Good Shepherd Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Blair, Nebraska.
- Location
- 2242 Wright Street, Blair, Nebraska 68008
- CMS Provider Number
- 285148
- Inspections on file
- 17
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Good Shepherd Lutheran Home during CMS and state inspections, most recent first.
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.
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.
Latest citations in Nebraska
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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