Crowell Memorial Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Blair, Nebraska.
- Location
- 245 South 22nd Street, Blair, Nebraska 68008
- CMS Provider Number
- 285210
- Inspections on file
- 28
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Crowell Memorial Home during CMS and state inspections, most recent first.
Surveyors found that staff did not follow care-planned fall prevention and transfer interventions for three residents at high risk for falls. One resident, fully dependent for transfers and previously injured in a fall, was care-planned for Hoyer lift transfers only but was instead manually transferred from the toilet to a w/c without a gait belt, resulting in a fall and pelvic fracture. Another resident, totally dependent for transfers and toileting with a high fall risk score, was observed in bed without the required fall mat in place and without the fall alarm moved from the w/c to the bed. A third cognitively intact resident, care-planned to be transferred to the bathroom by w/c with a gait belt and to have blue Dycem under the w/c gel cushion, was instead ambulated to the bathroom with a walker, and the Dycem was missing; the NA reported not knowing the resident was to be taken by w/c, and the DON confirmed ambulation should not have occurred.
The facility failed to report a significant injury to the state agency as required by its abuse, neglect, and exploitation policy and state regulations. A resident with significant cognitive and functional impairments, requiring extensive to total assistance with transfers and ADLs, fell while being assisted from the toilet to a wheelchair and was sent to the ED. The resident returned to the ED the next day with hip pain and clinical signs of leg rotation and shortening, and was diagnosed with a closed pelvic fracture. Despite policy requirements for timely reporting of serious injuries, the DON and administrator acknowledged that the incident and resulting pelvic fracture were not reported to the state agency because they believed it was not a new injury.
Staff did not implement required fall prevention interventions for a resident with multiple risk factors, including not using a pressure detection alarm as outlined in the care plan. The resident, who had impaired cognition and needed assistance with daily activities, was found on the floor without the alarm in place, despite staff acknowledging it should have been used.
A resident with Parkinson's disease and constipation was not consistently monitored for bowel movements, and required interventions such as prune juice and Miralax were not administered as per protocol. Staff interviews confirmed inconsistent documentation and communication, resulting in the resident experiencing multiple days without a recorded bowel movement and eventual hospital admission.
A resident prescribed risperidone for bipolar disorder did not receive a Gradual Dose Reduction (GDR) as recommended by pharmacy review. The attending physician disagreed with the recommendation but failed to provide a documented rationale, and the facility did not ensure this explanation was obtained, contrary to policy.
Two residents with limited range of motion and mobility impairments did not receive restorative care services as outlined in their care plans, with documentation showing that prescribed bed mobility and PROM exercises were only provided on two days during the month. The DON confirmed the lack of consistent restorative care and the absence of a facility policy for restorative services.
A resident with respiratory conditions had undated oxygen tubing, and staff confirmed there was no system to track respiratory supply changes. For another resident with a gastrostomy tube, a hospice aide provided high-contact care without donning a gown as required by Enhanced Barrier Precautions, despite clear signage. Additionally, a medication aide administered eye drops to a resident without performing hand hygiene before gloving, in violation of facility policy.
A resident with intact cognition and a history of psychiatric conditions reported that a nurse aide requested money and made a threatening remark when refused, leading to the resident feeling fearful. The DON was informed of the incident but did not report it to APS or DHHS as required, citing the belief that it was not abuse and that the resident did not want to file a grievance.
A resident with intact cognition and multiple psychiatric and medical diagnoses reported that a nurse aide requested money and made a comment implying withdrawal of care, leading the resident to feel fearful. Although the DON was informed and spoke with both parties, a thorough written investigation was not completed as required by facility policy.
Staff failed to individualize and document the use of physical restraints for three residents with severe cognitive impairment and mobility issues, placing them in Merry Walkers they could not remove themselves from, without proper assessment, documentation, or care planning as required by facility policy. Interviews confirmed the lack of risk/benefit analysis, ongoing re-evaluation, and appropriate coding of the devices as restraints.
Two residents with severe cognitive impairment were regularly placed in a Merry Walker device, which they could not remove themselves from without assistance. Staff interviews and documentation confirmed that the use of the device was not coded as a restraint on the MDS or consistently addressed in care plans, despite nursing staff acknowledging it should have been documented as such.
The facility did not provide adequate supervision or maintain functional elopement prevention systems for residents with severe cognitive impairment and wandering behaviors. A resident was able to access a stairwell and fall after staff failed to respond to activated alarms, and multiple Wanderguard units were found to be nonfunctional, with staff not responding to substitute doorbell alarms. Other residents at risk for elopement were not consistently monitored or had incomplete care plan documentation.
The facility did not ensure dietary staff wore proper beard restraints that fully enclosed all facial hair during meal service observations. The Dietary Manager and a Dietary Aide were observed with beard restraints that did not fully enclose all facial hair, posing potential contamination risks. Additionally, issues were found in kitchen and dining area sanitation and storage practices, including unlabeled and undated food items, lack of covers for hot dish storage units, presence of food particles and dirt buildup, and equipment maintenance concerns such as nicks on the electric slicer blade and dried-on food spatters on the commercial mixer guard.
The facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 resident rooms and the 2nd floor north hallway nurses station. Observations revealed scrapes on walls, broken toilet tanks, cracked caulking, water stains, dirt buildup, and other issues. The Maintenance Director confirmed the need for cleaning and repairs, noting that these concerns had not been previously identified.
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate. A medication assistant crushed and administered medications to a resident despite 'do not crush' instructions, leading to the error.
A resident with an indwelling catheter had their catheter care mishandled by a nursing assistant, who placed wipes in a contaminated sink basin and on a handrail before use. Additionally, the resident's catheter bag was found uncovered and touching a floor mat, contrary to facility policy.
The facility failed to conduct APS and CPS registry checks for a newly hired Nursing Assistant (NA G). Despite the facility's policy requiring these checks before employment, NA G's file lacked the necessary documentation. This was confirmed through record review and interviews with the Administrator and Administrative Assistant.
Failure to Follow Care-Planned Fall Prevention and Transfer Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions and transfer methods for multiple residents identified as being at risk for falls. The facility’s fall prevention policy requires standardized fall risk assessments, categorization into risk levels, and implementation of individualized interventions based on high- or low/moderate-risk protocols, with ongoing monitoring and care plan revision. Despite this, surveyors found that for several residents, the interventions and transfer methods specified in their comprehensive care plans were not followed in practice. For one resident with significant ADL dependence, incontinence, and a history of a fall with major injury and pelvic fracture, the comprehensive care plan specified that all transfers were to be done with a Hoyer lift. Progress notes and incident documentation showed that this resident was instead transferred from the toilet to a wheelchair by a nursing assistant without a gait belt, contrary to the care plan. The resident fell during this transfer, complained of pain, and was later found to have a closed fracture of the pelvis. The DON confirmed that the resident had not been transferred properly and that the pelvic fracture resulted from this event. Another resident, who required total assistance with transfers, toileting, hygiene, dressing, bed mobility, and bathing, had a care plan identifying a high fall risk with a fall risk score of 15 and multiple fall prevention approaches, including use of a fall mat next to the bed and a fall alarm when in bed. During observation, this resident was found lying in bed with the fall mat leaning against the wall at the foot of the bed and no fall alarm in place. The nursing assistant confirmed that the fall mat was not next to the bed and that the fall alarm had not been moved from the wheelchair to the bed as required. A third resident, cognitively intact but requiring assistance with transfers and occasionally incontinent, had a fall risk score of 13 and a care plan specifying transfer to the bathroom by wheelchair with a gait belt and use of blue Dycem between the wheelchair seat and gel cushion to prevent slipping. Observations showed the resident being ambulated to the bathroom with a walker and gait belt instead of being taken by wheelchair, and the blue Dycem was absent from the wheelchair. The nursing assistant involved stated they were not aware the resident was to be taken to the bathroom by wheelchair, and the DON confirmed the resident should not have been ambulated.
Failure to Report Resident Fall With Pelvic Fracture to State Agency
Penalty
Summary
The facility failed to timely report a significant injury related to a fall to the state agency as required by its abuse, neglect, and exploitation policy and state regulations. The facility’s written policy, dated 09-23-2022, required procedures for identifying possible abuse, neglect, and exploitation, including physical injury of unknown source, and mandated reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified time frames. These time frames were defined as immediately, but no later than 2 hours when events involve abuse or result in serious bodily injury, and no later than 24 hours when events do not involve abuse and do not result in serious bodily injury. Record review showed that one resident had significant functional and cognitive impairments, including being rarely able to make self-understood, always incontinent of bowel and bladder, requiring extensive assistance with toilet transfers, and total assistance with lower body dressing, personal hygiene, bed mobility, and transfers. Progress notes documented that this resident fell on 12-19-2025 while being transferred from the toilet to a wheelchair, complained of left knee pain, and was sent to the emergency room. The following day, the resident complained of left hip pain, with staff noting the left leg was rotated inward and shorter than the right, leading to hospital transfer and admission for a possible pelvic fracture. Hospital records and the after-visit summary confirmed a closed fracture of the left inferior pubic ramus (pelvic fracture). In interviews, the DON and the administrator confirmed that this fall with pelvic fracture was not reported to the state agency because the facility believed it was not a new injury.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement assessed interventions to prevent falls for a resident with multiple risk factors, including Parkinson's disease, spinal stenosis, lumbar radiculopathy, hypertension, muscle weakness, and depression. The resident was assessed as having moderately impaired cognition and required partial to moderate assistance with several activities of daily living. The care plan identified the resident as being at risk for falls and included interventions such as the use of a pressure detection (pd) alarm in the wheelchair or bed due to the resident's non-compliance with calling for assistance. On the date of the incident, the resident was found on the floor, and documentation revealed that the call light was within reach, but the required wheelchair or bed/chair alarm was not in use at the time. Interviews with both an RN and the DON confirmed that the alarm should have been in place according to the care plan, but it was not implemented when the fall occurred.
Failure to Monitor and Intervene for Bowel Function
Penalty
Summary
The facility failed to ensure proper monitoring and intervention for bowel function for one resident with a diagnosis of Parkinson's disease and constipation, who also had a history of fecal impaction. According to the facility's bowel program, nursing staff were required to monitor bowel movements every shift and implement a stepwise intervention protocol, including the administration of prune juice, oral laxatives, and suppositories as needed, with physician notification if no bowel movement occurred after three days. Documentation revealed that the resident went multiple periods of four days without a recorded bowel movement, and the required interventions, including the administration of Miralax as ordered, were not provided during the month in question. Interviews with nursing and dietary staff confirmed inconsistent monitoring and communication regarding bowel management. Staff reported that the bowel movement tracking was not consistently completed, and dietary staff were not routinely informed about which residents required prune juice. The DON acknowledged that the documentation was incomplete and that the resident should have received interventions according to the protocol. The resident was eventually admitted to the hospital, and the deficiency was attributed to the lack of consistent monitoring and failure to follow the established bowel management procedures.
Lack of Rationale for Not Reducing Psychotropic Medication
Penalty
Summary
The facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR) of a psychotropic medication for one resident. Record review showed that the resident, who was cognitively intact with a BIMS score of 13/15, was prescribed risperidone for bipolar disorder. A pharmacy review recommended a reduction in the medication dosage, but the primary physician disagreed with this recommendation and did not document a rationale for the decision. Further review of the facility's pharmacy policy indicated that when a physician rejects a pharmacy recommendation, an explanation must be provided. In this case, the Director of Nursing confirmed that no rationale was documented by the physician for not implementing the GDR. The facility did not follow its own policy requiring documentation of the physician's reasoning when declining a pharmacy recommendation.
Failure to Provide Restorative Care as Care Planned for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative care services as outlined in the care plans for two residents with limited range of motion (ROM) and mobility issues. One resident, who was unable to complete a cognitive assessment and had diagnoses including muscle wasting, contracture of the left hand, and anoxic brain damage, was care planned to receive bed mobility and passive range of motion (PROM) exercises at least 2-3 times per week. However, documentation showed that these exercises were only provided on two days during the month of June. The Director of Nursing (DON) confirmed that only two days were marked for restorative care for this resident in that month. Another resident, who was cognitively intact and had hemiplegia and hemiparesis following a cerebral infarction, was also care planned to receive bed mobility and PROM exercises at least 2-3 times per week. Similarly, records indicated that this resident received the prescribed exercises only on two days in June. The DON confirmed the lack of restorative care documentation for this resident as well and acknowledged that the facility did not have a restorative care policy in place.
Failure to Date Oxygen Tubing, Adhere to Enhanced Barrier Precautions, and Perform Hand Hygiene
Penalty
Summary
The facility failed to properly date and track oxygen tubing for a resident with multiple respiratory diagnoses, including dyspnea, congestive heart failure, obstructive sleep apnea, and acute and chronic respiratory failure. Observations over several days revealed that the resident's oxygen tubing and nasal cannula were not marked with the date they were placed, and interviews with nursing staff and the DON confirmed that there was no method in place for tracking the change of respiratory supplies, despite a policy that tubing should be changed weekly. Additionally, the facility did not ensure that staff followed Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube who required assistance with all activities of daily living. Despite signage indicating the need for gown and glove use during high-contact care activities, a hospice nurse aide was observed providing toileting, hygiene, and transfer assistance without donning a gown, in direct violation of the posted EBP requirements. This was confirmed by both the aide and the facility wound nurse during interviews. The facility also failed to enforce proper hand hygiene practices during medication administration. An observation showed a medication aide preparing and administering eye drops to a resident without performing hand hygiene prior to donning gloves, contrary to facility policy. The aide confirmed in an interview that hand hygiene was not performed before gloving, as required.
Failure to Timely Report Alleged Misappropriation to Authorities
Penalty
Summary
The facility failed to report an allegation of misappropriation involving a resident within the required timeframe to Adult Protective Services (APS) and the Department of Health and Human Services (DHHS). According to facility policy, all alleged violations, including misappropriation of resident property, must be reported immediately, but not later than 2 hours if abuse or serious bodily injury is involved, or within 24 hours otherwise. The incident involved a nurse aide (NA-B) who told a resident that they owed the aide five dollars. The resident did not give the money and later reported feeling fearful of the aide, who allegedly responded by saying, 'see if I do anything for you anymore.' The resident reported the incident to a nurse and left a voicemail for the Director of Nursing (DON). The DON confirmed knowledge of the incident, spoke with both the resident and the aide, and instructed the aide not to enter the resident's room. However, the DON did not report the incident to APS or DHHS, stating that it was not considered abuse and that the resident did not wish to file a grievance. The failure to report the allegation as required by policy and regulation constituted the deficiency. The resident involved had a history of psychiatric and mood disorders, including psychosis, major depressive disorder, schizophrenia, and anxiety, but was assessed as having intact cognition and moderate depression at the time of the incident.
Failure to Investigate Alleged Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving one resident. According to facility policy, any alleged violation, including misappropriation of resident property, requires an immediate and comprehensive investigation, including identification and interviews of all involved parties and complete documentation. In this case, a resident with intact cognition and a history of psychiatric and medical conditions reported to staff and left a voicemail for the DON that a nurse aide had told the resident they owed the aide five dollars and subsequently made a comment implying withdrawal of assistance. The resident expressed fear of the aide following the incident. The DON acknowledged awareness of the incident and confirmed speaking with both the resident and the nurse aide on the day of the report. The DON instructed the aide not to enter the resident's room but did not conduct a thorough written investigation, as required by facility policy. The DON stated the aide was joking and did not believe the incident constituted abuse or required reporting, especially since the resident did not wish to file a grievance. As a result, the facility did not complete the necessary investigative steps or documentation for the alleged misappropriation.
Failure to Individualize and Document Use of Physical Restraints
Penalty
Summary
Facility staff failed to ensure the individualized use of physical restraints for three residents, as required by both facility policy and state regulations. The facility's policy mandates that before a restraint is used, there must be identification of a specific medical symptom, documentation of the duration and monitoring of restraint use, evaluation of less restrictive alternatives, and ongoing re-evaluation of the need for the restraint. However, for all three residents sampled, these requirements were not met. The use of Merry Walkers, which are considered restraints if the resident cannot remove themselves, was not properly assessed, documented, or care planned as restraints. One resident with dementia and severe cognitive impairment was regularly placed in a Merry Walker and could not remove themselves from the device. Staff interviews confirmed that the resident was unable to exit the Merry Walker independently, and the device was not coded as a restraint on the MDS or included in the care plan as such. There was no documentation of risk/benefit discussions with the resident's representative, and the physical therapist had not re-evaluated the need for the device since the initial assessment. The resident experienced a fall while in the Merry Walker, resulting in multiple bruises and a hospital transfer. Two other residents, both with severe cognitive impairment and mobility issues, were also placed in Merry Walkers without proper documentation or individualized assessment. Staff confirmed that these residents could not remove themselves from the devices, and there was no evidence of risk/benefit analysis or ongoing re-evaluation. The devices were not identified as restraints in the residents' records, and the required documentation and care planning were absent. The DON and other staff acknowledged these deficiencies during interviews.
Failure to Accurately Code Use of Restraints on MDS
Penalty
Summary
The facility failed to accurately code the use of restraints on the Minimum Data Set (MDS) for two residents who utilized a Merry Walker device. Both residents had severe cognitive impairment, as indicated by low BIMS scores, and required assistance for ambulation. Documentation and interviews revealed that both residents were regularly placed in the Merry Walker, could not remove themselves from the device independently, and were supervised or assisted by staff for mobility and toileting. Despite this, the use of the Merry Walker was not identified or coded as a restraint on the MDS, nor was it consistently addressed in the care plans as a restraint. Staff interviews confirmed that the residents were unable to exit the Merry Walker without assistance, and that the device was used for extended periods throughout the day. Registered nursing staff acknowledged during interviews that the Merry Walker should have been documented as a restraint on the MDS and included in the care plan, but this was not done. The failure to accurately assess and code the use of the Merry Walker as a restraint constituted the deficiency identified during the survey.
Failure to Prevent Elopement and Maintain Functional Safety Alarms
Penalty
Summary
The facility failed to provide adequate supervision and maintain functional safety systems to prevent elopement and accidents for residents with severe cognitive impairment and a history of wandering. One resident with dementia and a BIMS score indicating severe cognitive impairment was left unsupervised, allowing the resident to pass through alarmed doors and access a stairwell, resulting in a fall down two flights of stairs. The alarms on the doors and the resident's Wanderguard device were activated, but staff did not respond appropriately to the alarms, and the resident was found on the stair landing with multiple bruises. Other residents at risk for elopement were also not adequately protected. One resident with a history of wandering and a BIMS score indicating severe cognitive impairment had a Wanderguard bracelet in place, but this intervention was not documented in the care plan. Another resident with severe cognitive impairment and a history of wandering had a Wanderguard bracelet, but there was no documentation of wandering behaviors in the progress notes, despite care plan interventions requiring monitoring and documentation. Additionally, multiple Wanderguard alarm units on the first floor were found to be nonfunctional for extended periods, with staff and maintenance aware of the issue. Doorbell alarms were installed as a substitute, but staff did not respond when these alarms sounded during observations. The lack of functioning elopement prevention systems and inadequate staff response to alarms contributed to the failure to ensure a safe environment and adequate supervision for residents at risk of elopement.
Dietary Staff Beard Restraint and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure compliance with dietary staff wearing proper beard restraints that fully enclosed all facial hair during meal service observations. The Dietary Manager and a Dietary Aide were observed with beard restraints that did not fully enclose all hair on the face, potentially leading to contamination risks. Additionally, the storage and sanitation practices in the kitchen and dining areas were found to be substandard. Issues included unlabeled and undated food items, lack of covers for hot dish storage units, presence of food particles and buildup of dirt in various areas, and equipment maintenance concerns such as nicks on the electric slicer blade and dried-on food spatters on the large commercial mixer guard. Observations during meal services on multiple occasions highlighted the non-compliance with proper beard restraints by staff members, including the Dietary Manager and a Dietary Aide. The failure to fully enclose all facial hair could pose risks of contamination during food preparation and service. Furthermore, storage and sanitation concerns were identified in various areas of the kitchen and dining room, including unlabeled food items, lack of covers for hot dish storage, presence of food particles, and equipment maintenance issues like nicks on the electric slicer blade and dried-on food spatters on the large commercial mixer guard.
Facility Fails to Maintain Cleanliness and Condition of Resident Rooms and Common Areas
Penalty
Summary
The facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 of 59 occupied resident rooms and the 2nd floor north hallway nurses station. Observations during an environmental tour revealed several scrapes on walls in various rooms, broken and cracked toilet tanks, cracked caulking, water stains, and plaster peeling on bathroom ceilings. Additionally, there were brown stains and dirt buildup around the base of toilets, large stains on floors, cracked linoleum, burned-out light bulbs, broken cable TV outlet covers, loose baseboards, heavy dirt buildup along bathroom walls and corners, and dead bugs inside light fixtures. These deficiencies were confirmed by the Maintenance Director (MD) during the tour, who acknowledged that no work orders had been placed for the identified areas and that these concerns had not been previously identified. The specific rooms affected included rooms 102, 105, 106, 113, 116, 122, 123, 125, 131, 132, 134, 144, 146, 158, 159, 162, 203, 205, 212, 215, 225, 233, 236, and 238. The issues ranged from scrapes on walls, broken toilet tanks, cracked caulking, water stains, and dirt buildup to more severe problems like large cracks in walls and heavy dirt and wax buildup. The MD confirmed the need for cleaning and repairs but noted that these issues had not been previously identified or addressed, indicating a lapse in the facility's maintenance and cleanliness protocols.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.69% error rate. This deficiency affected one resident (Resident 44) out of three sampled residents. During an observation, Medication Assistant (MA) D was seen preparing medications for Resident 44. MA D crushed both an 81 mg delayed-release aspirin tablet and a 100 mg DOK tablet, despite the medication orders explicitly stating that these medications should not be crushed. The crushed medications were then mixed with pudding and administered to Resident 44. This action was confirmed as a medication error by both MA D and the Assistant Director of Nursing (ADON). The facility's policy on medication administration also clearly states that medications should be administered as ordered and in accordance with manufacturer specifications, including not crushing medications that have 'do not crush' instructions. Record reviews of Resident 44's active orders and the medication cards confirmed that both the aspirin and DOK tablets had 'do not crush' instructions. The facility's policy on medication administration, dated 04-09-2024, was reviewed and it was found to include guidelines that medications should be administered as ordered and in accordance with manufacturer specifications. The failure to adhere to these guidelines led to the medication errors observed. The facility census at the time was 60 residents.
Improper Handling of Catheter and Linens
Penalty
Summary
The facility failed to handle linens and a catheter drainage bag in a manner to prevent potential cross-contamination for one resident. Resident 44, who had a diagnosis of Chronic Kidney Disease Stage 3 and an indwelling catheter following a recent hospitalization for Acute Kidney Injury, was observed receiving catheter care from Nursing Assistant C. During the procedure, NA C placed wipes in a contaminated sink basin and then on a handrail before using them to clean the catheter insertion site and tubing. This practice was confirmed by NA C and the Assistant Director of Nursing as inappropriate and potentially cross-contaminating. Additionally, Resident 44's indwelling catheter bag was observed hanging uncovered on the bed frame and touching a floor mat. This was confirmed by Nursing Assistant B and the facility Infection Preventionist as improper handling that could lead to cross-contamination. The facility's policy on catheter care and infection prevention clearly states that catheter bags should not touch the floor and that linens should be handled in a manner to prevent infection spread. The Assistant Director of Nursing confirmed that these practices were not followed, leading to the deficiency.
Failure to Conduct APS and CPS Registry Checks for New Hire
Penalty
Summary
The facility failed to conduct adult and child protective service (APS and CPS) registry checks upon hire for a newly employed Nursing Assistant (NA G). NA G was hired on March 4, 2024, but the employee file did not contain the results from the required APS and CPS registry checks. This deficiency was identified during a record review and confirmed through interviews with the Administrator and the Administrative Assistant. Both acknowledged that APS and CPS registry checks are mandatory upon hire and that employees should not commence work until the results are received. The facility's policy on Background Investigations, dated June 2015, mandates that personal reference checks, driving record investigations, and background investigations, including APS and CPS registry checks, be conducted for all personnel. Despite this policy, the required checks were not completed for NA G. The policy also specifies that the Administrative Assistant is responsible for conducting these background investigations in compliance with the Omnibus Budget Reconciliation Act of 1987. The failure to adhere to this policy resulted in the deficiency noted in the report.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
A resident who was cognitively intact, required extensive assistance with ADLs, and was at risk for pressure ulcers was readmitted from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle. Despite the facility's policy requiring immediate notification of the physician for significant changes in condition, there were no treatment orders or documented treatments for these pressure ulcers in the transition orders, order summary, or treatment administration record. The WIN confirmed that the physician was not contacted to obtain necessary wound care orders, resulting in a failure to notify the provider of new pressure ulcers.
A resident who was cognitively intact and dependent for multiple ADLs returned from a hospital stay with a new left BKA, a PICC line for IV antibiotics to treat MRSA, open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. Facility policy required immediate care planning for high-risk issues such as skin/wounds and review of the care plan with significant changes in condition. Despite this, the comprehensive care plan completed after the resident’s return did not include the BKA, MRSA infection, IV antibiotics, or the new pressure ulcers, a lapse confirmed by the MDS coordinator.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
Failure to Notify Physician and Obtain Orders for New Pressure Ulcers
Penalty
Summary
The facility failed to follow its "Notification of Changes" policy and licensure requirements by not notifying the attending physician of new pressure ulcers for one resident. The policy, dated 01-2024, requires that changes in a resident's condition, including significant changes and conditions that may require physician intervention, be immediately reported to the resident, resident representative, and the attending physician or delegate. This includes new or altered skin conditions such as pressure ulcers. Surveyors reviewed the policy and determined that it obligated staff to promptly communicate such changes to ensure appropriate care decisions. Record review for one resident showed that the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had existing venous ulcers. After a hospital stay, the resident was readmitted with documented unmeasured pressure ulcers to the right outer ankle, right lateral foot, and right 5th toe, and the hospital transition documentation further identified unstageable pressure ulcers to the right lateral ankle, right lateral foot, right lateral 5th toe, and right heel, along with other wounds. However, there were no corresponding treatment orders for these right foot and ankle pressure ulcers in the transition orders, the order summary, or the treatment administration record for March. In an interview, the Wound and Infection Nurse confirmed that the resident did not have treatment orders for these pressure ulcers and acknowledged that the facility should have called the physician to obtain orders, demonstrating that the provider was not notified of the new pressure ulcers as required.
Failure to Revise Care Plan After Amputation, MRSA Infection, and New Pressure Ulcers
Penalty
Summary
The facility failed to review and revise a resident’s comprehensive care plan to reflect significant changes in condition, including a new left below-the-knee amputation (BKA), MRSA infection, IV antibiotic therapy, and multiple pressure ulcers. Facility policy required that high-risk areas such as skin/wounds be care-planned immediately upon identifying risk, and that the interdisciplinary team review the plan of care quarterly, annually, with significant change, and when desired outcomes were not met. The resident’s MDS dated 01-04-2026 showed the resident was cognitively intact with a BIMS score of 13, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had two venous ulcers. Record review showed the resident was hospitalized and, upon return, transition orders dated 03-04-2026 documented a left BKA, a PICC line for IV antibiotics to treat a MRSA infection, two open buttock wounds, an incision at the BKA site, and multiple unstageable pressure ulcers on the right foot, ankle, fifth toe, and heel. However, the comprehensive care plan dated 03-17-2026 did not include the left BKA, the MRSA infection, or the use of IV antibiotics. During interview, the MDS Coordinator confirmed that the care plan had not been revised to include care and services for the resistant infection, IV medications, the new BKA site, and the pressure ulcers on the right foot and ankle, and acknowledged that it should have been updated.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
