Life Care Center Of Elkhorn
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhorn, Nebraska.
- Location
- 20275 Hopper Street, Elkhorn, Nebraska 68022
- CMS Provider Number
- 285134
- Inspections on file
- 22
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Life Care Center Of Elkhorn during CMS and state inspections, most recent first.
Three nurse aides did not complete the required 12 hours of annual in-service education, with training hours ranging from 3 to 5 hours. The DON confirmed the deficiency and acknowledged the absence of an effective tracking system for staff education compliance.
Staff failed to follow infection control protocols by carrying soiled linens against their bodies, neglecting to clean nebulizer kits and PAP equipment after use, and not using enhanced barrier precautions during catheter care for a resident with an indwelling device. These actions were observed and confirmed by staff and facility leadership as not meeting established policies.
Surveyors found that ventilation systems in the bathrooms of four resident rooms were not functioning, as evidenced by a lack of airflow during testing with toilet paper. The Maintenance Supervisor confirmed the issue and stated that no routine checks of the ventilation systems had been performed.
A resident with multiple serious medical conditions and moderate cognitive impairment was admitted without receiving or acknowledging the required notice of rights, as documented in facility policy. The admission paperwork was incomplete, and the electronic health record did not contain evidence that the resident or their representative had been informed of their rights at admission.
A resident with multiple complex medical conditions and moderate cognitive impairment was admitted without completion of required admission paperwork, including documentation of privacy practices, resident rights, and other key policies. The Admissions Director confirmed the omission, resulting in an incomplete medical record.
A resident with heart failure did not consistently receive daily weights or have significant weight gains reported to the practitioner as ordered. Fluid restrictions were not properly implemented or monitored, with frequent overages and incomplete documentation. Staff interviews and observations revealed a lack of awareness and communication regarding the resident's fluid management, and the facility did not have a policy in place for fluid restriction implementation.
Facility staff did not notify the practitioner of significant weight increases in a resident with heart failure, despite clear orders and policy requiring notification for weight gains of 1 to 5 lbs. Multiple weight increases exceeding this threshold were not reported, as confirmed by record review and DON interview.
A resident with heart failure did not consistently receive BiPAP therapy as ordered, with multiple missed applications documented over several weeks. Staff interviews revealed poor communication and lack of clarity regarding responsibility for applying the BiPAP mask, and there was no documentation of resident refusal when the therapy was not provided.
A resident experienced significant weight loss due to the facility's failure to implement recommended nutritional interventions. Despite a Registered Dietician's recommendation for a Magic Cup supplement, it was not provided with meals, and staff were unaware of the recommendation. The facility did not adhere to its policy on hydration and nutrition, failing to assess and address the resident's weight loss.
The facility failed to maintain proper food safety and sanitation practices, affecting all 86 residents. Observations revealed unsealed, unlabeled, and undated food items in refrigerators and freezers, improper food handling by Cook-M, and unsanitary kitchen conditions. The DFS and Registered Dietician confirmed these deficiencies, which were not in line with the facility's policies.
The facility failed to update care plans for four residents, leading to deficiencies in their care. A resident's care plan was not updated after a Foley catheter was discontinued. Another resident's care plan did not reflect multiple open wounds. A third resident's care plan was outdated regarding feeding tube orders, and a fourth resident's care plan did not accurately reflect their dental status. These oversights were confirmed by facility staff.
The facility failed to maintain safe water temperatures in resident bathrooms, with readings between 123.4 and 132.4 degrees Fahrenheit, affecting 14 residents. Interviews with the Maintenance Supervisor and DON confirmed awareness of the issue, leading to the water being shut off in the affected area.
The facility failed to maintain flooring in good repair for 12 resident rooms, affecting 13 residents. Observations revealed missing transition strips between hall carpets and room flooring, and cracked or bubbled linoleum in several bathrooms. The Maintenance Supervisor confirmed these issues, indicating a potential safety concern.
The facility staff failed to clean and sanitize respiratory equipment for several residents, leading to potential cross-contamination. Observations showed that equipment was not maintained according to policy, with visible contamination. Additionally, staff did not implement enhanced barrier precautions during care activities for residents with wounds or indwelling devices, and failed to provide necessary signage for a resident with venous stasis ulcers. Interviews confirmed these deficiencies, highlighting lapses in hygiene and precautionary measures.
A resident experienced a significant weight loss of 6.6 pounds, or 5.47%, over a short period, but the facility failed to notify the physician. Despite the resident's awareness of the weight loss and the RD's recommendation for nutritional supplements, the facility did not follow its policy to inform the physician of such concerns.
A resident with dementia and other conditions fell in the bathroom, resulting in a laceration requiring stitches. Despite the facility's policy to report serious injuries within two hours, the incident was not reported to the state agency, leading to a deficiency finding.
A facility failed to accurately document a resident's care needs in the MDS, omitting tube feeding and incorrectly including insulin administration. The resident, with multiple medical conditions, was on enteral feeding via a G-tube, not insulin. Observations and interviews confirmed the MDS inaccuracies, leading to a deficiency finding.
The facility failed to adhere to oxygen orders for two residents, leading to deficiencies in respiratory care. One resident with COPD and Chronic Respiratory Failure was observed without prescribed oxygen therapy multiple times, despite having orders for continuous oxygen. Another resident was using oxygen continuously without a physician's order for such use outside of AVAPS. Interviews confirmed these discrepancies, highlighting the facility's failure to ensure valid and followed oxygen orders.
The facility failed to ensure proper assessment of dialysis shunt sites for two residents before and after their dialysis treatments. The Pre/Post Dialysis Communication forms were frequently incomplete or missing, indicating that the required assessments were not consistently performed. Observations showed that one resident was left unattended in the hallway after dialysis, and the LPN responsible did not know the location of the shunt site or perform the necessary assessments. The DON confirmed that the staff was not completing the communication sheets accurately, and the shunt site assessments were not always conducted.
Failure to Ensure Required Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides completed the required 12 hours of annual in-service education, as mandated by licensure regulations. Record reviews showed that one nurse aide had completed only 3.5 hours, another 5 hours, and a third 3 hours of training, despite being employed for sufficient time to meet the requirement. The Director of Nursing confirmed during an interview that the 12-hour education training requirement had not been met for these nurse aides and acknowledged that the facility lacked an effective system to track and ensure compliance with the required training hours. This deficiency had the potential to affect all 86 residents in the facility.
Infection Control Failures in Linen Handling, Equipment Cleaning, and Barrier Precautions
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols in several instances involving the handling of soiled linens, cleaning of respiratory equipment, and use of enhanced barrier precautions. Observations revealed that nursing assistants carried soiled linens and bedding against their bodies and clothing, contrary to facility policy, which requires soiled linen to be bagged and handled with minimal agitation to prevent contamination. Staff were seen carrying soiled items uncovered through hallways and placing soiled gowns under their arms while assisting residents, actions confirmed by both the staff involved and facility leadership as improper. Additionally, staff did not consistently clean and disinfect non-critical patient care equipment such as nebulizer kits and PAP (Positive Airway Pressure) machines. Multiple observations showed nebulizer kits with residual medication and facial oils left uncleaned on bedside tables after use for two residents. Similarly, a resident's BiPAP machine and mask were found with facial oils, water left in the humidifier, and missing filters over several days, despite orders and manufacturer guidelines requiring daily and weekly cleaning. Interviews with staff and a family member confirmed that cleaning was not performed as required. The facility also failed to implement enhanced barrier precautions during high-contact care activities for a resident with a urinary catheter. During catheter and incontinence care, staff did not wear gowns as mandated by facility policy for residents with indwelling medical devices. Staff interviews confirmed awareness of the requirement but acknowledged that enhanced barrier precautions were not used during the observed care.
Non-Operational Ventilation Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure operational ventilation systems in resident bathrooms for four rooms (106, 108, 114, and 115) out of fifteen occupied rooms on the 100 hall. During an inspection with the Maintenance Supervisor, it was noted that the ventilation system did not draw a single ply of toilet paper to the surface of the ventilation cover in these bathrooms, indicating the systems were not functioning properly. The Maintenance Supervisor confirmed these findings and also acknowledged that no routine checks had been conducted to verify the operational status of the ventilation systems.
Failure to Provide Notice of Resident Rights on Admission
Penalty
Summary
The facility failed to provide a notice of resident rights upon admission for one resident. According to the facility's own admission policy, residents or their representatives must be informed of their rights and facility policies both orally and in writing, with accommodations for impairments and language needs. The policy also requires written acknowledgment of this explanation to be documented in the admission agreement. Record review showed that for the resident in question, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no documentation in the electronic health record indicating that the resident or their representative received or acknowledged the notice of rights at admission. Further review revealed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork, including the required notice of rights, had not been completed at the time of admission, and the medical record lacked the necessary documentation to show that the resident or their representative had received this information.
Failure to Complete Admission Paperwork for Resident
Penalty
Summary
The facility failed to complete required admission paperwork for one resident upon admission. According to the facility's own admission policy, residents or their legal representatives must be oriented to various policies and receive a copy of the admissions agreement, which is to be signed and filed in the resident's chart. Record review revealed that for this particular resident, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no completed admission paperwork in the electronic health record. This included missing documentation on privacy practices, antidiscrimination policy, grievance policy, resident rights, trust fund, financial agreement, smoking policies, resident care policies, and other required documents. Further review showed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork had not been completed at the time of admission and that the resident's medical record was incomplete due to the absence of these documents.
Failure to Follow Physician Orders for Daily Weights and Fluid Restrictions
Penalty
Summary
Facility staff failed to follow physician's orders for a resident with a diagnosis of heart failure, specifically regarding daily weights and fluid restrictions. The resident had multiple orders for daily weights, with instructions to notify the practitioner of weight increases between 1-5 lbs. However, there were several documented instances where daily weights were not obtained, and significant weight gains were not reported to the practitioner as required. For example, an 8.6 lb. weight gain in one day and other increases of 6.7 lbs., 3.9 lbs., and 3.8 lbs. were not communicated to the practitioner. These omissions were confirmed by the DON during interviews. Additionally, the facility did not consistently implement or monitor the resident's fluid restriction orders. The resident was placed on various fluid restrictions, including 1000 ml and later 1440 ml per day, with specific allocations for dietary and nursing staff. Despite these orders, the resident's fluid intake regularly exceeded the prescribed limits, and there were days when fluid intake was not recorded at all. Observations and interviews revealed that staff were not always aware of the fluid restriction, did not consistently document fluids provided, and dietary staff did not record the amount of fluids given. The DON confirmed that the facility lacked a policy for implementing fluid restrictions and was unaware of how IV fluids were included in the daily total. The resident experienced multiple hospitalizations for conditions related to heart failure, fluid overload, and other complications during the period in question. Observations showed the resident receiving unmeasured fluids during meals and activities, and staff interviews indicated a lack of communication and understanding regarding the resident's fluid management needs. The facility was unable to provide additional information or documentation regarding the implementation of fluid restrictions prior to the survey exit.
Failure to Notify Practitioner of Significant Weight Changes
Penalty
Summary
Facility staff failed to notify the medical practitioner of significant changes in a resident's daily weights, as required by both facility policy and physician orders. The resident, who was cognitively intact and had a diagnosis of heart failure, had orders in place for daily weights with instructions to call the physician for any weight increase of 1 to 5 pounds. Despite this, the medical record review showed multiple instances where the resident experienced weight gains exceeding the notification threshold, including an 8.6-pound increase in one day and other increases of 6.7, 3.9, and 3.8 pounds on separate occasions. There was no documentation that the practitioner was informed of these changes. Interviews with the Director of Nursing confirmed that the practitioner was not notified of the significant weight increases, despite the clear orders and facility policy requiring such communication. The lack of notification was corroborated by the absence of related documentation in the resident's progress notes, faxes, and practitioner orders. The deficiency was identified through record review and staff interviews, which established that the required notifications did not occur as specified.
Failure to Provide Ordered BiPAP Respiratory Care
Penalty
Summary
Facility staff failed to ensure that a resident with a diagnosis of heart failure received appropriate respiratory care as ordered. The resident required BiPAP therapy while sleeping or napping, as documented in physician orders and the treatment administration record (TAR). Multiple instances were identified where the BiPAP was not applied during various shifts across September and October, despite clear orders. The resident was cognitively intact and required extensive to total assistance with activities of daily living. Documentation showed that the BiPAP was not used on several occasions, and there was no record of resident refusal or staff documentation of such refusals. Interviews with staff revealed confusion and lack of communication regarding responsibility for applying the BiPAP mask. Medication aides indicated that only nurses could apply the mask, but nurses interviewed were either unaware of the resident's needs or had not been informed of the mask not being in use. Observations confirmed the resident was not wearing the BiPAP mask when required, and the resident reported discomfort from air blowing in the eyes when the mask was applied. The Director of Nursing confirmed that the nurse assigned to the resident should have ensured the BiPAP was applied and documented any refusals, which did not occur.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to evaluate and implement interventions to prevent significant weight loss for a resident, identified as Resident 37. The resident was admitted following surgery for a diaphragmatic hernia with obstruction and had other diagnoses including GERD, Barrett's Esophagus with dysphagia. The resident's Minimum Data Set (MDS) indicated a weight of 120 pounds and required assistance with various activities of daily living. Despite the resident's awareness of weight loss, the facility did not take appropriate action to address the issue. The resident's weight was recorded multiple times, showing a decrease from 120.6 pounds to 114.0 pounds over a period of less than a month, indicating a significant weight loss of 5.47%. The facility's Registered Dietician (RD) had recommended nutritional supplements, specifically a Magic Cup, to be added to the resident's meals to address the low BMI and potential weight loss. However, this recommendation was not implemented, as evidenced by the absence of the Magic Cup on the resident's meal trays during observations. Interviews with facility staff, including the RD, Director of Food Service (DFS), and nursing staff, revealed a lack of communication and follow-through on the dietary recommendations. The RD was not informed of the resident's weight loss, and the DFS was unaware of the recommendation for the Magic Cup. Additionally, the facility's policy on hydration and nutrition, which requires ongoing assessment and physician notification of concerns, was not adhered to, as there was no documentation of further nutritional evaluation or physician notification regarding the resident's significant weight loss.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, which had the potential to affect all 86 residents consuming food from the kitchen. Observations revealed multiple food items in the kitchen's refrigerators and freezers were not sealed, labeled, or dated, contrary to the facility's Food Safety policy. Items such as an open bag of shredded purple substance, a zip lock bag of white chunks, and an open package of bologna were found without proper labeling or sealing. Additionally, the dry storage contained unsealed bags of macaroni and overripe bananas, while the walk-in refrigerator and freezer had unlabeled and undated food items. The Director of Food Services (DFS) confirmed these observations and acknowledged the failure to adhere to food safety protocols. Further deficiencies were noted in food preparation and kitchen cleanliness. Cook-M was observed handling beef packages in a manner that allowed the outside of the packaging to contact the food product, and did not follow the recipe or measure ingredients during food preparation. The DFS and Registered Dietician confirmed these practices were inappropriate. Additionally, the facility's cleaning logs did not show evidence of regular cleaning of floors, vents, and fans, leading to unsanitary conditions such as crumbs on the kitchen floor, brown drippings on the freezer vent, and a gray fuzzy substance on HVAC vents. The DFS and Maintenance Supervisor confirmed these areas were not cleaned as required, posing a risk of contamination to food and eating surfaces.
Failure to Update and Revise Care Plans for Residents
Penalty
Summary
The facility failed to update and revise care plans for four residents, leading to deficiencies in their care. Resident 6, who was admitted with an indwelling Foley catheter, had the catheter discontinued, but the care plan was not updated to reflect this change. The care plan continued to include interventions related to the catheter, which was no longer in use. This oversight was confirmed by the Minimum Data Set Nurse during an interview. Resident 68 had multiple open wounds on their legs, which were not documented in the care plan. Despite ongoing wound assessments indicating the presence of these wounds, the care plan remained focused on skin integrity related to urinary incontinence and xerosis cutis, without addressing the actual wounds. The Wound Nurse acknowledged that the care plan had not been updated to include the open wounds. Resident 34's care plan was outdated and did not reflect the current orders for bolus feedings via a feeding tube. The care plan incorrectly indicated continuous feeding, while the actual orders specified bolus feedings four times a day. This discrepancy was confirmed by the facility's Registered Dietician and the MDS Nurse. Additionally, Resident 14's care plan was not accurate, as it did not reflect the resident's current dental status, including the absence of teeth and the fact that dentures were at home. The Social Service Assistant confirmed the care plan was outdated.
Unsafe Water Temperatures in Resident Bathrooms
Penalty
Summary
The facility failed to ensure safe water temperatures in resident bathrooms, which posed a potential risk to 14 residents. During an observation on August 7, 2024, it was found that water temperatures in several resident rooms were above the recommended safe level of 120 degrees Fahrenheit, with temperatures ranging from 123.4 to 132.4 degrees Fahrenheit. This issue was identified in rooms 101, 102, 109, 113, 114, 117, 118, 120, 122, and 123. The facility census at the time was 86 residents. Interviews conducted with the Maintenance Supervisor and the Director of Nursing revealed awareness of the elevated water temperatures. The Maintenance Supervisor confirmed taking a water temperature reading above 124 degrees Fahrenheit in one of the rooms. The Director of Nursing acknowledged that the water temperatures in the bathrooms on the 100 Hall were too high, leading to the water being shut off. A review of the facility's Direct Supply TELS logbook indicated that water temperatures should be maintained below 120 degrees Fahrenheit for burn prevention, as per federal guidelines.
Deficiency in Flooring Maintenance
Penalty
Summary
The facility failed to maintain flooring in good repair for 12 resident rooms, which had the potential to affect 13 residents. During a tour with the Maintenance Supervisor, it was observed that rooms 104, 105, 106, 108, 109, 111, 113, 114, 121, and 122 did not have a transition strip between the hall carpet and the flooring in the resident's room. Additionally, rooms 104, 113, 114, 122, 123, and 207 had cracked or bubbled linoleum in the resident's bathroom. An interview with the Maintenance Supervisor confirmed that the resident room floors were not maintained and could potentially be a safety concern.
Infection Control and Precaution Failures in LTC Facility
Penalty
Summary
The facility staff failed to ensure proper cleaning and sanitization of respiratory equipment and supplies for several residents, leading to potential cross-contamination. Observations revealed that the BiPAP/CPAP masks, nebulizer kits, and oxygen concentrators for Residents 26, 38, and 42 were not cleaned according to the facility's policies. The equipment was found with facial oils, residual medication, and a gray fuzzy substance, indicating neglect in maintaining hygiene standards. Interviews with staff confirmed the equipment was not cleaned as required. Additionally, the facility staff did not implement enhanced barrier precautions during activities of daily living (ADL) care for Resident 14 and catheter care for Resident 37. Observations showed that staff did not wear gowns during high-contact care activities, despite the presence of enhanced barrier precaution signage. Interviews with staff confirmed the failure to adhere to the precautionary measures outlined in the facility's policy, which mandates gown and glove use during specific care activities for residents with wounds or indwelling medical devices. Furthermore, the facility failed to provide enhanced barrier signage for Resident 68, who had venous stasis ulcer wounds. Observations over several days revealed the absence of signage on the resident's door, which is necessary to alert staff of the need for precautions. The Infection Preventionist was unaware of the resident's condition, indicating a lapse in communication and policy implementation. The facility's policy requires signage to communicate the need for enhanced barrier precautions for residents with chronic wounds or indwelling medical devices.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician of a significant weight loss, which was identified during a survey. The resident, who had a history of diaphragmatic hernia surgery, GERD, BPH, and Barrett's Esophagus with dysphagia, experienced a weight loss of 6.6 pounds, or 5.47%, over a period of less than a month. Despite the resident's awareness of weight loss, the facility did not inform the physician of this clinically significant change. The resident's Minimum Data Set indicated a BIMS score of 15, suggesting cognitive intactness, and required varying levels of assistance for daily activities. The facility's Registered Dietician (RD) had noted the resident's low BMI and recommended nutritional supplements, but the weight loss was not communicated to the physician. The facility's policy on Hydration and Nutrition mandates physician notification of any concerns, including weight loss, but this protocol was not followed. The RD confirmed that the weight loss was significant and that the physician had not been updated, highlighting a lapse in the facility's communication and monitoring processes.
Failure to Report Resident Fall with Serious Injury
Penalty
Summary
The facility failed to report a fall resulting in serious bodily injury to the state agency for a resident. The resident, who had diagnoses of dementia, COPD, anxiety, and depression, was found on the bathroom floor by staff after their roommate called for help. The resident was crying and had bleeding from the right cheek, which required transfer to the hospital. At the hospital, the resident received three stitches for the laceration on the right cheek. Despite the facility's policy requiring immediate reporting of serious bodily injuries to the state agency, the incident was not reported. Interviews with the RN and the DON confirmed the fall and the subsequent hospital visit for sutures. The facility's policy mandates reporting such incidents within two hours, but this protocol was not followed, resulting in a deficiency finding during the survey.
Inaccurate MDS Documentation for Resident's Care Needs
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. The MDS dated 07/12/2024 did not include the resident's tube feeding requirement, and incorrectly documented the resident as receiving insulin and insulin injections, which were not part of the resident's care plan. The resident, who had multiple medical diagnoses including hemiplegia, chronic respiratory failure, and required G-tube feeding, was not accurately represented in the MDS, leading to a deficiency in the resident's comprehensive assessment. Observations and interviews confirmed the inaccuracies in the resident's MDS. The resident's Medication Administration Record and Treatment Administration Record from April to August 2024 showed the resident was on enteral feeding via a G-tube, with no record of insulin administration. Interviews with the resident's Power of Attorney and the facility's MDS Nurse corroborated that the resident was not on insulin or insulin injections, highlighting the error in the MDS documentation. This failure to accurately assess and document the resident's needs and treatments resulted in a deficiency finding during the survey.
Failure to Follow Oxygen Orders for Residents
Penalty
Summary
The facility failed to ensure proper adherence to oxygen orders for two residents, leading to deficiencies in respiratory care. Resident 26, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with Hypoxia, was observed multiple times without the prescribed oxygen therapy. Despite having a physician's order for continuous oxygen at 1 liter per minute via nasal cannula and oxygen with CPAP, the resident was found without oxygen on several occasions, both while sleeping and during activities. Interviews confirmed that the resident did not refuse oxygen, and the charge nurse acknowledged the resident's order for continuous oxygen was not being followed. Similarly, Resident 42, diagnosed with Chronic Respiratory Failure with Hypoxia and Obstructive Sleep Apnea, was observed using oxygen continuously, although there was no physician's order for oxygen use outside of the AVAPS setting. The resident confirmed continuous oxygen use, and the charge nurse verified the absence of an order for oxygen when not on AVAPS. These observations and interviews highlight the facility's failure to ensure valid and followed oxygen orders for the residents, resulting in a deficiency in providing safe and appropriate respiratory care.
Failure to Assess Dialysis Shunt Sites
Penalty
Summary
The facility failed to ensure proper assessment of dialysis shunt sites for two residents, Resident 26 and Resident 57, before and after their dialysis treatments. The facility's Hemodialysis Offsite Policy mandates ongoing assessment of residents' conditions and monitoring for complications related to dialysis. However, record reviews revealed that the Pre/Post Dialysis Communication forms for both residents were frequently incomplete or missing, indicating that the required assessments were not consistently performed. Resident 57, who has multiple complex medical conditions including End Stage Renal Disease and dependence on renal dialysis, was not assessed for shunt site bruit, thrill, or bleeding as required. Observations showed that upon returning from dialysis, the resident was left unattended in the hallway, and the LPN responsible for the resident's care did not know the location of the shunt site or perform the necessary assessments. The Director of Nursing confirmed that the staff was not completing the Pre/Post Dialysis Communication sheets accurately, and the shunt site assessments were not always conducted. Similarly, Resident 26, who also has End Stage Renal Disease and is dependent on dialysis, did not receive the required shunt site assessments. The resident's Pre/Post Dialysis Communication forms were often incomplete, and the Medication Administration Record and Treatment Administration Record indicated that the shunt site was not assessed every shift as ordered. The Director of Nursing acknowledged the deficiencies in completing the communication sheets and the failure to perform the necessary shunt site assessments.
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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