Good Shepherd Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Blair, Nebraska.
- Location
- 2242 Wright Street, Blair, Nebraska 68008
- CMS Provider Number
- 285148
- Inspections on file
- 17
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Good Shepherd Lutheran Home during CMS and state inspections, most recent first.
Staff failed to ensure privacy during wound care for a resident with severe cognitive impairment and multiple complex wounds, including MASD and Stage 3 pressure injuries. During wound treatment to the hips, the resident’s bed was positioned without a privacy curtain in place, while the roommate sat nearby eating breakfast and was able to view the resident’s exposed buttocks and all care provided. The roommate made a comment about the resident’s body, and the RN and resident laughed before the RN covered the resident, with the RN later confirming that the missing curtain for several weeks allowed the roommate to see all personal and wound care and constituted a breach of privacy and dignity.
Two residents with existing pressure injuries and complex medical conditions were found lying on pressure-relieving air mattresses that were not calibrated to their documented weights, despite care plan interventions and orders requiring proper inflation and monitoring. One resident with severe cognitive impairment, multiple open wounds, MASD, and several Stage 3 and unstageable pressure injuries had a weight of about 154 lbs, but the mattress was set to 180 lbs. Another resident with moderate cognitive impairment, diabetes, neuropathy, and a Stage 3 pressure injury to the right buttock weighed about 197 lbs, yet the mattress was set at the maximum setting of 380 lbs. An RN confirmed in both cases that the mattresses should have been set according to each resident’s weight and that incorrect settings could contribute to skin breakdown.
Staff failed to follow infection control and hand hygiene practices during wound care for three residents with Stage 3 and other complex pressure injuries. An RN allowed a resident’s brief and blanket to contact an open hip wound, did not change gloves between touching soiled items and cleansing the wound, and applied triad paste after the wound had been exposed to the blanket without re-cleaning. For another resident with a buttock pressure injury, an RN allowed wound paste to contact the brief and then handled a clean foam dressing with a contaminated glove before applying it. For a third resident with a Stage 3 buttock wound with undermining, an LPN cleansed the wound and then, without changing gloves, applied peri-wound paste and Gentelle Blue foam while repeatedly allowing the buttocks to close over the wound and dressing, creating repeated opportunities for cross contamination.
Surveyors observed that dietary staff failed to follow proper hand hygiene and gloving procedures, including inadequate hand washing and donning gloves without cleaning hands after touching contaminated surfaces. The kitchen environment was also found to be unsanitary, with rust, food and grease buildup, dirty floors, and soiled ventilation covers. The Dietary Manager confirmed these issues, and cleaning logs did not address the specific concerns identified. All residents consumed food prepared in this environment.
Staff failed to maintain infection control standards by storing resident care supplies in areas with water damage and visible mold, not changing a resident's oxygen tubing as ordered, and not using required PPE during high-contact care activities for a resident on enhanced barrier precautions. These actions resulted in multiple deficiencies related to infection prevention.
The facility did not repair ongoing roof leaks, leading to water damage and mold-like spots in the therapy gym, offices, and other areas. Despite management being aware and a partial patch repair being made, no further action was taken, and the damage persisted, potentially affecting all residents.
A deficiency was identified when surveyors found that the ventilation systems in the bathrooms of 20 occupied rooms on two halls were not operational, as demonstrated by a lack of air draw during testing. The Maintenance Director and Environmental Services Account Manager both confirmed there was no documentation of recent operational checks for these ventilation systems.
A resident repeatedly refused multiple prescribed medications for various health conditions, but the facility did not notify the medical practitioner or family as required by policy. The DON confirmed that the practitioner was not informed, and documentation of these refusals was incomplete.
A resident with multiple psychiatric and neurological diagnoses was continued on a PRN lorazepam order for six months without the required clinical rationale documented by the provider, despite facility policy and pharmacist recommendation specifying the need for such documentation. The DON confirmed the absence of the necessary rationale in the resident's record.
A resident with severe cognitive impairment and total dependence on staff was involved in a resident-to-resident abuse incident that was not reported to APS within the required 24-hour timeframe. Facility staff failed to immediately notify administration of the incident, resulting in delayed reporting despite established policy and prior staff education.
A resident with multiple medical and psychiatric diagnoses was transferred to an acute care hospital on two occasions without receiving written notification of the specific reason for transfer, as required by facility policy. The bed-hold agreements provided did not include the reason for transfer, and the Social Services Designee confirmed that this information was not communicated in writing to the resident or their representative.
A resident admitted with multiple diagnoses and significant care needs did not have a comprehensive care plan developed within the required timeframe after the MDS assessment. The care plan failed to address several identified areas, including cognition/dementia, communication, urinary incontinence, psychosocial, and dental needs, as confirmed by the MDS Coordinator.
Surveyors identified that the facility's medication error rate was 8%, exceeding the regulatory limit. Two residents were affected: one received rapid-acting insulin without a meal or snack, and another was given polyethylene glycol from a container labeled for a different resident. These errors were observed during medication administration by an RN and an LPN.
A nurse administered rapid-acting insulin to a resident without providing a meal or snack, and breakfast was not served until more than an hour later, contrary to facility policy requiring insulin to be given immediately before meals or with food.
The facility failed to ensure that the designated infection preventionist was certified, potentially affecting all residents. The Infection Preventionist admitted they were not currently certified but expected to complete the certification by May 2024. The Facility Administrator confirmed the lack of a certified Infection Preventionist.
A resident with a suprapubic catheter was observed multiple times with the catheter bag improperly positioned, touching the floor and a trash can, leading to potential cross-contamination. The DON confirmed the issue and acknowledged the need for proper positioning.
A resident with Alzheimer's disease experienced significant weight loss and severe malnutrition, but the facility failed to notify the responsible party. Despite adjustments in medication and nutritional supplements by the physician, the lack of communication was confirmed by the Director of Nursing.
Failure to Ensure Privacy During Wound Care
Penalty
Summary
Facility staff failed to maintain privacy and confidentiality during personal and medical care for one resident. The resident had been admitted to the facility on an unspecified date and had a BIMS score of 5, indicating severe cognitive impairment. The resident’s care plan and clinical profile documented multiple significant medical conditions, including lymphedema, venous insufficiency, osteoarthritis, rheumatoid arthritis, multiple open wounds on the buttocks and lower extremities, pressure ulcers on both heels, severe protein calorie malnutrition, metabolic encephalopathy, and various staged pressure injuries and moisture-associated skin damage. The resident had physician orders for specific wound care to the right and left posterior hips, including cleansing with saline, application of triad paste and silver alginate, and covering with a silicone superabsorbent dressing. During an observation of wound care performed by an RN, the resident’s bed was in a low position with a fall mat beside it, and the resident was lying on their left side. The room did not have a privacy curtain, and it had been missing for a few weeks. While the RN provided wound care, the resident’s roommate was seated at the side of their own bed eating breakfast and was able to see the resident’s exposed buttocks and all personal and wound care being provided. The roommate commented, “nice butt,” and both the resident and the RN laughed before the RN covered the resident with a blanket. In a subsequent interview, the RN confirmed that the lack of a privacy curtain allowed the roommate to view all aspects of the resident’s care and acknowledged this as a breach of the resident’s privacy and dignity.
Improper Calibration of Pressure-Relieving Air Mattresses for Residents With Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pressure-relieving air mattresses were inflated according to residents’ weights, as required by physician orders and care plan interventions. For one resident with severe cognitive impairment and multiple complex medical conditions, including lymphedema, venous insufficiency, osteoarthritis, rheumatoid arthritis, severe protein-calorie malnutrition, metabolic encephalopathy, and numerous open wounds and pressure injuries (including MASD to both buttocks, unstageable and Stage 3 pressure injuries on the heels, legs, hip, and root), the care plan and orders specified use of an air mattress with monitoring to ensure it was inflated and functioning properly. The resident’s weight was documented as 154.3 lbs, but during observation the air mattress was found set at 180 lbs. The RN interviewed confirmed the mattress setting did not match the resident’s weight and acknowledged that the mattress should be calibrated according to the individual’s weight and that an incorrectly set mattress could contribute to skin breakdown. A second resident, who was moderately cognitively impaired and had diagnoses including type 2 diabetes, prior right tibia fracture, spinal stenosis, polyneuritis, arthropathy, and osteoarthritis, had a documented Stage 3 pressure injury to the right buttock. Skin observation notes by the ADON described the wound measurements and identified it as a pressure injury, and the resident’s care plan included an intervention for an air mattress. The resident’s weight was documented as 196.9 lbs. However, during observation, this resident’s pressure-relieving air mattress was found set at the maximum inflation setting of 380 lbs rather than being adjusted to the resident’s actual weight. In both cases, the facility had established care plan interventions and physician orders requiring that the air mattresses be properly inflated and functioning, with specific monitoring instructions. Despite these directives, surveyor observations and staff interviews confirmed that the mattresses for two residents with existing pressure injuries were not calibrated according to their documented weights. The RN acknowledged in each instance that the settings were incorrect and that the mattresses should have been set based on the residents’ weights, and further confirmed that incorrect inflation could contribute to skin breakdown.
Improper Wound Care Technique Leading to Cross Contamination Risk
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in a manner that prevented cross contamination for three residents, despite having infection control and hand hygiene policies in place. The facility’s Infection Control Guidelines and Handwashing policy required staff to perform hand hygiene after handling items potentially contaminated with blood, body fluids, secretions, contaminated linens, and after contact with broken skin. These policies also directed staff to use alcohol-based hand rub before and after direct resident contact and when moving from dirty to clean tasks. Observations of wound care for three residents showed that these procedures were not consistently followed, resulting in multiple opportunities for cross contamination of open wounds. For one resident with multiple complex wounds and pressure injuries, including Stage 3 pressure injuries and an unstageable pressure ulcer, an RN performed wound care to the hip area in a manner that allowed the resident’s brief and blanket to come into contact with an open, undressed wound. During the dressing change, the RN removed the old dressing, pulled the brief back up over the open wound, then later pulled it down again without changing gloves between touching the brief and cleansing the wound. The RN also pushed the brief away from the wound and cleansed the wound using the same gloves without performing hand hygiene. After the blanket touched the uncovered wound, the RN re-entered the room wearing gloves, exposed the wound, and applied triad paste with a cotton-tipped applicator without changing gloves, using hand sanitizer, or re-cleaning the wound. The RN confirmed these actions, including entering the room with gloves on, not changing gloves between dirty and clean tasks, and allowing the brief and blanket to touch the open wound, created opportunities for cross contamination. For a second resident with a Stage 3 pressure injury to the right buttock, an RN conducted wound care after donning a gown and gloves and exposing the resident’s buttock. The RN used one gloved hand to reposition the buttock and the other to apply triad paste with a cotton applicator. When the RN needed both hands to peel back the adhesive on the bordered foam dressing, the resident’s wound and triad paste came into contact with the resident’s brief. The RN then used the same gloved hand that had been repositioning the buttock to handle the clean dressing and apply it to the wound. The RN acknowledged that the contact between the wound paste and the brief, and touching the clean dressing with a contaminated glove, provided opportunities for cross contamination and that hand hygiene and glove changes should have occurred before handling the clean dressing. For a third resident with dementia, sarcopenia, and a Stage 3 pressure injury with undermining to the left buttock, an LPN performed wound care using saline, triad paste, Gentelle Blue foam, and a silicone foam dressing. After exposing the resident’s buttocks and placing a chux pad, the LPN cleansed the wound with saline and patted it dry using gloved hands and gauze, but did not change the soiled gloves or perform hand hygiene before proceeding. The LPN then applied triad paste to the peri-wound area and allowed the resident’s buttocks to come together, causing contact between the wound area and the resident’s brief. The LPN separated the buttocks again to place the Gentelle Blue foam into the undermined wound, then released the buttocks, allowing them to close over the dressing, and used both hands to apply the silicone dressing. The LPN confirmed that allowing the buttocks to touch the brief and then close over the dressing, and failing to change gloves after cleaning the wound and before applying paste, created multiple opportunities for cross contamination of the wound.
Deficient Hand Hygiene and Kitchen Sanitation in Food Service
Penalty
Summary
The facility failed to ensure proper hand hygiene and gloving practices in the kitchen, as required by both facility policy and professional standards. Observations revealed that a dietary staff member repeatedly performed hand washing for significantly less than the required 20 seconds, often washing for only 6 to 10 seconds between tasks. The staff member also donned new gloves without performing hand hygiene after touching potentially contaminated surfaces, such as cooler door handles and storage areas, and handled food and food preparation equipment without adequate hand washing. The Dietary Manager confirmed that the observed hand hygiene practices did not meet facility policy and that all residents consumed food prepared in this kitchen. In addition to hand hygiene deficiencies, the facility kitchen was observed to have multiple sanitation concerns. These included the presence of rust on a wire dish rack, torn weather stripping on the serving window, food and grease spatters on kitchen equipment, burned and dried food residues on ovens and backsplashes, and grease and sticky substances on various surfaces. The kitchen also had non-operational ovens, dirty and sticky floors, food particles and dirt in storage and preparation areas, and heavily soiled ventilation covers directly above food preparation areas. These conditions were confirmed by the Dietary Manager during a walkthrough. Review of the facility's cleaning schedules indicated that logs were filled out as required, but the specific sanitation issues identified during the survey were not addressed in these records. The Dietary Manager acknowledged the need for cleaning and maintenance in the areas noted by surveyors but was unsure how long some equipment had been out of service. All 66 residents in the facility were potentially affected, as they consumed food prepared in the kitchen where these deficiencies were observed.
Infection Control Failures in Supply Storage, Oxygen Equipment, and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement effective infection prevention and control measures, resulting in multiple deficiencies. On the second floor, which was unoccupied by residents, surveyors observed 65 boxes of incontinent products, disinfectant cleaner, and other resident care supplies stored in rooms with missing ceiling tiles and visible black spots, which staff identified as mold. Additional observations in the therapy gym and office revealed discolored and damaged ceiling tiles, missing plaster exposing brick, and further black spots attributed to water damage from a leaking roof. Despite management and ownership being notified of the water damage, no repairs had been completed since the initial report, and there was no current plan to address the ongoing leaks or mold-like spots. For one resident, staff failed to follow physician orders and facility policy regarding oxygen tubing changes. The resident's treatment administration record required weekly changes of oxygen tubing, with proper labeling and cleaning of the concentrator. However, observations over several days showed the tubing was not changed as ordered, with dates on the tubing indicating it had not been replaced for at least eight days. The DON confirmed the tubing had not been changed and that the documentation was invalid, indicating a lapse in infection control practices related to respiratory equipment. In another case, staff did not adhere to enhanced barrier precautions for a resident with severe cognitive impairment, an indwelling medical device, and an order for contact precautions due to MRSA. During a transfer from a recliner to a wheelchair and then to bed, staff did not wear the required PPE, only donning gown and gloves after the transfer was completed. Interviews with staff confirmed that they were aware of the need for PPE during high-contact activities but failed to implement these precautions during the observed transfer.
Failure to Repair Roof Leaks Resulting in Water Damage and Mold
Penalty
Summary
The facility failed to repair leaks in the roof, resulting in ongoing water damage in multiple areas, including the therapy gym and offices. Observations revealed discolored, water-stained ceiling tiles with brown and black spots, missing plaster exposing brick, and black spots identified by staff as mold. The east window of the therapy office also had missing plaster, and similar damage was observed in the supply room on the second floor. The facility's own policy requires storage areas to be kept free from trash and debris, but the report focuses on the physical damage and lack of repair. Record reviews showed that the management company was made aware of the roof damage, and a payment was made to a roofing company for a patch repair. However, interviews with the Administrator confirmed that no further repairs had been completed since that time, and there was no current plan to address the ongoing leaks or the mold-like spots. The deficiency had the potential to affect all 66 residents in the facility, as the water damage and mold were present in common and therapy areas.
Non-Operational Ventilation Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure a working ventilation system in 20 out of 28 occupied resident rooms on the 300 and 400 halls. During an environmental inspection, it was found that the ventilation systems in the bathrooms of these rooms did not function, as evidenced by the inability of the vents to draw a tissue square to the surface, indicating non-operation. The Maintenance Director confirmed the lack of ventilation draw in these bathrooms and was unable to provide documentation of the last operational check. Additionally, the Environmental Services Account Manager verified that there was no documentation available regarding recent checks of the ventilation systems' operation.
Failure to Notify Practitioner and Family of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the medical practitioner and family of a resident's repeated refusals to take prescribed medications. Record reviews showed that the resident, who was unable to complete a cognitive assessment, had multiple medications ordered for conditions including pain, heart health, hyperlipidemia, hypertension, depression, GERD, memory support, dementia, and constipation. The Medication Administration Record indicated that the resident refused several medications on numerous occasions throughout the month. Despite these repeated refusals, there was no documentation in the progress notes that the primary medical provider was notified of these events. An interview with the Director of Nursing confirmed that the practitioner was not informed of the resident's medication refusals, which was contrary to facility policy. The policy required documentation of the refusal, including notification of the healthcare practitioner within a timeframe determined by the resident's condition and the potential seriousness of the consequences. The lack of notification and documentation represented a failure to follow established procedures for managing medication refusals.
Lack of Documented Rationale for Continued PRN Psychotropic Medication Use
Penalty
Summary
Facility staff failed to ensure that a clinical rationale was documented for the continued use of a PRN (as needed) antianxiety medication for one resident. The facility's policy requires that PRN psychotropic medication orders be time-limited, with extensions beyond 14 days only permitted if the prescriber documents a clinical rationale, including effectiveness, ongoing diagnosis, indication, and duration. For the resident in question, who had diagnoses including delirium, major depressive disorder, psychosis, unspecified mood disorder, senile degeneration of the brain, and Alzheimer's disease, a PRN order for lorazepam was continued for six months without the required documentation of rationale by the provider. Record reviews showed that the resident had severe cognitive impairment and was receiving antipsychotic and antidepressant medications, but did not display behaviors according to the MDS. The pharmacist recommended continuation of the PRN lorazepam, and the provider agreed, but failed to document the necessary clinical rationale for its continued use. The DON confirmed during interview that no rationale was documented for the ongoing PRN lorazepam order.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the required 24-hour timeframe to Adult Protective Services (APS) for one resident. According to the facility's policy, all staff, residents, and visitors are required to immediately report any incidents or suspected incidents of abuse, neglect, or exploitation. The policy further specifies that staff must notify the charge nurse, department head, or administration immediately, and that the administrator or designee must notify APS within 24 hours if the incident does not result in bodily harm. In this case, an incident involving resident-to-resident abuse occurred, but administration was not notified until several days later, and APS was not contacted until after the 24-hour window had passed. The resident involved had severe cognitive impairment, as indicated by a BIMS score of 6, and was dependent on staff for all activities of daily living. The incident was first identified in a facility investigation initiated by the administrator, which revealed that the event had occurred days prior and that no injury had resulted. The Director of Nursing confirmed that staff did not immediately notify administration as required, despite previous education on the reporting process. As a result, the allegation of abuse was not reported to APS within the mandated timeframe.
Failure to Provide Written Notification of Hospital Transfer Reason
Penalty
Summary
Facility staff failed to provide written notification to a resident and their representative regarding the specific reason for the resident's transfer to an acute care hospital. According to the facility's Bed-hold Agreement policy, a copy of the bed-hold agreement, including the specific reason and basis for the transfer, must be provided to the resident or their representative at the time of transfer. Record review showed that for two separate hospital transfers, the bed-hold agreements were signed by the Social Services Designee but did not include the reason for the transfers. The resident involved had multiple diagnoses, including Influenza A, COPD, chronic respiratory failure, cognitive communication deficit, fracture of the neck of the left femur, iron deficiency anemia, schizophrenia, bipolar disorder, hypertension, and dementia. The resident was assessed as cognitively intact at the time of the deficiency. Interviews with the Social Services Designee confirmed that the required written notification of the reason for transfer was not provided to the resident or their representative, and that the bed-hold agreement was not sent at the time of transfer as required.
Failure to Develop Comprehensive Care Plan Following MDS Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days of completing the Minimum Data Set (MDS) assessment for one resident. According to facility policy, the care plan should be developed within seven days of the required MDS assessment and no more than 21 days after admission. For the resident in question, who was admitted with diagnoses including hypertension, thyroid disorder, cerebral infarction (stroke), and neuropathy, the MDS identified significant care needs such as dependence on staff for toileting, bathing, transfers, wheelchair mobility, dressing, and personal hygiene. Despite the MDS and Care Area Assessments (CAAs) indicating the need for care planning in areas such as cognition/dementia, communication, functional abilities, urinary incontinence, psychosocial, behavior, falls, dental, and pressure ulcers, the comprehensive care plan only addressed transfers under functional abilities. There were no interventions listed for cognition/dementia, communication, urinary incontinence, psychosocial, or dental needs. The MDS Coordinator confirmed these omissions and acknowledged that additional interventions should have been included for the resident's identified needs.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, with an observed error rate of 8% during the survey. In one instance, a registered nurse administered 5 units of rapid-acting insulin subcutaneously to a resident without providing a snack or ensuring the insulin was given immediately prior to a meal. The resident's blood sugar was checked, and the insulin was administered at 7:01 AM, but breakfast was not served until after 8:20 AM, contrary to facility policy that rapid-acting insulin should be given immediately before a meal or with food. In another instance, a licensed practical nurse administered polyethylene glycol to a different resident using a container labeled for another resident. The nurse confirmed that the medication was not labeled for the intended recipient and acknowledged the error. These two medication errors were identified among 25 observed medication administrations, affecting two residents.
Significant Medication Error: Improper Timing of Rapid-Acting Insulin Administration
Penalty
Summary
A registered nurse administered 5 units of rapid-acting insulin lispro to a resident in the morning after giving oral medications with water, but did not provide a snack or meal at the time of injection. Facility policy states that rapid-acting insulin should be injected immediately prior to a meal or concurrent with food. Observation showed that breakfast was not served until over an hour after the insulin was given. The nurse confirmed that the insulin was administered without a snack and acknowledged that rapid-acting insulin should be given within 30 minutes of meals.
Facility Lacks Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated infection preventionist was certified, which had the potential to affect all residents in the facility. A record review of the facility's Infection Control Program revealed that a nurse (RN or LPN) would be designated as the Infection Preventionist and complete the required training. However, during an interview, the designated Infection Preventionist admitted they were not currently certified but expected to complete the certification by May 2024. The Facility Administrator confirmed that the facility did not have a certified Infection Preventionist at the time of the interview.
Improper Positioning of Catheter Bag Leading to Potential Cross-Contamination
Penalty
Summary
The facility failed to position a catheter bag in a manner to prevent potential cross-contamination for one resident observed with a urinary catheter. Resident 20, who had a suprapubic catheter due to neurogenic bladder, was observed multiple times with the catheter bag attached to a trash can, with the back of the bag in contact with the exterior of the trash can and the bottom of the bag touching the floor. This was observed on two consecutive days at different times, indicating a consistent issue with the catheter bag's positioning. Resident 20 had a diagnosis of neuromuscular dysfunction of the bladder and a malignant neoplasm of the renal pelvis and was totally dependent on staff for toileting hygiene. The resident's cognitive status was intact, as indicated by a BIMS score of 13. The Director of Nursing confirmed that the catheter bag's contact with the floor and trash can could cause potential cross-contamination and acknowledged that the catheter bag should be positioned to avoid such contact.
Failure to Notify Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to notify the responsible party of a significant weight loss for a resident diagnosed with Alzheimer's disease. The resident experienced a weight loss of 5% or more in the last month and 10% or more in the last six months. The Registered Dietitian's assessment revealed severe malnutrition, decreased appetite, and a significant decline in meal intakes over the last six days. Despite these findings, there was no evidence in the Electronic Medical Record that the responsible party had been informed of the resident's weight loss or decreased intake. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the lack of notification to the responsible party. The resident's physician had responded to the annual nutrition assessment by adding a diagnosis of severe malnutrition and adjusting the resident's medication and nutritional supplements. However, the failure to communicate these critical changes to the responsible party represents a significant lapse in the facility's duty to keep family members informed about the resident's health status.
Latest citations in Nebraska
Surveyors found that the facility 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.
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