inside of a privacy bag and hung next to the recliner
on the drawer of a dresser, below the level of the resident's bladder.
An interview with the Registered Nurse (RN)-G on 11/24/25 at 11:00 AM confirmed the staff were to perform hand hygiene whenever removing soiled gloves and before putting on clean gloves. In addition, RN-G confirmed staff should not have placed the resident's urinary catheter drainage bag directly on the resident's bed linens and the drainage bag should not have been positioned above the resident's head and above the level of the resident's bladder when transferring the resident with the lift.
D. Review of the Skilled Nursing Facility Covid-19 Work Guidelines with a reviewed date of October 2025 revealed the following; -Symptomatic employees were to be restricted from the workplace until Covid-19 infection was ruled out by testing.
E. An observation of the Director of Nursing (DON) on 11/24/25 at 7:30 AM revealed the DON had a blue mask on, voice was hoarse and cough was noted.
An interview with the DON on 11/24/25 at 7:45 AM revealed that the DON had not completed a Covid-19 test and was not going to complete one.
An interview with Registered Nurse (RN)-B on 11/24/25 at 1:45 PM confirmed that the facility does not test staff or residents when presenting with respiratory symptoms or increased temperature.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Good Samaritan Society - Bloomfield in Bloomfield, NE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Bloomfield, NE, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Good Samaritan Society - Bloomfield or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.