Kimball County Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Kimball, Nebraska.
- Location
- 810 East 7th Street, Kimball, Nebraska 69145
- CMS Provider Number
- 285256
- Inspections on file
- 20
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Kimball County Manor during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A resident with moderate cognitive impairment reported being hit by a staff member, but the LPN who received the allegation did not report it or initiate an investigation, instead dismissing the claim as a misconception. The resident provided a detailed description of the alleged perpetrator and expressed fear, while other staff reported ongoing concerns about the conduct of certain aides. Facility policy requiring immediate reporting and investigation of abuse was not followed, resulting in a deficiency.
The facility did not complete required background and nurse aide registry checks for a housekeeper, activities supervisor, and dietary aide before hire or rehire, despite these staff having direct and unsupervised access to residents. Human Resources confirmed the oversight and lack of awareness regarding the requirement for nurse aide registry checks for such staff.
Five nurse aides did not complete the required 12 hours of annual ongoing training, with completed hours ranging from 3.82 to 10.82 and some hours discounted due to duplicate courses. The facility's assessment listed training topics but did not ensure compliance with the annual education requirement, as confirmed by the NHA.
The facility did not develop or implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters, unresolved wounds, or stage III pressure ulcers. Observations found no PPE indicators outside affected residents' rooms, and staff interviews revealed inconsistent knowledge and lack of training on EBP requirements. Both the DON and Administrator confirmed they were unaware of the EBP regulation and had not enacted related policies.
A review of staff records and interviews revealed that multiple new, rehired, and agency staff did not receive required orientation and training on topics such as resident rights, emergency procedures, adult abuse/neglect, medical emergency directives, and dementia care within two weeks of employment. This lapse was confirmed by both HR and the DON, and affected nearly all sampled staff, potentially impacting all residents in the facility.
The facility did not ensure that nurse aides completed the required 4 hours of annual dementia training, with several aides either lacking any documented training or having completed only a portion of the required hours. The administrator was unaware of this requirement, and the deficiency had the potential to impact all residents.
A resident reported to an LPN that staff had hit them the previous night, but the LPN did not report the allegation to the NHA or State Agency, nor initiate an investigation, believing the claim was not credible. The NHA was unaware of the allegation until later, and the investigation report was submitted to the State Agency seven working days after the incident, exceeding the required timeframe.
Two residents with complex medical and mental health needs did not have complete care plans addressing all their diagnoses and high-risk medications. One resident's care plan lacked non-pharmacological interventions for anxiety and did not mention all prescribed psychotropic medications, while another resident's care plan omitted key conditions such as CHF, diabetes, and the use of antiplatelet and diuretic medications. These omissions were confirmed by facility leadership and did not align with the facility's care planning policy.
A resident with cognitive impairment and mobility needs was provided bed rails at the request of their POA without evidence that alternatives were considered or attempted, and without proper documentation of risk-benefit assessment or informed consent. The DON confirmed that no alternatives were explored prior to bed rail installation, and the facility's policy did not require such steps.
The facility kitchen staff failed to follow proper handwashing and gloving techniques during meal preparation, risking cross-contamination for all 41 residents. Observations showed that a dietary staff member did not wash hands upon entering the kitchen or before changing gloves, and handled various items and food with soiled gloves.
The facility failed to implement proper hand hygiene practices during the distribution of resident laundry and medication administration. A laundry aide did not perform hand hygiene while distributing laundry, and an LPN did not wash hands between medication passes for different residents, contrary to facility policy and CDC guidelines.
The facility failed to implement an antibiotic stewardship program as required by their policy. The ADON confirmed that they only generated a monthly report listing residents on antibiotics but did not track or trend antibiotic use beyond this. Interviews revealed that the facility struggled with implementing the program, potentially affecting all 41 residents.
The facility failed to obtain an end date or rationale for the continued use of antibiotics for three residents, leading to indefinite antibiotic use without proper follow-up or documentation.
The facility had a medication error rate of 14.81%, exceeding the acceptable threshold of 5%. Errors included late administration of medications, failure to follow special instructions, and incorrect mixing of medication fluids.
A facility failed to ensure a resident's DNR order was added to their EHR. Staff confirmed they rely on the EHR for code status, but the resident's advance directive was only in the paper chart, not the EHR, contrary to facility policy.
The facility failed to administer oxygen per physician's orders for two residents. One resident with COPD had their oxygen flow rate set higher than prescribed, and another resident with acute respiratory failure had their oxygen set lower than ordered and was observed with the oxygen tank turned off.
The facility failed to provide a pneumococcal immunization for a resident. A review of the resident's medical records showed a signed consent form indicating the vaccine was received, but it lacked the date and type of vaccine. Interviews revealed that the facility had not verified the resident's previous vaccination status and had not administered the vaccine while the resident was in the facility.
A resident who had signed a consent form to receive the COVID-19 vaccine did not receive the vaccine due to a lapse in scheduling and documentation by the facility's staff.
The facility failed to ensure the use of two-persons while utilizing a Hoyer lift for a resident with severe cognitive impairment and multiple dependencies. Additionally, the facility did not ensure the oxygen concentrator was turned off when not in use, posing a fire hazard.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Report and Investigate Resident Abuse Allegation
Penalty
Summary
The facility failed to protect a resident from abuse after an allegation of staff-to-resident abuse was made. The resident, who had dementia with moderate cognitive impairment and difficulty expressing themselves, reported to an LPN that staff had hit them during the previous night. The LPN did not report the allegation to the Nursing Home Administrator (NHA) or initiate an investigation, as required by facility policy. Instead, the LPN dismissed the resident's report as a dream or misconception of reality, without clear justification for this determination. The resident later provided a detailed description of the alleged perpetrator and expressed fear and distress during interviews. Observations confirmed that a nurse aide matching the resident's description was present in the facility. Additional interviews with staff revealed ongoing concerns about the conduct of certain agency aides, including allegations of yelling at residents, improper feeding, and mishandling of mobility aids. These concerns had reportedly been communicated to supervisory staff but were dismissed or not acted upon. The facility's policies required immediate reporting and investigation of any suspected abuse, as well as protective measures for residents during investigations. However, these procedures were not followed in this case. The NHA and DON were unaware of the abuse allegation until it was brought to their attention by surveyors, and no immediate protective actions were taken for the resident following the initial report. The failure to report and investigate the allegation in accordance with policy resulted in a deficiency at the immediate jeopardy level.
Removal Plan
- DON will do a full head to toe skin assessment on Resident #39, noting any discolorations, bruises, or visible markings on body.
- DON and NHA will place phone call to resident family to inform them of the allegation of abuse and share with them the steps we are taking and findings from skin assessment.
- Alleged perpetrator will not be allowed to return to work until investigation is complete.
- DON will begin investigation into allegation by interviewing staff, residents, and speaking to family members.
- A report with the findings of the investigation will be provided to the State Agency.
- NHA will provide a copy of the Abuse Prohibition Policies and Procedures to all staff currently at facility to review and sign. Copies of this will be provided to all oncoming staff at the start of next shift to be reviewed and signed.
- An all staff Inservice is scheduled to educate staff on the importance of adhering to the Abuse Prohibition Policies and Procedures.
- DON and NHA upon arriving at facility, will read through progress notes for all residents on a daily basis, and immediately investigate any allegation of abuse or neglect. DON and NHA will alternate reading through progress notes on Saturday and Sunday.
- NHA will continue to ensure that all staff are compliant with their mandatory, annual Abuse/Neglect Inservice.
- SSD will conduct spot interviews with residents to ensure residents they feel they are receiving adequate care.
Failure to Complete Required Employee Background and Registry Checks
Penalty
Summary
The facility failed to implement its policies and procedures regarding the screening of potential employees prior to employment. Specifically, for three out of five sampled employees—a housekeeper, an activities supervisor, and a dietary aide—there was no evidence that required background checks, including nurse aide registry checks, were completed before hire or rehire. The facility's policy required checks of the Nebraska License Information System, Adult and Child Abuse Registries, criminal history, and the Nebraska State Patrol Sex Offender Registry, but did not explicitly require a nurse aide registry check for all staff with direct and unsupervised access to residents. Record reviews showed that the dietary aide was rehired without any background or registry checks, and both the housekeeper and activities supervisor did not have nurse aide registry checks completed prior to their hire. Human Resources confirmed these omissions and acknowledged being unaware of the requirement for nurse aide registry checks for staff with direct and unsupervised access to residents. This failure had the potential to affect all residents in the facility, which had a census of 39 at the time.
Failure to Ensure Nurse Aides Complete Required Annual Training Hours
Penalty
Summary
The facility failed to ensure that five sampled nurse aides completed at least 12 hours of ongoing training annually, as required by regulation. Record reviews showed that each of the five nurse aides had not met the minimum training hours based on their individual employment dates. Specifically, the training hours completed by each aide ranged from 3.82 to 10.82 hours within their respective annual periods, with some hours being discounted due to duplicate courses. The facility's assessment listed required training topics but did not provide evidence that the 12-hour annual education requirement was being met for nurse aides. An interview with the Nursing Home Administrator confirmed that the sampled nurse aides had not completed the required ongoing training. The deficiency had the potential to affect all residents in the facility, which had a census of 39 at the time of the survey. No information was provided regarding the medical history or condition of specific residents related to this deficiency.
Failure to Implement Enhanced Barrier Precautions for Residents with High-Risk Conditions
Penalty
Summary
The facility failed to develop and implement Enhanced Barrier Precautions (EBP) policies and procedures as required, specifically for residents with conditions that necessitate such precautions. Record reviews revealed that one resident had an indwelling catheter, another had unresolved wounds, and a third had a stage III pressure ulcer. Observations showed that there were no signs or indicators outside these residents' rooms to alert staff to the need for personal protective equipment (PPE) during high-contact care activities. Interviews with nurse aides indicated inconsistent understanding and application of EBP, with one aide stating EBP was used on everyone, while another denied any residents were on EBP and reported not receiving training regarding PPE use for wounds and catheters. The Director of Nursing and the Administrator both confirmed a lack of awareness and implementation of the EBP regulation, with the DON stating that new regulations are typically monitored by the Administrator, who also denied knowledge of the requirement.
Failure to Provide Timely Orientation and Mandatory Training to Staff
Penalty
Summary
The facility failed to ensure that all new and existing staff members received required initial orientation and training within two weeks of employment, as mandated by state regulations. Record reviews showed that 11 out of 12 sampled employees, including nurse aides, a housekeeper, an activities supervisor, and agency staff, did not complete training on essential topics such as resident rights, emergency procedures, adult abuse/neglect, medical emergency directives, and dementia care within the required timeframe. The facility's own assessment and compliance documents indicated that training on emergency preparedness, resident rights, and abuse and neglect was required, but there was no evidence of training on medical emergency directives. Personnel files and agency attestations further confirmed the lack of timely completion of these trainings for both direct hires and agency staff. Interviews with Human Resources and the Director of Nursing corroborated that several staff members, including those rehired or contracted through agencies, had not completed all required orientation topics. Specifically, there was no evidence that certain staff had completed training on emergency procedures, medical directives, dementia, or adult abuse and neglect within two weeks of starting employment. This deficiency had the potential to affect all residents in the facility, which had a census of 39 at the time of the survey.
Failure to Ensure Required Annual Dementia Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides completed at least 4 hours of annual dementia training as required by state regulations. Record reviews for five nurse aides showed that none had met the mandated training hours within their respective annual periods. Specifically, three nurse aides had no evidence of any dementia training completed during the required timeframe, while two others had only completed one hour each, falling short of the four-hour requirement. The facility's own assessment indicated that all staff would receive dementia training, but there was no documentation to confirm compliance with the specific annual hour requirement. An interview with the Nursing Home Administrator revealed a lack of awareness regarding the requirement for nurse aides to complete at least 4 hours of dementia training each year. The administrator confirmed that the identified nurse aides had not met this requirement. The deficiency had the potential to affect all residents in the facility, which had a census of 39 at the time of the survey.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to immediately investigate and report an allegation of staff-to-resident abuse within 24 hours, and did not submit the investigation to the State Agency (SA) within the required 5 working days. A review of the facility's policy indicated that all abuse allegations must be reported to the SA within 24 hours and a written investigation report submitted within five working days. However, documentation showed that when a resident reported to an LPN that staff had hit them the previous night, the LPN did not report the allegation to the Nursing Home Administrator (NHA) or the SA, nor did they initiate an investigation. The LPN determined the allegation was not credible, believing it to be a dream or misconception, but could not explain how this determination was made. The NHA confirmed that they were unaware of the resident's allegation because it had not been reported by the LPN, and acknowledged that the incident should have been reported and investigated immediately. Additionally, the investigation report was not submitted to the SA until seven working days after the incident, exceeding the required timeframe. The facility census at the time was 39 residents, and the deficiency was identified for one resident who made the abuse allegation.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with Parkinson's disease, dementia, and anxiety disorder, the care plan included the use of antianxiety medications but did not document any non-pharmacological interventions for anxiety, mood, or behavior. The resident had severely impaired cognition and was prescribed multiple psychotropic medications, including alprazolam, buspirone, and trazodone, all for anxiety disorder. The care plan did not mention trazodone or outline any non-pharmaceutical approaches, and this omission was confirmed by the Director of Nursing. For another resident with Alzheimer's disease, congestive heart failure (CHF), atrial fibrillation, diabetes, and a history of stroke, the care plan did not address several significant medical conditions or the use of high-risk medications. The resident was taking an antiplatelet and a diuretic, but the care plan lacked problem areas or interventions related to diabetes, CHF, antiplatelet, or diuretic use. This gap was confirmed by both the Nursing Home Administrator and the Director of Nursing, who acknowledged that these areas should have been included in the care plan. The facility's own policy requires that care plans address all problem areas identified through assessments, including measurable goals and approaches for each issue. In both cases, the care plans did not meet these requirements, as they failed to include all relevant diagnoses, medications, and necessary interventions, resulting in incomplete documentation and planning for the residents' care needs.
Failure to Attempt Alternatives and Document Assessment Prior to Bed Rail Use
Penalty
Summary
The facility failed to attempt the use of appropriate alternatives prior to the installation of bed rails for a resident with dementia, epilepsy, and an anxiety disorder who required maximum assistance with bed mobility and transfers. Documentation showed that the resident's Power of Attorney (POA) requested bilateral half-side bed rails to enhance independent bed mobility, and a potential risk of entrapment was identified. However, there was no evidence that alternatives to bed rails were considered or attempted, nor were contraindications to alternatives identified. The facility's policy did not require the use of alternatives prior to bed rail installation, and the required risk-benefit assessment and documentation of attempted alternatives were missing from the resident's records. Further review revealed that the Bed Side Rails Decision Tree was incomplete, lacking the resident's name and documentation of the decision-making pathway. The DON confirmed that no alternatives were considered or attempted before implementing the bed rails, and the POA was not informed of alternatives or the benefits and likelihood of benefits of bed rails. The deficiency was identified through record reviews and interviews, which demonstrated noncompliance with regulatory requirements for assessing and documenting the use of bed rails.
Failure to Follow Hand Hygiene and Gloving Techniques in Kitchen
Penalty
Summary
The facility kitchen staff failed to utilize proper handwashing and gloving techniques during meal preparation, which had the potential to affect all 41 residents who ate from the kitchen. Observations revealed that Dietary Staff (DS)-B did not wash hands upon entering the kitchen, before putting on gloves, or after changing gloves. DS-B was seen handling various items, including a box of buttermilk biscuit mix, a permanent marker, and refrigerator handles, without performing hand hygiene. Additionally, DS-B touched food items directly with soiled gloves, further increasing the risk of cross-contamination. An interview with DS-B confirmed awareness of the facility's hand hygiene and glove-changing policies, yet these practices were not followed. The facility's policies, last revised in November 2023, clearly stated the need for frequent handwashing and changing gloves to maintain cleanliness. Despite this, DS-B's actions demonstrated a failure to adhere to these standards, leading to the potential for cross-contamination during meal preparation.
Failure to Implement Hand Hygiene Practices
Penalty
Summary
The facility failed to implement proper hand hygiene practices during the distribution of resident laundry and medication administration. Observations revealed that a laundry aide did not perform hand hygiene at any time while distributing personal laundry to multiple resident rooms. The laundry aide confirmed that they had not been instructed to perform hand hygiene since the facility had COVID-19 cases. The facility's policy required hand hygiene after handling contaminated equipment and after contact with objects in the immediate vicinity of the resident, which was not followed by the laundry aide. Additionally, a Licensed Practical Nurse (LPN) did not perform hand hygiene between medication passes for different residents. The LPN was observed not washing hands before beginning medication passes for several residents and even touched one resident while holding another resident's medications. The LPN confirmed awareness of the need to perform hand hygiene between every resident. The facility's policy and CDC guidelines required hand hygiene before and after direct contact with residents and before preparing or handling medications, which were not adhered to by the LPN.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program as required by their policy. The policy outlined specific procedures for ordering antibiotics, including identifying the diagnosis, appropriate antibiotic, dose, duration, and route. It also required nursing staff to track antibiotic use, monitor adherence to evidence-based criteria, and report related data to the Quality Assurance and Assessment (QAA) committee. However, the Assistant Director of Nursing (ADON), who also served as the Infection Preventionist, confirmed that they only generated a monthly report listing residents who had been on antibiotics but did not track or trend antibiotic use beyond this report. Interviews with the Administrator and the ADON revealed that the facility struggled with implementing the antibiotic stewardship program. The ADON admitted that while they could generate a list of residents on antibiotics, they did not monitor clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms, or adverse drug events. Additionally, there was no evidence of tracking patterns of antibiotic use or providing reports to the QAA committee, as required by the facility's policy. This failure had the potential to affect all 41 residents in the facility.
Failure to Obtain End Date or Rationale for Continued Antibiotic Use
Penalty
Summary
The facility failed to obtain an end date or rationale for the continued use of antibiotics for three residents. Resident 8, who had severe cognitive impairment and multiple diagnoses including chronic kidney disease and overactive bladder, was on Bactrim for prophylactic UTI use indefinitely without a stop date. The Assistant Director of Nursing confirmed awareness of CDC recommendations against prophylactic antibiotic use but acknowledged the indefinite prescription for Resident 8. Resident 28, with a history of septic shock, UTI, and other urinary issues, was prescribed multiple antibiotics over several months without proper follow-up urinalysis to confirm the necessity of continued antibiotic use. Despite various symptoms and positive urinalysis results, there was no documentation of follow-up tests or a clear rationale for the ongoing antibiotic regimen. The resident continued to take Macrodantin indefinitely without a specific diagnosis or indication. Resident 39, admitted with periorbital cellulitis, was prescribed Doxycycline for an eye infection. Despite the infection being documented as resolved, the antibiotic was continued indefinitely as a prophylactic measure. There was no recent documentation regarding the resident's antibiotic use, adverse reactions, or the status of the eye condition. The lack of monitoring and rationale for continued antibiotic use was evident in the resident's records.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a 14.81% error rate for 4 out of 8 sampled residents. Specifically, Resident 29's levothyroxine was administered at 7:13 AM instead of the prescribed 6:00 AM, and Resident 38's gabapentin was administered at 7:27 AM instead of 6:00 AM. LPN-C admitted to being aware of the policy to administer medications within one hour before or after the prescribed time but was running behind schedule. Additionally, Resident 32's tamsulosin, which was supposed to be administered 30 minutes after breakfast, was given before breakfast while the resident was still awaiting the meal in the dining room. LPN-C confirmed this deviation from the special instructions during an interview. Furthermore, Resident 5's Miralax, which was ordered to be mixed with 8 ounces of fluid, was mixed with only 4 ounces of MedPass liquid before administration. LPN-C confirmed this error during an interview. These observations and interviews indicate a failure to adhere to the facility's medication administration policy, leading to a medication error rate significantly higher than the acceptable threshold of 5%.
Failure to Document Advance Directive in EHR
Penalty
Summary
The facility failed to ensure that a resident's advance directive was added to their electronic health record (EHR). Specifically, Resident 39 had a paper medical chart indicating a Do Not Resuscitate (DNR) order, but this information was not reflected in the EHR, which stated that no advance directive was on file. Interviews with various staff members, including a nurse aide, an LPN, the Assistant Director of Nursing (ADON), and a medical records staff member, confirmed that they would typically look in the EHR to determine a resident's code status. The facility's policy required that any advance directive be documented and included in the resident's medical record, but this was not done for Resident 39.
Failure to Administer Oxygen Per Physician's Orders
Penalty
Summary
The facility failed to ensure oxygen was administered per the physician's orders for two residents. Resident 13, who has COPD and is at risk for respiratory distress, had a physician's order for continuous oxygen at 1-2 LPM to keep saturations above 90%. However, documentation revealed that the oxygen flow rate was consistently set at 3 LPM, and an observation confirmed the oxygen concentrator was set at 2.5 LPM, which is not in accordance with the physician's order. Resident 35, who has a primary medical condition of acute respiratory failure with hypoxia, had a physician's order for continuous oxygen at 3 LPM via nasal cannula. Documentation showed that the oxygen was set at 2 LPM every shift for a month, contrary to the physician's order. An observation revealed that the resident's oxygen tank was set to the OFF position while the resident was using the nasal cannula. The Assistant Director of Nursing confirmed the discrepancy and adjusted the oxygen tank to 2 LPM, which still did not comply with the physician's order.
Failure to Provide Pneumococcal Immunization
Penalty
Summary
The facility failed to provide a pneumococcal immunization for one of the five sampled residents. A review of the facility's policy on influenza and pneumococcal vaccines revealed that residents should be interviewed about their immunization status upon admission, and if the status is unknown, Social Services or Nursing should contact the physician clinic for further records before administering the vaccine. However, a review of Resident 35's medical records showed a signed pneumococcal vaccine consent form indicating the resident had received the vaccine, but the form lacked the date and type of vaccine. Additionally, the form had a handwritten note stating 'may need booster.' Interviews with the Assistant Director of Nursing and Social Services revealed that the facility had not verified whether Resident 35 had previously received the pneumococcal vaccine and that the resident had not received the vaccine while residing in the facility.
Failure to Administer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide a COVID-19 immunization for one resident, despite the resident having signed a consent form indicating their desire to receive the vaccine. A review of the resident's medical records showed that the consent form was signed on 12/11/2023. However, a subsequent review of the resident's immunization records on 5/6/2024 revealed no evidence that the vaccine had been administered. Interviews with the Assistant Director of Nursing and Social Services staff confirmed that the resident had not been scheduled for the vaccination, highlighting a lapse in the facility's process for managing and documenting immunizations.
Failure to Ensure Proper Use of Hoyer Lift and Oxygen Concentrator Safety
Penalty
Summary
The facility failed to ensure the use of two-persons while utilizing a Hoyer lift for a resident with severe cognitive impairment and multiple dependencies. The resident, admitted with diagnoses including Dementia and Chronic Kidney Disease, required assistance for all transfers. Despite the care plan and facility policy mandating a two-person assist for Hoyer lift transfers, a nurse aide was observed transferring the resident alone. The nurse aide admitted to frequently using the Hoyer lift without a second person and acknowledged being aware of the requirement but not trained to operate the lift alone. The Assistant Director of Nursing confirmed the expectation for a two-person assist with the Hoyer lift. Additionally, the facility failed to ensure the oxygen concentrator was turned off when not in use for another resident. Observations revealed the oxygen concentrator was left on with the tubing laying across the bed sheets while the resident was not in the room. This was confirmed as a fire hazard by a Licensed Practical Nurse and a Medication Aide. The facility's failure to adhere to safe oxygen storage practices was evident in multiple observations, posing a significant risk to resident safety.
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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