Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kimball County Manor during CMS and state inspections, most recent first.
Kitchen staff failed to date and properly label multiple stored food items, including several expired products, and surveyors also observed improper hand hygiene and food handling practices. The DM was seen washing hands for too short a time, working with an empty soap dispenser, handling food with gloves and a knife in a way that raised cross-contamination concerns, and entering a bathroom while wearing a kitchen apron; facility policy required handwashing before and after glove use and food handling.
Failure to Obtain Informed Consent for Psychotropic Medications: The facility administered psychotropic medications to multiple residents, including antidepressants and antipsychotics, without documented informed consent from the resident or representative. Records for residents with depression, dementia with agitation, and schizophrenia showed orders for medications such as mirtazapine, Paxil, Seroquel, duloxetine, risperidone, and Lexapro, but no evidence of advance discussion of risks, benefits, or alternative treatment options.
Failure to Notify Provider of Abnormal BP Readings The facility did not notify the provider when a resident’s BP was outside ordered parameters. One resident with HTN, stroke history, and repeated falls had many BP readings above the ordered limits over several months, with no documentation of provider notification. Two other residents with HTN also had BP readings below ordered limits, including low readings during med pass, and their records likewise showed no evidence that the provider was notified.
Hand hygiene was not performed during medication administration for multiple residents. An MA entered resident rooms, handled medications and resident items, donned and removed gloves without cleaning hands, and administered oral meds, creams, and eye drops without hand hygiene between residents. The MA confirmed hands were not being washed during med passes, and the Administrator stated staff frequently lacked readily available hand sanitizer at resident rooms.
A resident with an indwelling urinary catheter for urinary retention was observed multiple times in common areas with the catheter collection bag exposed and not covered by a dignity pouch. The bag was attached to the walker or a trash can in the dining room, therapy room, hallway, and room, and urine was visible to others; an NA confirmed there was no dignity bag concealing it.
Failure to Address Increasing AIMS Scores: A resident receiving mirtazapine had rising AIMS scores from 0 to minimal and then mild abnormal involuntary movements. The facility documented no referrals were needed and continued the current plan of care, but there was no evidence the provider was notified or that the increasing scores were otherwise addressed; the DON/administrator stated the nurse did not know any action was needed.
A resident admitted after a right hip fracture was discharged to the family home, but the facility did not notify the Ombudsman of the discharge. Record review showed no evidence of notification, and the Administrator confirmed the facility only notified the Ombudsman for facility-initiated discharges.
A resident with overactive bladder was given Macrobid for a presumed UTI after staff reported dysuria, confusion, and increased urination, but the urine culture grew only 10,000-50,000 CFU/ml of E. coli, below the threshold used to define a symptomatic UTI. The record showed no clear evidence of urinary symptoms in the surrounding progress notes, and facility leadership confirmed the culture did not meet the amount of growth required to justify antibiotic use.
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.
Kitchen Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to date and properly label multiple food items stored in the kitchen. During an initial kitchen tour, surveyors observed numerous items without required open, use-by, received, best-by, or expiration dates, including chicken base, baking soda, cornbread mix, biscuit mix, ketchup, mayonnaise packets, dill pickle relish, miracle whip, banana pudding, apricot halves, apples, cherry pie filling, bread, rolls, buns, almond milk, and ice cream mix. Surveyors also observed ceiling damage in the kitchen, including water staining on multiple ceiling panels and a ceiling tile with a hole. The Dietary Manager confirmed the expired dates on the listed items and discarded them. Surveyors also observed improper hand hygiene and food handling practices by the Dietary Manager and Dietary Aid. The Dietary Manager performed hand hygiene for only 3 seconds before stating soap was unavailable at the sink, and the soap dispenser was observed empty. After refilling the dispenser, the Dietary Manager and the Dietary Aid performed hand hygiene for 15 seconds and 12 seconds, respectively. Later, the Dietary Manager prepared vegetables, washed hands for 10 seconds, donned gloves, cut through butter with the wrapper still on, removed the wrapper, and used the same knife to cut the butter into smaller chunks and add them to the vegetable basins. The Dietary Manager then removed gloves and washed hands for 13 seconds. The Dietary Manager was also observed walking into the bathroom with a kitchen apron on. The Dietary Manager stated they should wash their hands for probably 30 seconds, and the facility policy required handwashing before and after glove use and food handling, with soap-and-water handwashing for a minimum of 15 seconds.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from residents or their representatives before administering psychotropic medications for 5 of 5 sampled residents. The deficiency was identified under 175 NAC 12-006.05(E) after record review and interview showed that the facility administrator confirmed there were no policies specific to psychotropic medications and that informed consents had not been obtained prior to administration for residents currently prescribed these medications. Resident 1 had an order for mirtazapine 7.5 mg daily for depression, with no evidence in the medical record that the resident or representative was informed in advance of the risks, benefits, and alternative treatment options. Resident 31 had an order for Paxil 20 mg at bedtime for depression, and the record likewise showed no evidence of informed discussion or consent before use. Both residents were documented as receiving antidepressant therapy for depression, but the records reviewed did not contain consent documentation. Resident 6 had diagnoses including depression and orders for Seroquel 100 mg twice daily and duloxetine 30 mg twice daily for depression, with care plan interventions addressing psychotropic drug use and non-pharmacological approaches, but the EMR contained no consent for psychotropic medication use or documentation of alternative treatment options and education. Resident 7 had diagnoses including dementia with agitation and depression, with an order for mirtazapine 15 mg at bedtime and care plan entries for psychotropic drug use, yet the EMR also lacked consent and documentation of alternative treatment options and education. Resident 8 had schizophrenia and orders for risperidone 0.5 mg twice daily and Lexapro 10 mg daily, with care plan interventions for psychotropic drug use and gradual dose reduction attempts, but the EMR again showed no consent or documentation of alternative treatment options and education.
Failure to Notify Provider of Abnormal Blood Pressures
Penalty
Summary
The facility failed to notify the provider when residents’ blood pressures were outside the parameters ordered by the provider. The report cites a facility policy titled “Notification of Physicians,” which required nursing personnel to notify the attending physician or physician on call when there was specific instruction to do so or when there was a significant change in condition, and to document all attempts to notify the physician in the medical record. Resident 6 had diagnoses including hypertension, cerebral infarction, repeated falls, and gait/mobility abnormalities. The resident’s care plan identified unstable blood pressure related to hypertension, and the provider order required notification if systolic blood pressure was greater than 180 or less than 90, or diastolic blood pressure was greater than 100 or less than 60. The record showed numerous blood pressure readings outside those parameters over many months, including repeated elevated systolic readings and several diastolic readings above 100, yet the medical record contained no evidence that the provider was notified. The Administrator confirmed that the physician was not notified every time Resident 6’s blood pressure was outside the set parameters. Resident 5 had a diagnosis of essential hypertension and active orders for losartan, metoprolol succinate, and provider notification if blood pressure was greater than 180/100 or less than 90/60. The record showed blood pressure readings of 93/56, 96/58, and 106/59, and there was no evidence that the provider was notified of these abnormal readings. Resident 31 also had diagnoses including hypertension, atherosclerotic heart disease, pulmonary heart disease, peripheral vascular disease, and other nonrheumatic pulmonary valve disorders. The resident had an order to notify the provider if blood pressure was outside the same parameters, and the MAR showed several low blood pressure readings during medication administration times, including 85/50, 90/56, 85/52, 93/57, and 100/57. The medical record contained no evidence that the provider was notified of these abnormal blood pressures.
Hand Hygiene Not Performed During Medication Pass
Penalty
Summary
The facility failed to ensure hand hygiene was performed during medication administration for 7 residents, including residents 5, 25, 26, 32, 39, 40, and 43. The cited policy on hand hygiene required alcohol-based hand rub or soap and water before and after direct resident contact, before preparing or handling medications, after contact with objects in the resident’s immediate vicinity, and after removing gloves. During continuous observation from 7:13 AM to 8:30 AM, Medication Aid B prepared and administered medications to multiple residents without performing hand hygiene between residents or before entering and leaving resident rooms. Observations included entering Resident 43’s room without hand hygiene, handling the resident’s water jug and spoon, attempting to use a pulse oximeter, and returning to the cart before performing hand hygiene; similarly, MA-B did not perform hand hygiene before or after medication administration for Residents 5, 40, 32, and 25. Additional observations showed MA-B donned gloves without hand hygiene while preparing creams for Resident 39, removed gloves without hand hygiene, donned new gloves, and assisted with eye drops. MA-D also donned gloves without hand hygiene before entering Resident 26’s room and administering eye drops while holding the resident’s eyes open. MA-B stated during interview that they were not washing their hands during medication passes in between residents. The Administrator stated that staff frequently failed to perform hand hygiene because hand sanitizer was not readily available at residents’ rooms.
Failure to Conceal Catheter Bag and Preserve Resident Dignity
Penalty
Summary
The facility failed to preserve the dignity of Resident 27 by not ensuring the resident’s indwelling urinary catheter collection bag was concealed when the resident was in view of other residents and staff. Resident 27’s continuity of care document showed admission to the facility, and the care plan identified an indwelling urinary catheter related to urinary retention with an intervention to store the collection bag inside a protective dignity pouch. During multiple observations, Resident 27 was seen walking and sitting in common areas with the catheter bag attached to the walker or a trash can without a dignity bag covering it. The bag was observed in the dining room, therapy room, hallway, and the resident’s room, and urine was visible in the bag from across the hallway and from several feet away. An NA confirmed there was no dignity bag concealing the catheter bag.
Failure to Address Increasing AIMS Scores
Penalty
Summary
The facility failed to ensure that 1 resident did not experience adverse consequences related to psychotropic medication use, as shown by increasing AIMS assessment scores. The resident was admitted to the facility and had an order for mirtazapine 7.5 mg daily starting 3/3/2026. An AIMS assessment showed a total score of 0, indicating no abnormal involuntary movements. Subsequent AIMS assessments showed the resident's score increased to 2 with a severity judgment of minimal, and later to 4 with a severity judgment of mild. Each evaluation noted the score was an increase in symptoms compared to the prior assessment, and the facility documented that no referrals were necessary and that the current plan of care would continue. The resident's records contained no evidence that the provider was notified or that the increasing AIMS scores were otherwise addressed. The administrator stated the nurse performing the AIMS assessments was not aware anything needed to be done with the information gathered, and confirmed the provider had not been notified of the increasing scores.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of Resident 47’s discharge from the facility. Resident 47 was admitted following a right hip fracture and was later discharged to the family home on 4/1/2026. Record review showed no evidence that the Ombudsman was notified of the discharge, and an interview with the Administrator on 6/24/26 at 2:45 PM confirmed that the facility had not notified the Ombudsman of this resident’s discharge. The Administrator stated that the facility only notified the Ombudsman of facility-initiated discharges.
Unnecessary antibiotic given for unsupported UTI
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs when it administered Macrobid for a urinary tract infection that was not supported by the documented culture results. Resident 42 had a diagnosis of overactive bladder and had been seen for urinary frequency and urgency, with the Myrbetriq dose increased from 25 mg to 50 mg. Later, the provider documented frequency and burning sensations and ordered a urinalysis with reflex culture for dysuria, even though progress notes from the surrounding period did not show evidence of urinary frequency, urgency, or painful urination. The urinalysis was obtained and the facility was notified that it was positive for infection, after which Macrobid 100 mg twice daily for 7 days was ordered for a diagnosis of UTI. However, the urine culture final result showed 10,000-50,000 CFU/ml of Escherichia coli, which was below the 100,000 CFU/ml threshold referenced in the CDC NHSN LTC UTI criteria for defining a non-catheter associated symptomatic UTI. The facility administrator and infection preventionist confirmed that the culture did not meet the required amount of bacterial growth to constitute an infection necessitating antibiotic use. Progress notes after the antibiotic was started documented mixed urinary symptoms, including denial of burning or painful urination and reports that frequency had improved or subsided. Observations of the resident on subsequent days showed repeated trips to the bathroom and use of the toilet, including episodes of very frequent bathroom use within minutes of each other. During interview, facility leadership stated staff had reported the resident was more confused, had dysuria, and had increased urination before the provider visit, and that this information was relayed to the provider, leading to the urinalysis order.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kimball
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Srmc Long Term Care, Llc Dba Pole Creek Estates | 37 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.