Life Care Center Of Elkhorn
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhorn, Nebraska.
- Location
- 20275 Hopper Street, Elkhorn, Nebraska 68022
- CMS Provider Number
- 285134
- Inspections on file
- 22
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Life Care Center Of Elkhorn during CMS and state inspections, most recent first.
Three nurse aides did not complete the required 12 hours of annual in-service education, with training hours ranging from 3 to 5 hours. The DON confirmed the deficiency and acknowledged the absence of an effective tracking system for staff education compliance.
Staff failed to follow infection control protocols by carrying soiled linens against their bodies, neglecting to clean nebulizer kits and PAP equipment after use, and not using enhanced barrier precautions during catheter care for a resident with an indwelling device. These actions were observed and confirmed by staff and facility leadership as not meeting established policies.
Surveyors found that ventilation systems in the bathrooms of four resident rooms were not functioning, as evidenced by a lack of airflow during testing with toilet paper. The Maintenance Supervisor confirmed the issue and stated that no routine checks of the ventilation systems had been performed.
A resident with multiple serious medical conditions and moderate cognitive impairment was admitted without receiving or acknowledging the required notice of rights, as documented in facility policy. The admission paperwork was incomplete, and the electronic health record did not contain evidence that the resident or their representative had been informed of their rights at admission.
A resident with multiple complex medical conditions and moderate cognitive impairment was admitted without completion of required admission paperwork, including documentation of privacy practices, resident rights, and other key policies. The Admissions Director confirmed the omission, resulting in an incomplete medical record.
A resident with heart failure did not consistently receive daily weights or have significant weight gains reported to the practitioner as ordered. Fluid restrictions were not properly implemented or monitored, with frequent overages and incomplete documentation. Staff interviews and observations revealed a lack of awareness and communication regarding the resident's fluid management, and the facility did not have a policy in place for fluid restriction implementation.
Facility staff did not notify the practitioner of significant weight increases in a resident with heart failure, despite clear orders and policy requiring notification for weight gains of 1 to 5 lbs. Multiple weight increases exceeding this threshold were not reported, as confirmed by record review and DON interview.
A resident with heart failure did not consistently receive BiPAP therapy as ordered, with multiple missed applications documented over several weeks. Staff interviews revealed poor communication and lack of clarity regarding responsibility for applying the BiPAP mask, and there was no documentation of resident refusal when the therapy was not provided.
A resident experienced significant weight loss due to the facility's failure to implement recommended nutritional interventions. Despite a Registered Dietician's recommendation for a Magic Cup supplement, it was not provided with meals, and staff were unaware of the recommendation. The facility did not adhere to its policy on hydration and nutrition, failing to assess and address the resident's weight loss.
The facility failed to maintain proper food safety and sanitation practices, affecting all 86 residents. Observations revealed unsealed, unlabeled, and undated food items in refrigerators and freezers, improper food handling by Cook-M, and unsanitary kitchen conditions. The DFS and Registered Dietician confirmed these deficiencies, which were not in line with the facility's policies.
The facility failed to update care plans for four residents, leading to deficiencies in their care. A resident's care plan was not updated after a Foley catheter was discontinued. Another resident's care plan did not reflect multiple open wounds. A third resident's care plan was outdated regarding feeding tube orders, and a fourth resident's care plan did not accurately reflect their dental status. These oversights were confirmed by facility staff.
The facility failed to maintain safe water temperatures in resident bathrooms, with readings between 123.4 and 132.4 degrees Fahrenheit, affecting 14 residents. Interviews with the Maintenance Supervisor and DON confirmed awareness of the issue, leading to the water being shut off in the affected area.
The facility failed to maintain flooring in good repair for 12 resident rooms, affecting 13 residents. Observations revealed missing transition strips between hall carpets and room flooring, and cracked or bubbled linoleum in several bathrooms. The Maintenance Supervisor confirmed these issues, indicating a potential safety concern.
The facility staff failed to clean and sanitize respiratory equipment for several residents, leading to potential cross-contamination. Observations showed that equipment was not maintained according to policy, with visible contamination. Additionally, staff did not implement enhanced barrier precautions during care activities for residents with wounds or indwelling devices, and failed to provide necessary signage for a resident with venous stasis ulcers. Interviews confirmed these deficiencies, highlighting lapses in hygiene and precautionary measures.
A resident experienced a significant weight loss of 6.6 pounds, or 5.47%, over a short period, but the facility failed to notify the physician. Despite the resident's awareness of the weight loss and the RD's recommendation for nutritional supplements, the facility did not follow its policy to inform the physician of such concerns.
A resident with dementia and other conditions fell in the bathroom, resulting in a laceration requiring stitches. Despite the facility's policy to report serious injuries within two hours, the incident was not reported to the state agency, leading to a deficiency finding.
A facility failed to accurately document a resident's care needs in the MDS, omitting tube feeding and incorrectly including insulin administration. The resident, with multiple medical conditions, was on enteral feeding via a G-tube, not insulin. Observations and interviews confirmed the MDS inaccuracies, leading to a deficiency finding.
The facility failed to adhere to oxygen orders for two residents, leading to deficiencies in respiratory care. One resident with COPD and Chronic Respiratory Failure was observed without prescribed oxygen therapy multiple times, despite having orders for continuous oxygen. Another resident was using oxygen continuously without a physician's order for such use outside of AVAPS. Interviews confirmed these discrepancies, highlighting the facility's failure to ensure valid and followed oxygen orders.
The facility failed to ensure proper assessment of dialysis shunt sites for two residents before and after their dialysis treatments. The Pre/Post Dialysis Communication forms were frequently incomplete or missing, indicating that the required assessments were not consistently performed. Observations showed that one resident was left unattended in the hallway after dialysis, and the LPN responsible did not know the location of the shunt site or perform the necessary assessments. The DON confirmed that the staff was not completing the communication sheets accurately, and the shunt site assessments were not always conducted.
Failure to Ensure Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides completed the required 12 hours of annual in-service education, as mandated by licensure regulations. Record reviews showed that one nurse aide had completed only 3.5 hours, another 5 hours, and a third 3 hours of training, despite being employed for sufficient time to meet the requirement. The Director of Nursing confirmed during an interview that the 12-hour education training requirement had not been met for these nurse aides and acknowledged that the facility lacked an effective system to track and ensure compliance with the required training hours. This deficiency had the potential to affect all 86 residents in the facility.
Infection Control Failures in Linen Handling, Equipment Cleaning, and Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols in several instances involving the handling of soiled linens, cleaning of respiratory equipment, and use of enhanced barrier precautions. Observations revealed that nursing assistants carried soiled linens and bedding against their bodies and clothing, contrary to facility policy, which requires soiled linen to be bagged and handled with minimal agitation to prevent contamination. Staff were seen carrying soiled items uncovered through hallways and placing soiled gowns under their arms while assisting residents, actions confirmed by both the staff involved and facility leadership as improper. Additionally, staff did not consistently clean and disinfect non-critical patient care equipment such as nebulizer kits and PAP (Positive Airway Pressure) machines. Multiple observations showed nebulizer kits with residual medication and facial oils left uncleaned on bedside tables after use for two residents. Similarly, a resident's BiPAP machine and mask were found with facial oils, water left in the humidifier, and missing filters over several days, despite orders and manufacturer guidelines requiring daily and weekly cleaning. Interviews with staff and a family member confirmed that cleaning was not performed as required. The facility also failed to implement enhanced barrier precautions during high-contact care activities for a resident with a urinary catheter. During catheter and incontinence care, staff did not wear gowns as mandated by facility policy for residents with indwelling medical devices. Staff interviews confirmed awareness of the requirement but acknowledged that enhanced barrier precautions were not used during the observed care.
Non-Operational Ventilation Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure operational ventilation systems in resident bathrooms for four rooms (106, 108, 114, and 115) out of fifteen occupied rooms on the 100 hall. During an inspection with the Maintenance Supervisor, it was noted that the ventilation system did not draw a single ply of toilet paper to the surface of the ventilation cover in these bathrooms, indicating the systems were not functioning properly. The Maintenance Supervisor confirmed these findings and also acknowledged that no routine checks had been conducted to verify the operational status of the ventilation systems.
Failure to Provide Notice of Resident Rights on Admission
Penalty
Summary
The facility failed to provide a notice of resident rights upon admission for one resident. According to the facility's own admission policy, residents or their representatives must be informed of their rights and facility policies both orally and in writing, with accommodations for impairments and language needs. The policy also requires written acknowledgment of this explanation to be documented in the admission agreement. Record review showed that for the resident in question, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no documentation in the electronic health record indicating that the resident or their representative received or acknowledged the notice of rights at admission. Further review revealed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork, including the required notice of rights, had not been completed at the time of admission, and the medical record lacked the necessary documentation to show that the resident or their representative had received this information.
Failure to Complete Admission Paperwork for Resident
Penalty
Summary
The facility failed to complete required admission paperwork for one resident upon admission. According to the facility's own admission policy, residents or their legal representatives must be oriented to various policies and receive a copy of the admissions agreement, which is to be signed and filed in the resident's chart. Record review revealed that for this particular resident, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no completed admission paperwork in the electronic health record. This included missing documentation on privacy practices, antidiscrimination policy, grievance policy, resident rights, trust fund, financial agreement, smoking policies, resident care policies, and other required documents. Further review showed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork had not been completed at the time of admission and that the resident's medical record was incomplete due to the absence of these documents.
Failure to Follow Physician Orders for Daily Weights and Fluid Restrictions
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with a diagnosis of heart failure, specifically regarding daily weights and fluid restrictions. The resident had multiple orders for daily weights, with instructions to notify the practitioner of weight increases between 1-5 lbs. However, there were several documented instances where daily weights were not obtained, and significant weight gains were not reported to the practitioner as required. For example, an 8.6 lb. weight gain in one day and other increases of 6.7 lbs., 3.9 lbs., and 3.8 lbs. were not communicated to the practitioner. These omissions were confirmed by the DON during interviews. Additionally, the facility did not consistently implement or monitor the resident's fluid restriction orders. The resident was placed on various fluid restrictions, including 1000 ml and later 1440 ml per day, with specific allocations for dietary and nursing staff. Despite these orders, the resident's fluid intake regularly exceeded the prescribed limits, and there were days when fluid intake was not recorded at all. Observations and interviews revealed that staff were not always aware of the fluid restriction, did not consistently document fluids provided, and dietary staff did not record the amount of fluids given. The DON confirmed that the facility lacked a policy for implementing fluid restrictions and was unaware of how IV fluids were included in the daily total. The resident experienced multiple hospitalizations for conditions related to heart failure, fluid overload, and other complications during the period in question. Observations showed the resident receiving unmeasured fluids during meals and activities, and staff interviews indicated a lack of communication and understanding regarding the resident's fluid management needs. The facility was unable to provide additional information or documentation regarding the implementation of fluid restrictions prior to the survey exit.
Failure to Notify Practitioner of Significant Weight Changes
Penalty
Summary
Facility staff failed to notify the medical practitioner of significant changes in a resident's daily weights, as required by both facility policy and physician orders. The resident, who was cognitively intact and had a diagnosis of heart failure, had orders in place for daily weights with instructions to call the physician for any weight increase of 1 to 5 pounds. Despite this, the medical record review showed multiple instances where the resident experienced weight gains exceeding the notification threshold, including an 8.6-pound increase in one day and other increases of 6.7, 3.9, and 3.8 pounds on separate occasions. There was no documentation that the practitioner was informed of these changes. Interviews with the Director of Nursing confirmed that the practitioner was not notified of the significant weight increases, despite the clear orders and facility policy requiring such communication. The lack of notification was corroborated by the absence of related documentation in the resident's progress notes, faxes, and practitioner orders. The deficiency was identified through record review and staff interviews, which established that the required notifications did not occur as specified.
Failure to Provide Ordered BiPAP Respiratory Care
Penalty
Summary
Facility staff failed to ensure that a resident with a diagnosis of heart failure received appropriate respiratory care as ordered. The resident required BiPAP therapy while sleeping or napping, as documented in physician orders and the treatment administration record (TAR). Multiple instances were identified where the BiPAP was not applied during various shifts across September and October, despite clear orders. The resident was cognitively intact and required extensive to total assistance with activities of daily living. Documentation showed that the BiPAP was not used on several occasions, and there was no record of resident refusal or staff documentation of such refusals. Interviews with staff revealed confusion and lack of communication regarding responsibility for applying the BiPAP mask. Medication aides indicated that only nurses could apply the mask, but nurses interviewed were either unaware of the resident's needs or had not been informed of the mask not being in use. Observations confirmed the resident was not wearing the BiPAP mask when required, and the resident reported discomfort from air blowing in the eyes when the mask was applied. The Director of Nursing confirmed that the nurse assigned to the resident should have ensured the BiPAP was applied and documented any refusals, which did not occur.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to evaluate and implement interventions to prevent significant weight loss for a resident, identified as Resident 37. The resident was admitted following surgery for a diaphragmatic hernia with obstruction and had other diagnoses including GERD, Barrett's Esophagus with dysphagia. The resident's Minimum Data Set (MDS) indicated a weight of 120 pounds and required assistance with various activities of daily living. Despite the resident's awareness of weight loss, the facility did not take appropriate action to address the issue. The resident's weight was recorded multiple times, showing a decrease from 120.6 pounds to 114.0 pounds over a period of less than a month, indicating a significant weight loss of 5.47%. The facility's Registered Dietician (RD) had recommended nutritional supplements, specifically a Magic Cup, to be added to the resident's meals to address the low BMI and potential weight loss. However, this recommendation was not implemented, as evidenced by the absence of the Magic Cup on the resident's meal trays during observations. Interviews with facility staff, including the RD, Director of Food Service (DFS), and nursing staff, revealed a lack of communication and follow-through on the dietary recommendations. The RD was not informed of the resident's weight loss, and the DFS was unaware of the recommendation for the Magic Cup. Additionally, the facility's policy on hydration and nutrition, which requires ongoing assessment and physician notification of concerns, was not adhered to, as there was no documentation of further nutritional evaluation or physician notification regarding the resident's significant weight loss.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, which had the potential to affect all 86 residents consuming food from the kitchen. Observations revealed multiple food items in the kitchen's refrigerators and freezers were not sealed, labeled, or dated, contrary to the facility's Food Safety policy. Items such as an open bag of shredded purple substance, a zip lock bag of white chunks, and an open package of bologna were found without proper labeling or sealing. Additionally, the dry storage contained unsealed bags of macaroni and overripe bananas, while the walk-in refrigerator and freezer had unlabeled and undated food items. The Director of Food Services (DFS) confirmed these observations and acknowledged the failure to adhere to food safety protocols. Further deficiencies were noted in food preparation and kitchen cleanliness. Cook-M was observed handling beef packages in a manner that allowed the outside of the packaging to contact the food product, and did not follow the recipe or measure ingredients during food preparation. The DFS and Registered Dietician confirmed these practices were inappropriate. Additionally, the facility's cleaning logs did not show evidence of regular cleaning of floors, vents, and fans, leading to unsanitary conditions such as crumbs on the kitchen floor, brown drippings on the freezer vent, and a gray fuzzy substance on HVAC vents. The DFS and Maintenance Supervisor confirmed these areas were not cleaned as required, posing a risk of contamination to food and eating surfaces.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in their care. Resident 6, who was admitted with an indwelling Foley catheter, had the catheter discontinued, but the care plan was not updated to reflect this change. The care plan continued to include interventions related to the catheter, which was no longer in use. This oversight was confirmed by the Minimum Data Set Nurse during an interview. Resident 68 had multiple open wounds on their legs, which were not documented in the care plan. Despite ongoing wound assessments indicating the presence of these wounds, the care plan remained focused on skin integrity related to urinary incontinence and xerosis cutis, without addressing the actual wounds. The Wound Nurse acknowledged that the care plan had not been updated to include the open wounds. Resident 34's care plan was outdated and did not reflect the current orders for bolus feedings via a feeding tube. The care plan incorrectly indicated continuous feeding, while the actual orders specified bolus feedings four times a day. This discrepancy was confirmed by the facility's Registered Dietician and the MDS Nurse. Additionally, Resident 14's care plan was not accurate, as it did not reflect the resident's current dental status, including the absence of teeth and the fact that dentures were at home. The Social Service Assistant confirmed the care plan was outdated.
Unsafe Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure safe water temperatures in resident bathrooms, which posed a potential risk to 14 residents. During an observation on August 7, 2024, it was found that water temperatures in several resident rooms were above the recommended safe level of 120 degrees Fahrenheit, with temperatures ranging from 123.4 to 132.4 degrees Fahrenheit. This issue was identified in rooms 101, 102, 109, 113, 114, 117, 118, 120, 122, and 123. The facility census at the time was 86 residents. Interviews conducted with the Maintenance Supervisor and the Director of Nursing revealed awareness of the elevated water temperatures. The Maintenance Supervisor confirmed taking a water temperature reading above 124 degrees Fahrenheit in one of the rooms. The Director of Nursing acknowledged that the water temperatures in the bathrooms on the 100 Hall were too high, leading to the water being shut off. A review of the facility's Direct Supply TELS logbook indicated that water temperatures should be maintained below 120 degrees Fahrenheit for burn prevention, as per federal guidelines.
Deficiency in Flooring Maintenance
Penalty
Summary
The facility failed to maintain flooring in good repair for 12 resident rooms, which had the potential to affect 13 residents. During a tour with the Maintenance Supervisor, it was observed that rooms 104, 105, 106, 108, 109, 111, 113, 114, 121, and 122 did not have a transition strip between the hall carpet and the flooring in the resident's room. Additionally, rooms 104, 113, 114, 122, 123, and 207 had cracked or bubbled linoleum in the resident's bathroom. An interview with the Maintenance Supervisor confirmed that the resident room floors were not maintained and could potentially be a safety concern.
Infection Control and Precaution Failures in LTC Facility
Penalty
Summary
The facility staff failed to ensure proper cleaning and sanitization of respiratory equipment and supplies for several residents, leading to potential cross-contamination. Observations revealed that the BiPAP/CPAP masks, nebulizer kits, and oxygen concentrators for Residents 26, 38, and 42 were not cleaned according to the facility's policies. The equipment was found with facial oils, residual medication, and a gray fuzzy substance, indicating neglect in maintaining hygiene standards. Interviews with staff confirmed the equipment was not cleaned as required. Additionally, the facility staff did not implement enhanced barrier precautions during activities of daily living (ADL) care for Resident 14 and catheter care for Resident 37. Observations showed that staff did not wear gowns during high-contact care activities, despite the presence of enhanced barrier precaution signage. Interviews with staff confirmed the failure to adhere to the precautionary measures outlined in the facility's policy, which mandates gown and glove use during specific care activities for residents with wounds or indwelling medical devices. Furthermore, the facility failed to provide enhanced barrier signage for Resident 68, who had venous stasis ulcer wounds. Observations over several days revealed the absence of signage on the resident's door, which is necessary to alert staff of the need for precautions. The Infection Preventionist was unaware of the resident's condition, indicating a lapse in communication and policy implementation. The facility's policy requires signage to communicate the need for enhanced barrier precautions for residents with chronic wounds or indwelling medical devices.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician of a significant weight loss, which was identified during a survey. The resident, who had a history of diaphragmatic hernia surgery, GERD, BPH, and Barrett's Esophagus with dysphagia, experienced a weight loss of 6.6 pounds, or 5.47%, over a period of less than a month. Despite the resident's awareness of weight loss, the facility did not inform the physician of this clinically significant change. The resident's Minimum Data Set indicated a BIMS score of 15, suggesting cognitive intactness, and required varying levels of assistance for daily activities. The facility's Registered Dietician (RD) had noted the resident's low BMI and recommended nutritional supplements, but the weight loss was not communicated to the physician. The facility's policy on Hydration and Nutrition mandates physician notification of any concerns, including weight loss, but this protocol was not followed. The RD confirmed that the weight loss was significant and that the physician had not been updated, highlighting a lapse in the facility's communication and monitoring processes.
Failure to Report Resident Fall with Serious Injury
Penalty
Summary
The facility failed to report a fall resulting in serious bodily injury to the state agency for a resident. The resident, who had diagnoses of dementia, COPD, anxiety, and depression, was found on the bathroom floor by staff after their roommate called for help. The resident was crying and had bleeding from the right cheek, which required transfer to the hospital. At the hospital, the resident received three stitches for the laceration on the right cheek. Despite the facility's policy requiring immediate reporting of serious bodily injuries to the state agency, the incident was not reported. Interviews with the RN and the DON confirmed the fall and the subsequent hospital visit for sutures. The facility's policy mandates reporting such incidents within two hours, but this protocol was not followed, resulting in a deficiency finding during the survey.
Inaccurate MDS Documentation for Resident's Care Needs
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. The MDS dated 07/12/2024 did not include the resident's tube feeding requirement, and incorrectly documented the resident as receiving insulin and insulin injections, which were not part of the resident's care plan. The resident, who had multiple medical diagnoses including hemiplegia, chronic respiratory failure, and required G-tube feeding, was not accurately represented in the MDS, leading to a deficiency in the resident's comprehensive assessment. Observations and interviews confirmed the inaccuracies in the resident's MDS. The resident's Medication Administration Record and Treatment Administration Record from April to August 2024 showed the resident was on enteral feeding via a G-tube, with no record of insulin administration. Interviews with the resident's Power of Attorney and the facility's MDS Nurse corroborated that the resident was not on insulin or insulin injections, highlighting the error in the MDS documentation. This failure to accurately assess and document the resident's needs and treatments resulted in a deficiency finding during the survey.
Failure to Follow Oxygen Orders for Residents
Penalty
Summary
The facility failed to ensure proper adherence to oxygen orders for two residents, leading to deficiencies in respiratory care. Resident 26, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with Hypoxia, was observed multiple times without the prescribed oxygen therapy. Despite having a physician's order for continuous oxygen at 1 liter per minute via nasal cannula and oxygen with CPAP, the resident was found without oxygen on several occasions, both while sleeping and during activities. Interviews confirmed that the resident did not refuse oxygen, and the charge nurse acknowledged the resident's order for continuous oxygen was not being followed. Similarly, Resident 42, diagnosed with Chronic Respiratory Failure with Hypoxia and Obstructive Sleep Apnea, was observed using oxygen continuously, although there was no physician's order for oxygen use outside of the AVAPS setting. The resident confirmed continuous oxygen use, and the charge nurse verified the absence of an order for oxygen when not on AVAPS. These observations and interviews highlight the facility's failure to ensure valid and followed oxygen orders for the residents, resulting in a deficiency in providing safe and appropriate respiratory care.
Failure to Assess Dialysis Shunt Sites
Penalty
Summary
The facility failed to ensure proper assessment of dialysis shunt sites for two residents, Resident 26 and Resident 57, before and after their dialysis treatments. The facility's Hemodialysis Offsite Policy mandates ongoing assessment of residents' conditions and monitoring for complications related to dialysis. However, record reviews revealed that the Pre/Post Dialysis Communication forms for both residents were frequently incomplete or missing, indicating that the required assessments were not consistently performed. Resident 57, who has multiple complex medical conditions including End Stage Renal Disease and dependence on renal dialysis, was not assessed for shunt site bruit, thrill, or bleeding as required. Observations showed that upon returning from dialysis, the resident was left unattended in the hallway, and the LPN responsible for the resident's care did not know the location of the shunt site or perform the necessary assessments. The Director of Nursing confirmed that the staff was not completing the Pre/Post Dialysis Communication sheets accurately, and the shunt site assessments were not always conducted. Similarly, Resident 26, who also has End Stage Renal Disease and is dependent on dialysis, did not receive the required shunt site assessments. The resident's Pre/Post Dialysis Communication forms were often incomplete, and the Medication Administration Record and Treatment Administration Record indicated that the shunt site was not assessed every shift as ordered. The Director of Nursing acknowledged the deficiencies in completing the communication sheets and the failure to perform the necessary shunt site assessments.
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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