Life Care Center Of Omaha
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 6032 Ville De Sante Drive, Omaha, Nebraska 68104
- CMS Provider Number
- 285137
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Life Care Center Of Omaha during CMS and state inspections, most recent first.
The facility failed to complete and document a discharge plan for a cognitively intact resident with multiple comorbidities, including generalized muscle weakness, gait difficulty, cognitive communication deficit, type 2 DM, morbid obesity, HTN, and CHF. Despite facility policy requiring early identification of discharge goals, incorporation into the care plan, and confirmation that the discharge destination met health, safety, and preference needs, the resident’s care plan contained no discharge plan. The resident independently applied for an independent living apartment and arranged A&D waiver services, while documentation showed a care plan conference noting no discharge plans and non-attendance by the resident. An MDS LPN later confirmed via email that the resident had been approved for independent living with a caregiver, and the SSD documented that the resident discharged to independent living, refused SSD assistance, and that the SSD could not confirm the transition or produce any discharge planning documentation.
A resident with a pressure ulcer did not receive timely wound care or recommended nutritional support after hospital readmission. Wound treatment orders were delayed, and the prescribed supplement for wound healing was not provided, resulting in the development of additional wounds and worsening of existing pressure ulcers, as confirmed by staff interviews and record review.
Staff failed to ensure continuous tube feeding for a resident as ordered, with the feeding pump found idle and not restarted as required. Additionally, another resident did not receive feeding tube site care per physician orders, as Vaseline gauze was omitted and the dressing caused discomfort and bleeding, with the LPN confirming the lapse.
Two residents were emergently transferred to the hospital without the facility providing required reports on their care needs to the receiving institution. One resident, with complex care needs including dialysis and an infectious disease, and another resident, who was unresponsive and required total assistance, were both sent to the hospital without staff communicating their clinical information. Both an LPN and the DON confirmed that the expected transfer reports were not provided.
Licensed staff provided care to a resident who was required to wear an external cardiac defibrillator (Life Vest) without having received prior training on the device. Multiple LPNs confirmed they had not been trained and had no access to training materials, and the DON verified that no training had occurred before care was provided.
Staff did not follow required contact and enhanced barrier precautions for infection control, including not wearing gowns during high-contact care for a resident with C. difficile and two residents with indwelling devices or MDROs, despite facility policy and posted signage.
A resident with severe cognitive impairment and protein calorie malnutrition received a tube feeding formula (Isosource) that did not match the physician's order for Nepro, and water flushes were administered without a physician's order. The feeding bags were not properly labeled or dated, and staff confirmed the discrepancies between the orders and care provided.
Surveyors observed that the facility's medication error rate exceeded 5%, with three errors out of 29 administrations. Two residents were affected: one did not receive prescribed eye drops due to unavailability, and another missed an allergy medication and received an eye medication late. These errors were confirmed by nursing staff and were not in accordance with the facility's medication administration policy.
Surveyors observed that 10 insulin pens in use for three residents were not labeled with the date they were opened, contrary to facility policy requiring all insulin pens to be dated upon initial use. A RN confirmed the absence of opened dates, which is necessary to ensure insulin is not used beyond its 28-day expiration period.
Facility staff failed to include a resident and their family in the quarterly care planning process, as required. A family member reported not being invited or aware of the process, and the Social Services Director confirmed the absence of documentation for the care planning. This indicates a failure to involve residents and families in person-centered care plans.
The facility failed to implement fall prevention interventions for three residents, as outlined in their care plans. A resident did not have a fall mat in place, another was observed sitting on a sling without a fall mat, and a third resident also lacked a fall mat, despite these being required interventions. These deficiencies were confirmed by facility staff.
The facility reported a medication error rate of 11.76%, affecting three residents. Errors included late administration of Atorvastatin and missed Metamucil for a resident, unavailability of Diltiazem for another, and early administration of Calcium Carbonate for a third resident. Staff confirmed these errors during interviews.
A facility failed to complete a PASARR Level II for a resident with Bipolar Disorder, a serious mental illness, which was not identified during the initial PASARR Level I screening. The resident's medical records and MDS assessment confirmed the diagnosis, but the facility did not make the required referral for a Level II evaluation. The Social Services Director acknowledged the oversight, which was contrary to the facility's PASARR policy.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident's electronic medical record showed no care plan was created, which was confirmed by the ADON. This omission violated the facility's policy on person-centered care planning, which aims to ensure continuity of care and resident safety.
A facility failed to complete a Comprehensive Care Plan (CCP) for a resident after a comprehensive assessment. The resident required assistance with various activities, but the CCP only addressed Advanced Directives and lacked necessary care information. An interview with the ADON confirmed the CCP was incomplete, violating the facility's policy on person-centered care planning.
A resident with dysphagia and anoxic brain damage was not provided with activities that met their needs and interests. Despite a care plan goal for participation in activities, the resident was often observed in bed without activities, and minimal participation was documented. The Activity Director noted potential discrepancies in recorded visits, but the resident's preferences for music and group activities were not adequately addressed.
A resident with a history of falls and medical conditions was not provided with adequate fall prevention measures as outlined in their care plan. Despite having interventions such as a fall mat and bed positioning, the resident was found in unsafe positions, and staff confirmed that necessary equipment like wedges was not consistently used.
A resident with dysphagia and anoxic brain damage received enteral feeding not in accordance with physician orders. The nurse administered an extra feeding earlier than scheduled and did not follow the prescribed water flush protocol, as confirmed by the ADON.
A resident with severe cognitive impairment and a history of attempting to leave the facility unattended was identified as at risk for elopement and equipped with a Wanderguard bracelet. Despite orders to check the bracelet's placement and function every shift, there were multiple instances where the resident attempted to leave the facility without the bracelet triggering an alarm. Incident reports documented the resident being found outside the building on two occasions, with the Wanderguard not functioning properly. Documentation revealed a lack of consistent monitoring and documentation of the bracelet's function, highlighting gaps in the facility's elopement prevention measures.
The facility failed to report two elopement incidents involving a resident with severe cognitive impairment to Adult Protective Services and did not submit an investigation to the state agency within the required 5 working days. Despite being identified as an elopement risk and having a care plan in place, the resident was found outside the facility on two separate occasions. The Administrator confirmed that the elopements were not reported because the resident did not leave the facility grounds.
The facility failed to ensure that two nurse aides completed the required 12 hours of yearly in-service training. One nurse aide completed only 1.95 hours of continuing education without any training on abuse prevention or dementia, while another completed only 1.03 hours. The DON confirmed these deficiencies.
The facility failed to ensure the posting of daily nursing staffing information. Observations revealed that the daily nursing staffing posting was outdated, and the Administrator confirmed the issue, noting that a new scheduler had just been hired.
Failure to Complete and Document Discharge Planning for Cognitively Intact Resident
Penalty
Summary
The facility failed to complete and document discharge planning for one cognitively intact resident. Facility policy required that discharge planning begin upon or shortly after admission, be incorporated into the baseline and comprehensive care plans, address the resident’s discharge goals and treatment preferences, identify the discharge destination, and ensure it met the resident’s health and safety needs and preferences. Record review showed that this resident, who had generalized muscle weakness, difficulty walking, a cognitive communication deficit, type 2 diabetes, morbid obesity, hypertension, and congestive heart failure, had no discharge plan initiated on the care plan. The resident’s Discharge MDS showed a BIMS score of 15, indicating intact cognition, and staff interviews confirmed the resident was able to make needs known. Documentation revealed the resident independently completed a rental application for an independent living apartment and later had a care plan conference record indicating no discharge plans and that the resident did not attend the conference. An email from the MDS LPN to the SSD, Administrator, DON, and Business Office Manager confirmed that the MDS LPN had received confirmation the resident was approved for independent living with a caregiver and was working with the Office on Aging to set up caregiver services. A progress note by the SSD on the discharge date stated the resident discharged to an independent living facility and refused assistance from SSD, and SSD was unable to confirm the transition. In interview, SSD stated there was no established discharge plan, that the resident had arranged the discharge and A&D waiver services independently, that SSD did not learn of the discharge plans until the day of discharge, and that the part‑time social services assistant had been collaborating with the resident. SSD was unable to provide any documentation of a discharge plan and confirmed they could not prove that discharge planning documentation had been completed.
Failure to Timely Implement Pressure Ulcer Treatment and Nutritional Interventions
Penalty
Summary
The facility failed to implement timely and appropriate treatment and interventions to promote healing and prevent new pressure ulcers for a resident who was identified as having a pressure ulcer upon readmission from the hospital. Upon return, the resident was noted to have an open wound to the coccyx, but there was no clear documentation of the unit of measurement, and no wound treatment order was in place until five days after the wound was identified. During this period, the resident did not receive wound care as per facility policy, and the recommended nutritional supplement for wound healing, Prosource, was not ordered or administered despite a registered dietician's recommendation. Subsequent wound assessments documented a decline in the resident's skin condition, with the development of additional wounds and progression of an existing wound from stage 2 to stage 3. The treatment administration records and medication administration records showed inconsistencies and delays in implementing wound care orders and nutritional interventions. There was also a lack of documentation for wound assessments on certain dates, and new treatment orders were not consistently reflected in the resident's records. Direct observation and interviews confirmed the presence of multiple pressure ulcers at different stages and locations, and staff acknowledged the delay in initiating wound care and the failure to implement the recommended nutritional support. The resident's wounds increased in number and severity during this period, indicating a lack of adherence to the facility's skin integrity and pressure ulcer prevention policy and failure to follow professional standards for wound management.
Failure to Provide Continuous Tube Feeding and Proper Site Care
Penalty
Summary
Facility staff failed to ensure continuous tube feeding for one resident who was assessed as requiring total assistance for all activities of daily living and had a physician's order for Jevity 1.5 at 40 ml per hour, 24 hours a day. Observations revealed that the resident's tube feeding pump was not running and had been idle for at least 10 minutes on two separate occasions. The nurse responsible confirmed that the tube feeding was not running as ordered and had not been restarted within the last hour. Additionally, staff did not provide feeding tube site care according to the practitioner's orders for another resident with moderate cognitive impairment and total care needs. The treatment order specified cleansing the site and applying Vaseline gauze followed by split gauze twice daily. During observation, the old dressing was found to lack Vaseline gauze, and bright red blood was present at the insertion site. The LPN confirmed the absence of Vaseline gauze and that the old dressing had adhered to the resident's skin, causing discomfort.
Failure to Provide Required Transfer Reports to Receiving Hospitals
Penalty
Summary
The facility failed to provide required reports to the receiving healthcare institution following emergent transfers for two of four sampled residents. For one resident, who was alert, oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions, the facility did not document or communicate the resident's care needs to the hospital after the resident and spouse requested hospital transfer due to body pain. The nurse responsible for the transfer confirmed that no report was given to the hospital. For another resident, who was rarely understood, required total assistance with all activities of daily living, and had a urinary catheter, the facility also failed to document or communicate the resident's care needs to the hospital after the resident was found unresponsive and sent to the hospital via 911. The Director of Nursing confirmed that staff are expected to call the hospital and provide a report, but this was not done in this case.
Lack of Staff Training on External Cardiac Defibrillator
Penalty
Summary
Facility staff failed to ensure that licensed nurses had received training on the use of an external cardiac defibrillator (Life Vest) prior to providing care for a resident who was required to wear the device at all times following hospital discharge. Record review showed that the resident was alert and oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions. Multiple LPNs who provided care to the resident confirmed in interviews that they had not received any training on the Life Vest, nor were there training materials available for staff reference. The Director of Nursing also confirmed that no training on the Life Vest had occurred prior to the resident's admission and care.
Failure to Follow Contact and Enhanced Barrier Precautions for Infection Control
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents requiring contact precautions and enhanced barrier precautions (EBP). For one resident with an active C. difficile infection, staff did not follow posted contact precaution protocols. Specifically, a housekeeper was observed mopping the resident's room without wearing a gown, despite signage and facility policy requiring both gown and gloves for entry and cleaning in such cases. The housekeeper confirmed not wearing the required gown, and the regional nurse consultant verified that this was not in accordance with the resident's isolation status and facility policy. For two other residents, both of whom required EBP due to the presence of indwelling medical devices or multidrug-resistant organisms (MDROs), staff did not wear gowns during high-contact care activities. In one instance, two nursing assistants provided post-shower care, perineal care, and dressing changes to a resident with a urinary catheter and a wound dressing, without wearing gowns. Both staff members stated they were unaware that gowns were required or that the resident was on EBP. In another case, two nursing assistants transferred a resident with an MDRO and a vascular access port for dialysis, and one continued to provide perineal care and a brief change, all without wearing a gown. The staff involved and a registered nurse confirmed they were not aware of the EBP requirement for this resident. Facility policy required the use of gowns and gloves for contact precautions and EBP during high-contact activities for residents with certain infections or indwelling devices. Observations and staff interviews confirmed that these protocols were not followed for the residents in question, despite clear signage and policy directives. The failure to adhere to these precautions was acknowledged by both the staff involved and the regional nurse consultant.
Failure to Administer Enteral Feedings and Water Flushes per Physician Orders
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 3, had a diagnosis of protein calorie malnutrition and required total assistance with all activities of daily living. The resident had a physician's order for Nepro enteral feeding at 45 ml per hour, to be administered continuously over 24 hours. However, observation revealed that the resident was receiving Isosource formula instead of Nepro, and the feeding bag in use was not properly labeled or dated. Additionally, a second feeding bag containing clear liquid (water) was found without a label or date, and the water flushes were being administered at 300 ml every 6 hours without a corresponding physician's order. Interviews with nursing staff confirmed that the tube feeding being administered did not match the physician's order, and that there was no order for the water flushes being provided. The facility's registered dietician also confirmed that Nepro and Isosource formulas are not interchangeable and that Isosource should not have been given to the resident. Review of facility policy indicated that enteral nutrition therapy should be provided in accordance with physician orders and professional standards, which was not followed in this case.
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 10.34% during the administration of 29 medications. Specifically, for one resident, a registered nurse did not administer the prescribed Refresh Tears Solution eye drops at the scheduled time because the medication was unavailable. This omission was confirmed by the nurse during an interview. Additionally, another resident did not receive two of their scheduled medications—Certirizine and Timolol Maleate—at the designated administration time. The LPN responsible confirmed that Certirizine was not administered and that Timolol Maleate was given late. These errors were identified through direct observation and staff interviews, and the facility's own medication administration policy requires adherence to physician orders and the correct timing of medication administration.
Insulin Pens Not Dated Upon Opening
Penalty
Summary
During an observation of a medication cart, surveyors found that 10 insulin pens for three residents were not labeled with the date they were opened, as required by facility policy and professional standards. Specifically, three Lantus pens and two lispro pens for one resident, three lispro pens for another resident, and one Lantus pen and one lispro pen for a third resident were all missing opened dates. Facility policy states that all insulin pens should be dated upon opening and that opened Lantus and lispro insulin expire 28 days after being opened. A registered nurse confirmed that the insulin pens in question did not have a date indicating when initial use began.
Failure to Include Resident and Family in Care Planning Process
Penalty
Summary
The facility staff failed to include a resident and their family member in the quarterly care planning process, as required by regulations. This deficiency was identified during a record review and interviews. Resident 2, who was admitted to the facility and later discharged, did not have a documented quarterly care planning process completed as of the review date. The last recorded care planning process for this resident was completed over a year prior. During an interview, a family member of Resident 2 reported not being invited or aware of the quarterly care planning process, despite being involved in planning care for the resident. Additionally, the Social Services Director confirmed that Resident 2's record did not reflect the completion of the care planning process and was unaware of any such process being completed for the resident. This oversight indicates a failure to adhere to the regulatory requirement of involving residents and their families in the development and implementation of person-centered care plans.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility staff failed to implement assessed interventions to prevent accidents and falls for three residents. Resident 1's Comprehensive Care Plan (CCP) indicated the need for a fall mat next to the bed, among other interventions, to prevent serious injury. However, observations revealed that Resident 1 did not have a fall mat in place, which was confirmed by an LPN. Similarly, Resident 3's CCP required the removal of a sling after being positioned in a chair and the presence of a fall mat at the bedside. Observations showed that Resident 3 was seated on a sling in a wheelchair and did not have a fall mat next to the bed, as confirmed by both an LPN and an RN. Resident 4's CCP also identified the need for a fall mat at the bedside and a low bed when asleep to prevent serious injury. Observations indicated that Resident 4 did not have a fall mat next to the bed, which was confirmed by an RN. These deficiencies highlight the facility's failure to adhere to the planned interventions outlined in the residents' care plans, potentially compromising the safety and well-being of the residents.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 11.76%. This deficiency affected three out of five sampled residents. For Resident 10, the medication administration record (MAR) indicated that Atorvastatin was to be given at 5:00 PM, but it was administered late at 7:33 PM. Additionally, Metamucil was not given as ordered. Licensed Practical Nurse (LPN) A confirmed these errors during an interview. Resident 11's medication order included Diltiazem to be given at bedtime, but during observation, the medication was not available for administration. Registered Nurse (RN) B confirmed the unavailability of the medication as an error. For Resident 13, the MAR indicated that Calcium Carbonate was to be administered at 10 AM and 3 PM, but it was given early at 7:23 AM. RN D confirmed this early administration as an error during an interview.
Failure to Complete PASARR Level II for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II was completed for a resident with a serious mental disorder. The deficiency was identified during a review of records and an interview with the facility's Social Services Director. The resident in question, referred to as Resident 6, was admitted to the facility with a diagnosis of Bipolar Disorder, a serious mental illness. However, this diagnosis was not identified during the initial PASARR Level I screening, which incorrectly indicated no signs of a serious mental illness or intellectual disability. Upon admission, Resident 6's medical records showed a diagnosis of Bipolar Disorder dated shortly after the initial screening. The Minimum Data Set (MDS) assessment for Resident 6 confirmed the presence of Bipolar Disorder, along with other conditions such as anxiety and depression. Despite these findings, the facility did not make a referral for a PASARR Level II evaluation, which is required when a serious mental disorder is identified after admission. The Social Services Director confirmed that a referral should have been made once the omission was recognized. The facility's policy on PASARR, dated 9/25/2023, outlines the procedures for ensuring that potential admissions are screened for serious mental disorders or intellectual disabilities. It specifies that a positive Level I screen necessitates a Level II evaluation by the state-designated authority. The policy also requires the facility to incorporate recommendations from the PASARR Level II determination into the resident's care plan. In this case, the facility did not adhere to these procedures, resulting in a failure to coordinate the necessary assessments and referrals for Resident 6.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to complete a baseline care plan for a resident within 48 hours of admission, as required by their policy and regulatory standards. The resident, identified as Resident 79, was admitted on a specific date, but a review of their electronic medical record revealed that no baseline care plan was developed or implemented in the Point Click Care system. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the baseline care plan for Resident 79 was blank and lacked necessary information about the resident's physical or medical needs, goals, or interventions. The facility's policy on person-centered care planning mandates that each resident should have a comprehensive care plan developed to meet their preferences and goals, addressing medical, physical, mental, and psychosocial needs. The baseline care plan is intended to ensure continuity of care and communication among staff, increase resident safety, and prevent adverse events immediately after admission. However, in this case, the facility did not adhere to its own procedures, resulting in a deficiency in care planning for Resident 79.
Incomplete Comprehensive Care Plan for a Resident
Penalty
Summary
The facility staff failed to complete a Comprehensive Care Plan (CCP) for a resident, identified as Resident 79, after the completion of a comprehensive assessment. This deficiency was identified during a record review and interview process. Resident 79's Minimum Data Set (MDS) indicated the need for setup or clean-up assistance with oral hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing. Despite these identified needs, the CCP for Resident 79, dated 06/22/2024, only included a focus area related to Advanced Directives and lacked information addressing the resident's care needs. An interview with the Assistant Director of Nursing (ADON) confirmed that Resident 79's CCP had not been completed. The facility's policy on Person-Centered Care Planning, dated 08/22/2023, requires that each resident have a comprehensive care plan developed to meet their preferences and goals, addressing medical, physical, mental, and psychosocial needs. The facility's procedure outlines that the CCP should include measurable goals, timeframes, and interventions to assist the resident in achieving their highest practicable well-being. However, these requirements were not met for Resident 79, as the CCP was incomplete and did not reflect the necessary interventions and goals based on the comprehensive assessment.
Failure to Meet Resident's Activity Needs
Penalty
Summary
The facility failed to provide activities that met the needs and interests of a resident with a diagnosis of dysphagia and anoxic brain damage. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs due to immobility, with a goal of participating in activities at least 1-2 times weekly. However, observations revealed that the resident was often in bed with no activities occurring, and the resident's participation in activities was minimal, with only a few 1-1 visits documented over several months. Interviews with the Activity Director indicated that more 1-1 visits might have been provided than recorded, but the resident was not consistently brought to activities when out of bed. The resident's preferences included listening to music, engaging in group activities, and going outside for fresh air, yet these interests were not adequately addressed. The facility's failure to ensure the resident's participation in activities as per their care plan and preferences led to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent potential falls for a resident identified as being at risk for falls. The resident, who was admitted with dysphagia and anoxic brain damage, had a care plan that included several interventions to mitigate fall risks, such as keeping the call light within reach, using a fall mat, and ensuring the bed was in a low position when appropriate. Despite these measures, the resident experienced two incidents where they were found on the fall mat next to the bed, indicating that the interventions were not effectively implemented. Observations revealed that the resident was often found in positions that increased the risk of falling, such as having feet off the edge of the bed without wedges in place to prevent this. Interviews with staff confirmed that wedges were not consistently used, and the bed was not always in the low position as required by the care plan. The facility's policy on fall management emphasized assessing residents for fall risks and implementing appropriate interventions, but these were not adequately followed for the resident in question.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that enteral feeding was provided in accordance with the physician's order for a resident with a diagnosis of dysphagia and anoxic brain damage. The resident was receiving more than 51% of their total calories from enteral tube feeding. The physician's orders specified that the resident should receive Jevity 1.5 formula via G-tube with specific water flushes at scheduled times. However, on a particular day, a registered nurse administered an extra feeding of Jevity 1.5 bolus at 9:10 AM, which was not due until 12 PM, and did not follow the prescribed water flush protocol. During the observation, the registered nurse encountered difficulty administering the tube feeding and initially flushed the tube with less water than ordered. The nurse left the room to consult with the nurse practitioner and later realized the error in the timing of the feeding. The Assistant Director of Nursing confirmed that the timing for the administration of the resident's tube feeding was not followed, indicating a failure to adhere to the practitioner's order as outlined in the facility's Enteral Tube Feeding Checklist.
Inconsistent Monitoring of Wanderguard Bracelet for Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure monitoring of a Wanderguard bracelet for Resident 1, who was at risk for elopement due to severe cognitive impairment and a history of attempting to leave the facility unattended. Despite being identified as at risk for elopement and having a Wanderguard bracelet in place, there were multiple instances where Resident 1 attempted to leave the facility without the bracelet triggering an alarm. Incident reports documented Resident 1 being found outside the building on two occasions, with the Wanderguard not functioning properly or alarming as intended. Documentation revealed that while there were orders in place to check the Wanderguard bracelet's placement and function every shift, there was a lack of consistent monitoring and documentation of this task. The facility's policy on elopement highlighted the risks associated with residents leaving the premises without supervision and emphasized the need for regular review and revision of care plans for residents at risk of elopement. Interviews with staff members revealed gaps in monitoring Resident 1's Wanderguard bracelet, with no evidence of consistent monitoring between the bracelet being placed and the deficiency being identified. The deficiency in ensuring the proper monitoring of the Wanderguard bracelet for Resident 1 highlights a critical lapse in supervision and safety measures for a resident at high risk of elopement. Despite the facility's policies and procedures in place for elopement prevention, the lack of consistent monitoring and documentation of the bracelet's function put Resident 1 at risk of leaving the facility unsupervised. The repeated instances of Resident 1 attempting to exit the building without the alarm sounding raise concerns about the effectiveness of the facility's elopement prevention measures and the need for improved monitoring protocols to ensure resident safety.
Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to report two elopement incidents involving a resident with severe cognitive impairment to Adult Protective Services and did not submit an investigation to the state agency within the required 5 working days. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with a BIMS score of 3, indicating severe cognitive impairment. Despite being identified as an elopement risk and having a care plan in place with interventions such as frequent monitoring and a Wanderguard bracelet, the resident was found outside the facility on two separate occasions. On one occasion, the resident was found walking up a hill and was retrieved by staff, and on another occasion, the resident was found walking outside the building by housekeeping staff. In both instances, the resident did not sustain any injuries, and the Wanderguard bracelet was found to be working properly. The facility's policy on missing residents and actual elopement events defines elopement as a resident leaving the premises or a safe area without authorization and necessary supervision. The policy also requires the Executive Director or designee to report such events to all appropriate agencies. However, the Administrator confirmed that the elopements were not reported because the resident did not leave the facility grounds. This failure to report and investigate the incidents as required by the facility's policy and state regulations constitutes a deficiency in the facility's compliance with reporting requirements.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that two nurse aides, identified as Nurse Aide C and Nurse Aide D, completed the required 12 hours of yearly in-service training. Specifically, Nurse Aide C, who was hired on 11/28/17, completed only 1.95 hours of continuing education between 11/28/22 and 11/28/23, with no training on abuse prevention or dementia. Similarly, Nurse Aide D, hired on 10/5/18, completed only 1.03 hours of continuing education between 10/5/22 and 10/5/23. The Director of Nursing confirmed these deficiencies during an interview. The facility had a total census of 85 residents at the time of the survey.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the posting of daily nursing staffing information. Observations on 4/2/24 at 1:00 PM revealed that the daily nursing staffing posting was dated 3/13/24. A review of the facility staff posting confirmed that the census and staffing hours were from 3/13/24. In an interview on 4/2/24 at 1:11 PM, the Administrator confirmed that the daily nursing staffing posting was not up-to-date and reported that a new scheduler had just been hired.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
