Prestige Care Center Of Nebraska City
Inspection history, citations, penalties and survey trends for this long-term care facility in Nebraska City, Nebraska.
- Location
- 1420 North 10th Street, Nebraska City, Nebraska 68410
- CMS Provider Number
- 285109
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Prestige Care Center Of Nebraska City during CMS and state inspections, most recent first.
Surveyors found that the Alzheimer's care unit had a persistent strong urine odor in the hallway over multiple days, confirmed by the DON, a MA, and a NA, while records showed limited deep cleaning of a resident room over several months. Despite a written policy requiring regular cleaning of horizontal surfaces and hard flooring, one room was repeatedly observed with black, brown, and white particles on the bedside table and a brown spot with similar particles on the floor, which a MA confirmed, demonstrating a failure to maintain a clean, odor-free, and homelike environment.
A resident with dysphagia, major depressive disorder, type 2 DM, moderately impaired cognition, significant weight loss, and on mechanically altered foods had an activated medical POA, per facility records. Facility policy required notifying the resident’s representative of significant treatment changes and documenting who was notified. A new physician order directed the resident to be up in a w/c for all meals, with refusals to get up recorded as meal refusals, but there was no documentation over an extended period that the POA was informed. An RN stated an attempt to notify was made but not charted, the family member identified as the contact reported not being notified of the order change, and the IDON confirmed there was no evidence of POA notification.
Surveyors found that a resident on hospice care with multiple cognitive and psychiatric diagnoses received PRN morphine for pain or shortness of breath without documented clinical justification. Facility policy required ongoing review of drug regimens and adequate monitoring for indications and efficacy, and the resident had orders for morphine every 1–2 hours PRN with pain monitoring each shift. However, the MAR showed multiple administrations of morphine with a recorded pain score of zero, and progress notes described behaviors such as restlessness, agitation, pacing, and striking objects or attempting to hit staff without documenting any pain or shortness-of-breath indicators. The IDON confirmed the absence of documented pain or respiratory symptoms at the times morphine was given.
Surveyors found that bathroom exhaust vents in two resident rooms were not functioning, as they did not pull air in, despite facility logs indicating that one of these rooms’ vents had previously been checked and recorded as working. Review of the exhaust fan inspection log showed that only a small number of rooms in each hall were checked monthly over several months, and during an on-site observation and interview, the MD confirmed that the vents in the identified rooms were not operating.
Staff did not consistently perform hand hygiene or change gloves appropriately during care for three residents, including catheter care, perineal care, and wound care. In several instances, staff touched resident belongings, supplies, and clean surfaces with contaminated gloves, changed gloves without hand hygiene, and used items that had fallen on the floor, creating opportunities for cross contamination.
A resident with quadriplegia and multiple medical conditions, fully dependent on staff for hydration, was not provided with adequate assistance or monitoring for fluid intake. Despite a recent hospital visit for dehydration and an order to encourage fluids, staff were unaware of the diagnosis and order, and the care plan lacked a hydration focus. Facility observations confirmed the resident's water pitcher remained full and assistance was only provided during meals, contrary to facility policy.
Facility staff did not notify a pulmonary specialist of medication changes for a resident with COPD, as directed by the primary care provider. The resident refused prescribed antibiotics due to adverse reactions and reported an allergy, but staff failed to communicate these issues to the specialist. The resident eventually contacted the pulmonologist independently, leading to a new prescription.
A resident experienced multiple falls resulting in a wrist fracture, and the facility failed to submit the required five-day written investigation report on time, instead submitting it two days late as confirmed by the RDO.
A resident's comprehensive admission MDS assessment was not completed within the required 14-day timeframe, as facility records showed the assessment was finalized 13 days late, which was confirmed by the Regional Director of Operations.
The facility did not implement new interventions after a resident with severe cognitive impairment experienced multiple falls, and failed to investigate or add preventive measures after another non-ambulatory resident sustained a skin tear. Required incident reporting and care plan updates were not completed, as confirmed by record review, staff interviews, and observation.
A resident with multiple medical conditions and intact cognition reported being hit and experiencing pain. The facility's investigation did not include required staff or resident interviews, and documentation was incomplete, as confirmed by the administrator.
The facility did not send federally required transfer documentation to the receiving health care institution for two residents who were transferred to the hospital after falls. Review of records and interviews with the Administrator confirmed that essential information, such as practitioner contacts, resident status, and care plans, was not provided at the time of transfer.
A resident with severe cognitive impairment and a high risk for falls did not receive all care plan interventions intended to prevent accidents, including the absence of a fall mat, dycem in the wheelchair, a visible reminder sign, and consistent 15-minute safety checks. Staff confirmed these interventions were not in place as required by facility policy.
The facility failed to maintain a clean and safe environment in 17 resident rooms, with issues such as cracked caulking, stained floors, and dust-coated ventilation covers. The Maintenance Director confirmed these concerns, noting no active work orders, indicating a lapse in the maintenance process.
A resident with severe cognitive impairment experienced significant weight loss due to the facility's failure to timely implement nutritional interventions. Despite requests from the resident's POA, there was a delay in ordering and administering a nutritional supplement. The facility's process for monitoring and addressing weight variances was ineffective, leading to continued weight loss.
The facility failed to conduct trauma-based assessments for two residents diagnosed with PTSD. One resident with severe cognitive impairment did not receive a PTSD assessment, and another resident's care plan lacked PTSD-related information despite receiving medication for the condition. The absence of trauma-informed care assessments was confirmed by facility staff.
The facility failed to implement practitioner's orders for medications, lab tests, and weight monitoring for two residents. One resident with congestive heart failure had inconsistent weight documentation and unimplemented orders for Zaroxlyn and a lab test. Another resident with heart failure and kidney disease had incomplete weight monitoring, despite orders. The facility's procedures for processing orders were not effectively followed, leading to these deficiencies.
A resident with congestive heart failure experienced a 6 lbs weight gain over four days, but the facility staff failed to notify the practitioner as required. The resident's care plan included daily weight monitoring, yet weights were not recorded for three days, and the practitioner was not informed of the significant weight change. Communication records showed that requested updates were not provided, contrary to facility policy.
Persistent Odor and Inadequate Cleaning in Alzheimer's Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in the Alzheimer's care unit by not preventing persistent urine odors in the hallway and not ensuring routine cleaning of a resident room. Record review showed that the Alzheimer's unit had 12 occupied beds, and the deep cleaning schedule indicated that one resident's room was deep cleaned only once in January, with no deep cleaning scheduled for February and the next deep cleaning not planned until the second Wednesday in March. On three separate observations on 03/02/2026, 03/04/2026, and 03/05/2026, surveyors noted a strong urine odor in the hallway of the Alzheimer's care unit. The DON/RN, a medication aide, and a nursing assistant each confirmed the presence of the urine odor during interviews on those dates. The facility's Routine Cleaning and Disinfection policy, revised 12/2025, required that horizontal surfaces with infrequent hand contact, such as window sills and hard surface flooring in routine resident-care areas, be cleaned on a regular basis, when soiling and spills occur, and when a resident is discharged. Despite this policy, observations of one resident room on 03/02/2026 and again on 03/03/2025 revealed black, brown, and white particles on the bedside table and a brown spot with white and brown particles on the floor. During the 03/03/2025 observation, a medication aide confirmed the presence of these particles and the brown spot on the floor, indicating that the room had not been cleaned in accordance with the facility’s stated cleaning and disinfection procedures.
Failure to Notify Medical POA of New Physician Order and Care Plan Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s activated medical power of attorney (POA) of a new physician order and change in the plan of care. Facility policy on Change of Condition, revised 09/2025, required nursing staff to notify the resident’s attending physician and family or representative of changes in medication or treatment, significant alterations in medical treatment, and to document in the record who was notified and any new orders. The resident, admitted on 02/28/2025, had diagnoses including dysphagia, major depressive disorder, and type 2 diabetes mellitus, and an annual MDS showing moderately impaired cognition (BIMS score of 11), need for partial assistance with eating, significant weight loss, and receipt of mechanically altered foods. The resident’s durable health care POA, effective immediately upon signing on 12/02/2025, was documented as invoked in the comprehensive care plan. Record review showed a physician order dated 01/01/2026 directing that the resident be up in a wheelchair for all meals, and that if the resident refused to get up, this would be charted as refusing meals. From 01/01/2026 to 03/02/2026, there was no documentation in the progress notes that the POA was notified of this new order. An RN reported attempting to notify the POA but stated they probably did not document the attempt in the progress notes. The resident’s family member, identified as the point of contact for order changes and communication, reported they were not contacted or notified of the new order regarding being out of bed for all meals and having refusals considered meal refusals. The Interim DON confirmed there was no evidence that the POA was notified of the new physician order and acknowledged that the POA should have been notified.
Failure to Document Pain Indicators for PRN Opioid Use
Penalty
Summary
Surveyors identified a deficiency related to unnecessary drugs when staff failed to document signs and symptoms of pain to justify the continued PRN use of opioid pain medication for one resident. Facility policy on unnecessary drugs required the attending physician to lead medication management and for each resident’s drug regimen to be reviewed on an ongoing basis, including indications, clinical need, and adequate monitoring for efficacy and adverse consequences. The resident, who had dementia, metabolic encephalopathy, schizoaffective disorder, and major depressive disorder, was admitted to hospice and had active orders for morphine solution 10 mg by mouth/sublingually every 1–2 hours PRN for pain or shortness of breath, along with an order to monitor pain every shift. The comprehensive care plan included an intervention to administer all medications as ordered. Record review of the resident’s MAR showed morphine was administered multiple times with a documented pain rating of zero, despite the order requiring a pain evaluation for administration. On several occasions, progress notes documented behaviors such as restlessness, agitation, pacing, pushing chairs, sitting on another resident’s bed, refusing cues, being “everywhere,” hitting tables with a walker, and attempting to hit staff, but did not document any indicators of pain or shortness of breath. Additional administrations of morphine were recorded with no accompanying documentation of pain or shortness of breath, including doses given late at night and one dose given specifically for restlessness without pain indicators. The Interim DON confirmed that the MAR reflected a pain rating of zero at the time of morphine administration and that there were no documented indicators of pain or shortness of breath in the progress notes.
Nonfunctioning Bathroom Exhaust Vents in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of adequate outside ventilation in resident bathrooms, as required by licensure regulation 175 NAC 12-007.04(D). Review of the facility’s “Exhaust Fan Annual Inspection Log For All Resident Room Restrooms Throughout Facility” dated from 10/15/2025 through 2/10/2026 showed that only three rooms per month were checked in various halls, and that one of the affected rooms in the 300 hall had been checked in December and logged as working. However, during observation on 03/02/2026 at 1:00 PM, the bathroom exhaust vents in two sampled rooms (one in the 300 hall and room 325) were found not to be functioning, as they did not pull air in. In a subsequent observation and interview on 03/03/2025 at 12:25 PM, the Maintenance Director confirmed that the bathroom vents in these rooms were not functioning and were not pulling air in. No information was provided in the report about the medical conditions or histories of the residents occupying the affected rooms at the time of the deficiency.
Failure to Perform Proper Hand Hygiene and Gloving During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene and gloving procedures during care for three residents, as observed and documented in the facility. The facility's policies required hand hygiene before and after glove use, after contact with potentially contaminated surfaces, and between clean and soiled tasks. However, multiple instances were observed where staff did not follow these protocols, leading to opportunities for cross contamination. For one resident with quadriplegia and multiple complex medical conditions, a registered nurse and a nurse aide provided catheter and perineal care. During the procedure, the nurse touched various surfaces and assisted the resident with a drink without changing gloves or using hand sanitizer between tasks. The nurse also handled supplies and resident belongings with contaminated gloves, and only performed hand hygiene at the end of the procedure. The nurse confirmed during an interview that these actions could have led to cross contamination. In another case, two nurse aides provided perineal care to a resident with heart failure, diabetes, and other chronic conditions. One aide changed gloves without performing hand hygiene and used a brief that had fallen on the floor, placing it under the resident. The aide acknowledged these actions could have resulted in bacterial contamination. Additionally, during wound care for a resident with Parkinson's disease and suspected MRSA, a nurse donned gloves without hand hygiene, touched the light switch and other surfaces, and moved between clean and soiled areas without sanitizing hands. The nurse confirmed these lapses in infection control during an interview.
Failure to Prevent Dehydration in Dependent Resident
Penalty
Summary
The facility failed to prevent dehydration for a resident who was dependent on staff for all care due to quadriplegia and other significant medical conditions, including autonomic dysreflexia, neuromuscular bladder dysfunction, acute cystitis with hematuria, and moderate protein calorie malnutrition. The resident was cognitively intact but unable to independently access fluids due to physical limitations, requiring assistance for all eating and drinking needs. Despite these needs, the care plan did not include a focus area for hydration, and there were no orders to monitor fluid intake and output or to observe for signs and symptoms of dehydration. The resident was sent to the emergency room with a high fever and dark, cloudy urine, where they were diagnosed with a urinary tract infection and dehydration, and received intravenous fluids. Upon return to the facility, the after-visit summary included an order to encourage increased fluid intake, which was acknowledged by a facility nurse. However, this order was not implemented, as there were no subsequent orders or documentation to monitor the resident's hydration status or fluid intake and output. Observations confirmed that the resident's water pitcher remained full throughout the day, and the resident reported receiving assistance with fluids only during meals, with no routine staff visits to help with drinking. Interviews with the DON and nursing staff revealed they were unaware of the dehydration diagnosis and the order to push fluids, and confirmed that the expected monitoring and assistance were not provided. The facility's own hydration policy, which requires systematic assessment, monitoring, and documentation of hydration status, was not followed for this resident.
Failure to Notify Pulmonary Specialist of Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's pulmonary specialist of medication changes as directed by the primary care provider. The resident, who had chronic obstructive pulmonary disease (COPD) and a history of antibiotic resistance, was admitted with intact cognition and had recently experienced increased shortness of breath and a productive cough. The primary care provider ordered doxycycline and other medications for a suspected COPD exacerbation, but the resident repeatedly refused the antibiotic, citing adverse reactions and later reporting an allergy. Despite the resident's requests and the primary care provider's explicit direction to notify the pulmonary specialist, facility records and electronic health records showed no evidence that the pulmonary specialist was contacted by staff regarding the medication changes or the resident's refusals. Communication logs indicated that the APRN repeatedly asked if the pulmonary specialist had been notified and if there was any response, but staff reported no contact or response from the specialist. The resident ultimately contacted the pulmonologist independently, resulting in a new prescription being faxed to the facility. The deficiency was identified through record review and interviews, which confirmed that the facility did not follow its own policy requiring notification of changes in treatment to the appropriate physician or specialist. The lack of timely communication with the pulmonary specialist occurred despite clear instructions from the primary care provider and ongoing documentation of the resident's medication refusals and reported allergy.
Late Submission of Five-Day Written Investigation Report Following Resident Falls
Penalty
Summary
The facility failed to complete and submit a five-day written investigation report regarding an allegation of potential neglect for one resident. The facility's policy requires the administrator or designee to report the results of an investigation within five working days of an incident. Record review showed that a resident experienced multiple falls over several days, resulting in a right wrist fracture. Documentation indicated that the resident was found on the floor, had been using a cane instead of a walker, and was not wearing non-skid socks. Although assessments were completed and the interdisciplinary team reviewed the falls, the facility submitted the required five-day written report two days late, on the seventh day after the incident, rather than within the mandated five-day period. This delay was confirmed by the Regional Director of Operations.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive admission Minimum Data Set (MDS) assessment within the required 14-day timeframe for one resident. According to facility policy and the MDS User's Manual, the admission MDS must be completed no later than the 14th calendar day after admission, except in certain readmission scenarios. Record review showed that a resident was admitted on 9/9/2025, but the admission MDS was not signed as completed until 10/11/2025, which was 13 days past the required deadline. This was confirmed by the Regional Director of Operations during an interview.
Failure to Implement and Update Interventions for Falls and Skin Tears
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident with severe cognitive impairment and multiple risk factors, despite the occurrence of three falls within a short period. The resident, who had diagnoses including Alzheimer's disease, dementia, unsteadiness, and difficulty walking, required supervision and assistance for mobility. The care plan listed several fall prevention interventions, but after the resident experienced multiple falls, no new interventions were added, and the existing interventions were simply repeated. Observations confirmed that some interventions, such as the use of a wheelchair, were not consistently in place, and staff interviews revealed that a wheelchair was not regularly used or available for the resident. Additionally, the facility did not investigate or implement interventions to prevent further skin tears for another resident who was non-ambulatory, dependent on staff for care, and receiving anticoagulant therapy. After the resident sustained a skin tear to the forearm, staff provided immediate wound care but did not complete an incident report or update the care plan with new interventions to prevent recurrence. The facility's policy required incident reporting and the implementation of preventive measures based on assessment, but these steps were not followed. Interviews with facility leadership confirmed that required post-incident assessments, care plan updates, and preventive interventions were not completed for either resident following their respective incidents. The failures were identified through record review, staff interviews, and direct observation, demonstrating noncompliance with facility policies and regulatory requirements for accident prevention and skin integrity management.
Failure to Complete Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse made by a resident. According to the facility's abuse policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying responsible staff, interviewing all involved parties, and documenting the process. In this case, a resident reported pain under the right breast and stated that someone had hit them, prompting an assessment by a licensed nurse, which found no visible injury. However, the subsequent investigation did not include interviews with staff or other residents, and there was a lack of documentation regarding these critical steps. The resident involved had a history of chronic obstructive pulmonary disease, schizophrenia, and osteoporosis, and was assessed as cognitively intact with a BIMS score of 13/15. The resident also exhibited some behavioral symptoms according to recent assessments. The facility administrator confirmed that the investigation was incomplete, as required interviews and documentation were not performed, resulting in a failure to meet regulatory requirements for responding to alleged violations.
Failure to Provide Required Transfer Documentation to Receiving Facility
Penalty
Summary
The facility failed to provide federally required transfer documentation to the receiving health care institution for two of three sampled residents. According to the facility's own policy, when a resident is transferred to another provider, specific information must be sent, including practitioner contact information, resident representative details, advance directives, current status, diagnoses, medications, recent labs, special instructions, and the resident's care plan goals. For both residents in question, record reviews showed that after each sustained a fall and was transferred to the hospital for evaluation and treatment, there was no evidence in the electronic health record or scanned documents that the required transfer information was sent to the hospital. Interviews with the facility Administrator confirmed that the necessary documentation was not provided at the time of transfer for either resident. The deficiency was identified through review of progress notes, assessments, and other records, which lacked the federally mandated information transfer. The facility's failure to send this information was acknowledged by the Administrator during the surveyor's interview.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement required fall prevention interventions for a resident identified as high risk for falls. The resident had multiple diagnoses, including neurocognitive disorder with Lewy bodies, Parkinson's disease, dementia, a history of falling, osteoarthritis of the right shoulder, and difficulty walking. The resident's assessments indicated severe cognitive impairment and a high risk for falls, with care plan interventions specifically outlined to address these risks. Despite the care plan listing several interventions such as the use of a fall mat, dycem in the wheelchair, a visible sign reminding the resident to call for assistance, and 15-minute safety checks, these were not consistently implemented. Observations revealed the absence of a fall mat at the bedside, no dycem in the wheelchair, and no sign displayed in the resident's room. Additionally, review of the 15-minute check documentation showed missing or incomplete records on several dates, indicating lapses in the required monitoring. Interviews with staff confirmed that the interventions listed in the care plan were not in place at the time of observation. The facility's policy required individualized interventions based on risk assessments and ongoing monitoring for effectiveness, but these were not fully carried out for the resident in question. The administrator confirmed that care plan interventions are expected to be implemented, yet several were not, resulting in a deficiency related to accident hazard prevention and supervision.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple environmental concerns observed in 17 out of 28 occupied resident rooms. These concerns included cracked and broken caulking around toilets, stained and brown areas around toilet bases and on linoleum, pulled away baseboards, scraped drywall and wood on doors, and dust-coated ventilation covers. Additionally, some bathroom doors would not close, carpets were stained, and caulking between sinks and walls was cracked, with sinks pulled away from walls. Fall stop strips were also pulled away from the floor, creating non-cleanable surfaces, and there were holes in the brick around electrical outlets and loose transition strips covered with duct tape. During an environmental tour with the Maintenance Director, these issues were confirmed, and it was noted that there were no active work orders for the identified concerns. The facility's assessment indicated that all rooms are inspected monthly by the Maintenance Director, and issues are supposed to be reported and addressed through the TELS system or verbally. However, the lack of active work orders suggests a failure in the reporting and maintenance process, leading to the persistence of these environmental deficiencies.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility failed to initiate timely interventions to prevent further weight loss for a resident with severe mental cognition impairment. The resident was admitted with a weight of 171 pounds and experienced a significant weight loss over a short period. Despite the resident's Power of Attorney (POA) requesting a nutritional supplement, there was a delay in ordering and administering the supplement, resulting in continued weight loss. The resident's care plan initially indicated a goal for meal and supplement consumption, but no new interventions were added when weight loss was noted. The facility's process for monitoring weights involved alerts for weight variances, but the Registered Dietician's (RD) recommendations for nutritional supplements were not promptly implemented. The RD's recommendations were delayed in being communicated to the physician and subsequently entered into the electronic medical record. Interviews with facility staff revealed systemic issues in the communication and implementation of nutritional interventions. The Director of Nursing (DON) and Corporate Nurse (CN) acknowledged delays in addressing the resident's nutritional needs, and the facility's process for handling weight variances was identified as a contributing factor to the deficiency. The facility's Nutrition Policy outlined responsibilities for maintaining residents' body weight, but these were not effectively executed in this case.
Failure to Conduct Trauma-Based Assessments for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-based assessments for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident 24, who was admitted with a diagnosis of PTSD, had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3. Despite this, the facility did not conduct a PTSD/trauma assessment for Resident 24, as confirmed by both the Corporate Nurse and the Social Service Director during interviews. This lack of assessment was noted despite the resident's active diagnosis of PTSD. Similarly, Resident 34, who was also admitted with a diagnosis of PTSD, did not have a trauma-informed care assessment conducted prior to the survey date. The resident's care plan, last revised in August 2024, lacked any information related to PTSD, even though the resident was receiving medication for the condition. The Social Service Director confirmed the absence of a trauma-informed care assessment for Resident 34 before the survey, highlighting a deficiency in the facility's approach to trauma-informed care for residents with PTSD.
Failure to Implement Practitioner's Orders for Medications and Weight Monitoring
Penalty
Summary
The facility staff failed to implement practitioner's orders for medications, laboratory testing, and weight monitoring for two residents. Resident 3, diagnosed with congestive heart failure, had orders for daily weights, which were inconsistently recorded. Despite having multiple orders for weight monitoring, several days in August 2024 lacked documented weights. Additionally, orders for Zaroxlyn and a Basic Metabolic Panel were not implemented, even after significant weight gain and worsening symptoms were reported to practitioners. Resident 1, with a history of heart failure and chronic kidney disease, also had orders for daily weight monitoring. However, the resident's MAR indicated that weights were not consistently recorded, with several instances of refusal or other codes noted. The facility's administrator confirmed that the daily weights for Resident 1 had not been completed as required, despite being checked off in the MAR. The facility's policy for using the Tele Doc application was reviewed, which outlined procedures for contacting providers and processing orders. However, the failure to implement orders for both residents suggests a breakdown in following these procedures. The administrator acknowledged the lack of documentation and completion of required orders, highlighting a deficiency in ensuring that practitioner's orders were consistently followed and documented.
Failure to Notify Practitioner of Resident's Weight Gain
Penalty
Summary
The facility staff failed to notify a resident's practitioner of a significant change in the resident's condition, specifically a weight gain of 6 lbs over a four-day period. The resident, who was admitted with a diagnosis of congestive heart failure, had an order for daily weight monitoring as part of their care plan. However, the electronic medical record did not show any weights recorded for three consecutive days, and there was no documentation of the practitioner being informed of the weight increase. Additionally, communication records indicated that the practitioner had requested updates on the resident's condition, which were not provided as requested. The facility's policy requires notifying the physician of significant changes in a resident's condition, such as a weight increase of over 5 lbs, which was not adhered to in this case. The administrator confirmed the expectation that the practitioner should have been notified of the weight gain and updated on the resident's condition as requested.
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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