Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Prestige Care Center Of Plattsmouth during CMS and state inspections, most recent first.
Food storage and meal service practices were deficient when staff failed to date and properly store opened and expired foods in multiple storage areas, including unit refrigerators, freezers, and cupboards. During meal prep, the DM handled raw bacon, clean dishes, and vegetables without proper hand hygiene and glove use, and a dietary aide served fruit with bare hands. During drink service, a dietary aide repeatedly touched the drinking surfaces of residents' cups and glasses and did not perform hand hygiene between residents.
Infection control failures were observed across multiple care activities. Staff handled clean clothing and towels against their bodies and clothing, an RN performed wound care with repeated breaks in hand hygiene and glove changes, and a medication aide opened a capsule without gloves and skipped hand hygiene during medication administration and blood glucose checks. A resident’s CPAP mask and nebulizer kit were stored without proper protection, and staff did not follow EBP during wound and perineal care for a resident with a chronic wound.
A facility failed to ensure restroom exhaust vents were working in resident bathrooms throughout the building. Survey observations found multiple vents not pulling air, with strong urine and feces odors noted in some restrooms, and the BMA-A later confirmed none of the restroom exhaust systems were working. The restrooms had no windows.
Unsafe hot water temperatures were found in multiple resident room and shared bathroom sinks, with readings above the facility policy limit of 120 degrees and some temperatures reaching the 140s and 160s. Residents with severe cognitive impairment and independent bathroom access were observed using these areas, while staff reported weekly checks, hand-testing during showers, and that a prior high reading was not rechecked after the hot water heater was adjusted. The ADM also confirmed the facility did not have a temperature control valve for hot water, and the DON stated resident room water should not exceed 120 degrees.
Food was not kept at an appealing temperature during lunch tray service. The DM plated the final room trays, including a test tray for residents eating in their rooms, then delivered the trays from the kitchen. When the test tray was checked in the recreation room, the pork, mashed potatoes with gravy, and green beans did not register on the thermometer and were cold, and the DM confirmed the food was cold.
Shared Closet Space in Semi-Private Rooms: The facility failed to ensure residents in semi-private rooms had private designated closet space. Observations showed multiple rooms with two residents sharing one closet, where only the hanging clothes were minimally separated by a tag or wood block on the bar, while the shelf and floor space remained shared and not private. The Administrator and BMA-A confirmed this arrangement during the observation.
A resident’s MDS was coded incorrectly for bladder and bowel status, showing urine incontinence and no indwelling catheter despite the care plan identifying a suprapubic catheter and observation showing a catheter bag at the bedside. The MDS Coordinator confirmed the coding error and stated that floor nurses complete the nursing MDS assessments, while the DON signs the MDS and audits a certain amount each month.
Wound Care Orders Not Followed: An LPN did not complete ordered wound care for a resident with severe cognitive impairment, hemiplegia/hemiparesis, and vascular dementia. During observation, the LPN treated the hip and foot wounds but did not cleanse the foot wounds with saline before applying betadine, and missed the newest buttock wound order, leaving that wound undressed. The LPN confirmed the care was not completed as ordered by the physician.
A resident with hemiplegia/hemiparesis after CVA and a BIMS score of 15 had an eye exam that resulted in a prescription for corrective lenses, but the glasses were never received. The resident used non-prescription reading glasses and reported blurry vision. The facility used an outside vision vendor, but the SSD stated follow-up occurred only if the resident or family raised concerns, despite the facility’s responsibility for timely services and tracking vendor recommendations.
A resident with aneurysm of the heart and HTN had an order for midodrine before meals with hold parameters based on SBP, but the MAR had no place to document BP at administration and multiple doses were given without recorded BP readings. The DON confirmed the missing BP documentation and that BP should have been monitored and recorded per the physician’s order.
Medication error rate exceeded 5% after observations showed two medication administration errors. An MA crushed a PPI that was ordered not to be crushed and gave it with other meds, and another MA checked a resident’s blood glucose after breakfast and then administered scheduled Novolog outside the ordered pre-meal timing.
A resident had an Accu-Chek ordered before meals and at bedtime, along with Novolog 12 units BID with breakfast and lunch. A MA checked the blood glucose after breakfast, then gave the insulin after the resident returned from the dining room, despite the order for the insulin to be given with meals.
Posted nurse staffing sheets were missing required information. The facility's policy stated the sheet would include the facility name and the total number and actual hours worked by RNs, LNs, and NAs each shift, but posted PPD Calculator staffing sheets did not show the facility name or each shift's staffing numbers or hours worked. The Administrator and Staffing Coordinator both confirmed the omissions.
The facility failed to maintain sanitary conditions in the kitchen and memory care unit, affecting 81 of 82 residents. Observations revealed unsanitary conditions, including a refrigerator with liquid splashes, a utility cart with food debris, and food containers placed directly on the floor. Open, unsealed bags of cereal were also found in the memory care unit. The Certified Dietary Manager confirmed these issues and the lack of adherence to the cleaning schedule.
The facility failed to maintain a functional doorbell at the north entrance, affecting 32 residents with independent mobility. Additionally, issues such as holes in walls, stained toilets, and unsecured handrails were observed in various areas, impacting resident safety and comfort. The Maintenance Director confirmed these issues with no active work orders to address them.
A facility failed to follow a practitioner's wound treatment orders for a resident with heart disease and seizures. The resident's care plan required betadine application to specific areas on the feet, but a nurse only treated one area. Interviews confirmed the oversight, which contradicted the facility's wound treatment policy.
A facility failed to implement fall prevention interventions for a resident with severe cognitive impairment. The care plan required Dycem on the wheelchair seat, but observations revealed its absence. Staff interviews confirmed the intervention was not implemented, despite the facility's policy for individualized care based on risk assessment.
A resident with severe cognitive impairment did not receive a prescribed nutritional supplement due to staff unawareness and miscommunication, despite the supplement being available. The facility's policy on maintaining nutritional status was not followed, leading to a deficiency in care.
A facility failed to maintain a medication error rate of 5% or less, resulting in a 7.14% error rate. A resident received levothyroxine and lansoprazole at incorrect times, contrary to physician orders. The facility's policy requires adherence to physician orders and professional standards, which was not followed in this instance.
A facility failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with cognitive impairments and an open lesion. RN A did not wear a gown as required and placed wound care supplies on soiled surfaces without barriers. The DON confirmed the need for barriers and gown use during such procedures.
Food Storage, Hand Hygiene, and Sanitary Serving Deficiencies
Penalty
Summary
The facility failed to ensure food was properly labeled, dated, sealed, and stored, and failed to keep satellite refrigerators and food storage areas clean and free of outdated items. In the dry storage room, surveyors found two bins of individually packaged salad dressings with no dates, a plastic bin of tea bags floating in water, and a leaking pipe above the area. In an additional storage room, a freezer used for supplements had many sticky items and a dirty bottom shelf with a dry white substance. In the dementia care unit refrigerator and cabinets, surveyors found multiple opened or prepared food items with no dates, expired seasonings and cocoa products, and spills and residue on cabinet shelves. In the activity room refrigerator, freezer, and cupboards, surveyors found opened condiments and creamers without dates, expired minced garlic, and three bags of mixed fruit with expiration dates that had passed. The activity director confirmed the items were outdated or not marked when opened and stated being unaware of the need to check expiration dates. The facility also failed to ensure staff used hand hygiene and gloves appropriately during food preparation. During observation of the dietary manager preparing spinach bake, the manager removed gloves after cutting raw bacon, put on new gloves without hand hygiene, removed gloves and touched clean dishes, washed hands, then touched their own face and clothes, and later chopped onion with bare hands before washing hands again. During another observation, a dietary aide emptied food from steam trays and then began serving fruit into bowls with bare hands, touching the inside of the bowls without hand hygiene. The dietary manager confirmed that glove use and hand hygiene were not completed during the cooking process and should have been, and confirmed the dietary aide did not follow hand hygiene when serving. The facility further failed to handle resident dinnerware and utensils in a sanitary manner during meal service. During breakfast service, a dietary aide poured drinks for multiple residents while touching the drinking surfaces of cups and glasses, including lids on spill-proof cups, and did not perform hand hygiene between residents. The aide also touched a surgical mask and continued serving drinks. The administrator later confirmed that dietary staff should not have touched the drinking surfaces of residents' cups or glasses and should have performed hand hygiene between serving residents.
Infection Control Failures During Linen Handling, Wound Care, Medication Administration, Equipment Storage, and EBP
Penalty
Summary
The facility failed to ensure clean clothing and linens were handled in a sanitary manner. A laundry aide delivered resident clothing to rooms while allowing the clothing to drag on the floor and contact the aide’s clothing. A medication aide and a nursing assistant were also observed carrying stacks of towels against their bodies and clothing while transporting them to the bath house. The Director of Nursing confirmed the clean resident laundry should not have contacted staff clothing or the floor. The facility also failed to ensure hand hygiene and glove use were followed during wound care for a resident with a wound. During wound care, the RN removed gloves and did not perform hand hygiene before continuing care, touched multiple objects in the room, touched the resident’s bed and wound, used a measuring tape directly on the wound bed, touched their own face while gloved, and handled dirty supplies and the medication cart without hand hygiene between glove changes. The RN later confirmed the concerns about cross contamination and hand hygiene, and confirmed handwashing should be completed for 20 seconds and before and after glove changes. Medication administration and equipment storage were also not handled according to infection control expectations. A medication aide opened a medication capsule without gloves and did not perform hand hygiene before donning or after removing gloves while administering medications and eye drops. Another medication aide did not perform hand hygiene when donning and doffing gloves during blood glucose monitoring and insulin administration. In addition, a resident’s CPAP mask and nebulizer kit were observed stored on equipment and a bedside table without a barrier or proper storage. The Infection Preventionist confirmed the CPAP mask and nebulizer kit were stored in a way that promoted potential cross contamination. The facility also failed to follow Enhanced Barrier Precautions for a resident with a chronic wound. During wound care and perineal care, staff wore gloves but did not wear gowns, and hand hygiene was not performed between glove changes. The RN and medication aide both confirmed the resident was on enhanced barrier precautions, that gowns should have been worn, and that hand hygiene should have been completed between glove changes.
Nonfunctioning restroom exhaust ventilation
Penalty
Summary
The facility failed to ensure the exhaust ventilation system was working in all resident restrooms. A review of the facility’s Safe and Homelike Environment policy stated resident rooms would have adequate outside ventilation by windows, mechanical ventilation, or both. During observations on 03/30/2026, multiple resident restroom exhaust vents were found not working or not pulling air from the restrooms in numerous rooms throughout the facility, and several restrooms had strong urine or feces odors noted during the observations. On 04/02/2026, the Administrator and Building Maintenance Aide-A observed all resident restroom exhaust ventilation systems in the facility and found the vents were not working or pulling air from the restrooms. The Building Maintenance Aide-A confirmed that none of the facility’s exhaust vents in the resident restrooms were working and stated they should have been. The report also noted there were no windows in any of the restrooms.
Unsafe Hot Water Temperatures in Resident Rooms and Shared Bathrooms
Penalty
Summary
The facility failed to maintain safe hot water temperatures in occupied resident rooms and shared bathrooms. Facility policy stated the maximum water temperature for sinks was 120 degrees, but surveyors found multiple resident room bathroom sinks measuring above that limit, including 140 degrees Fahrenheit in shared bathrooms for rooms 301, 302, 303, 306, 308, 503, 506, and 512, 127.2 degrees in one resident room, 143.2 degrees in two other resident rooms, 124.9 degrees in another shared restroom, and 122.4 degrees in two additional shared restrooms. The facility administrator was present during temperature testing and confirmed the facility did not have a temperature control valve for hot water. Resident 30 had severe vascular dementia with mood disturbance and a BIMS score of 0, indicating severe cognitive impairment. Resident 30 was independent with mobility and was observed going into the bathroom independently to change an incontinent brief. Resident 28 had diagnoses including multiple sclerosis, major depressive disorder, Alzheimer's disease, and senile degeneration of the brain, with a BIMS score of 2 indicating severe cognitive impairment. Resident 28 was independent with manual wheelchair mobility and was observed independently entering the bathroom and positioning herself facing the sink. The Maintenance Supervisor stated that one sink had been 160 degrees the prior week and that the hot water heater had been turned down, but the temperature was not rechecked afterward to determine whether it remained unsafe. Staff reported that water temperature was checked only weekly and that during showers they used the back of the hand and then had the resident check with the back of the hand. The Maintenance Supervisor also confirmed that the facility's infrared thermometer was used for testing hot water temperatures, while the Administrator later stated that the infrared thermometer was not appropriate for water temperature testing. The Director of Nursing confirmed that resident room hot water temperatures should not have been over 120 degrees Fahrenheit and bath house hot water temperatures should not have been over 110 degrees Fahrenheit.
Cold Room Trays Served at Lunch
Penalty
Summary
Food was not maintained at a temperature that was appealing to residents during the lunch meal service. On 04/01/2026 at 1:55 PM, the final room trays were being plated by the Dietary Manager, and the meal included pork, mashed potatoes with brown gravy, spinach bake, and green beans. A test tray was requested for residents who ate in their rooms, and at 2:09 PM the Dietary Manager took the room trays, including the test tray, out of the kitchen. After the last resident room tray was delivered, the test tray was brought to the recreation room at 2:13 PM. Using the facility thermometer, the Dietary Manager found that the pork, mashed potatoes and gravy, and green beans did not register temperature and were cold, although the pork and mashed potatoes with gravy had good flavor. The Dietary Manager confirmed that the pork, mashed potatoes and gravy, and green beans were cold.
Shared Closet Space in Semi-Private Rooms
Penalty
Summary
The facility failed to ensure that residents in semi-private rooms had their own private designated closet space. A review of the facility’s Resident Rooms policy and Safe and Homelike Environment policy, both dated 03/2026, stated that each resident bedroom would have individual private closet space and sufficient individual closet space in each resident room. However, a review of the Daily Census dated 04/01/2026 showed 87 residents in the facility, including 26 semi-private rooms and 52 residents with shared closets. Observations on 03/30/2026 found multiple semi-private resident rooms with only one closet and one door for two residents. In each observed room, the hanging clothes appeared to be separated only by a small square on the bar, while the upper shelf and floor space were not separated or private. During an observation with the Administrator and BMA-A on 04/02/2026, they confirmed that all semi-private rooms only had one closet and that the only separation was a small white square tag on the bar or a small wood block through the closet bar, with the upper shelf and floor areas not separated and not private.
Incorrect MDS Coding for Bladder and Catheter Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for Resident 8 related to bladder and bowel status. The MDS section H, dated 02/12/2026, coded the resident as always incontinent with urine and as not having an indwelling catheter, yet the care plan identified use of a suprapubic catheter dated 1/18/2021. During observation on 04/01/2026 at 07:39 AM, Resident 8 was in bed with a catheter bag hanging on the side of the bed. In interviews, the MDS Coordinator confirmed that the bowel and bladder section of the MDS was coded incorrectly and stated that floor nurses complete nursing MDS assessments while the MDS Coordinator only completes the BIMS. The DON stated that nursing was expected to complete the MDS nursing assessments, the MDS Coordinator completed only the BIMS, and the DON signs the MDS and audits a certain amount per month. The DON confirmed that the MDS dated [DATE] was incorrect for Resident 8.
Wound Care Orders Not Followed
Penalty
Summary
The facility failed to ensure that provider orders were followed for wound care for a resident with severe cognitive impairment, hemiplegia and hemiparesis following cerebral infarction, infection following left hip surgery, and vascular dementia with behavioral disturbance. The resident’s record included multiple active wound care orders for several sites, including the left anterior ankle, left posterior ankle, left buttock, left lateral 5th toe, left lateral foot, left lateral foot proximal area, left lateral heel, left lateral hip, and right lateral hip, with directions to cleanse with saline and apply ordered topical treatments and dressings on specified schedules. During observation of wound care, an LPN entered the room, prepared supplies, and treated the right lateral hip surgical wound by removing the dressing, cleansing the wound with saline-soaked gauze, applying silver alginate, and covering it with a bordered foam dressing. The LPN also treated the resident’s left foot areas by applying betadine to scabbed areas on the lateral toes, lateral side of the foot, and dorsal foot/lower shin. However, the LPN did not apply saline to the foot wounds before applying betadine as ordered. The observation also showed that the LPN did not complete the buttock wound care because the newest order dated 3/31/26 was missed, and the buttock wound was not dressed. In interview, the LPN confirmed they had missed the newest buttock order and acknowledged that the resident’s wound care was not completed as ordered by the physician. The LPN also confirmed the foot wound care was not performed according to the order requiring saline cleansing before betadine application.
Failure to Obtain Prescribed Corrective Lenses
Penalty
Summary
The facility failed to ensure that Resident 3 received proper treatment and an assistive device to maintain vision. Resident 3 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident’s MDS completed in February 2026 showed a BIMS score of 15, indicating normal thinking and memory. During interview, Resident 3 stated that an eye exam had been completed after admission and a prescription for glasses was written, but corrective lenses were never received. The resident was using non-prescription reading glasses and reported that vision remained blurry even with use of this device. Record review showed an eye care chart note dated 8/19/25 documenting an eye exam and a prescription for corrective lenses. The facility’s Use of Outside Resources policy stated that the facility would assume responsibility for the timeliness of services provided and maintain documentation and reports of recommendations. The facility services agreement also stated that the facility would assume responsibility for obtaining services that meet professional standards and the timeliness of services. During interviews, the Social Services Director stated that the facility used an outside vendor for vision services and only followed up if a resident or family expressed concerns. The vendor contact stated that the eye exam note and prescription were sent to the Social Services Director by email and uploaded to the chart, and the Social Services Director later confirmed that the facility should follow up with vendor recommendations.
Failure to Monitor Blood Pressure for Midodrine Administration
Penalty
Summary
The facility failed to monitor and record blood pressures for the continued use of a blood pressure support medication for one resident. The resident was admitted on 1/31/2025 and had diagnoses including aneurysm of the heart and hypertension. The resident had an order for midodrine 5 mg by mouth before meals, with instructions to hold the medication for a systolic blood pressure greater than 140 for hypotension. The March 2026 MAR showed the midodrine order scheduled for 8:00 AM, 12:00 PM, and 4:00 PM, but there was no place on the MAR to record the resident’s blood pressure at the time of administration. The WVS also showed multiple dates and times when blood pressure was not recorded before midodrine was given. During interview, the DON confirmed the missing blood pressure recordings and stated the resident’s blood pressure should have been monitored and recorded according to the physician’s orders.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5% for a census of 87. During observation of Resident 69’s medication administration, Medication Aide F crushed Pantoprazole even though the order stated, “Do not crush,” and administered it mixed with grape jelly along with Eliquis, Ferrous Sulfate, Vitamin D3, Losartan Potassium, Furosemide, and Acetaminophen. The aide confirmed during interview that Pantoprazole had been crushed and should not have been crushed. A separate observation involving Resident 47 showed Medication Aide G checking the resident’s blood glucose at 9:10 AM, after breakfast had already been eaten, with a result of 184, and then administering 12 units of Novolog immediately afterward. The resident’s orders required Accu-Chek before meals and at bedtime, with Novolog 12 units subcutaneously twice daily with breakfast and lunch. The aide confirmed the blood glucose check was done after breakfast, that the insulin was scheduled for 7:00 AM, and that the insulin was given when the resident had returned to the room from the dining room.
Significant insulin administration error
Penalty
Summary
The facility failed to ensure that one resident was free from a significant medication error. Resident 47 had orders for Accu-Chek blood glucose checks before meals and at bedtime, with instructions to notify the MD if blood sugar was below 60 or above 450, and an order for Novolog insulin 12 units subcutaneously twice daily with breakfast and lunch. During observation, a medication aide checked the resident’s blood glucose at 9:10 AM and obtained a result of 184, then administered 12 units of Novolog immediately afterward. The medication aide confirmed that the blood glucose monitoring was ordered before meals, that the insulin was scheduled for 7:00 AM, that the blood glucose check was performed after the resident had eaten breakfast, and that the insulin was given at 9:10 AM after the resident returned to the room from the dining room.
Posted Nurse Staffing Sheets Missing Required Information
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing sheets included the facility name and the staffing number and actual hours worked for each shift. A record review of the facility's Nurse Staffing Posting Information policy, revised 03/2026, stated that the Nurse Staffing Sheet would include the facility's name and the total number and actual hours worked by RNs, LNs, and NAs directly responsible for resident care each shift. However, review of the facility's PPD Calculator v.1.0 posted nursing staff sheets dated 02/28/2026 through 03/29/2026 did not show the facility's name or each shift's staffing numbers or hours worked. A posted nursing staff sheet dated 04/02/2026 also did not show the facility's name. During interviews, the Administrator confirmed that the 04/02/2026 sheet did not include the facility's name and should have, and the Staffing Coordinator confirmed that the sheets dated 02/28/2026 through 03/29/2026 did not include the facility's name or each shift's staffing numbers or hours and should have.
Sanitation Deficiencies in Kitchen and Memory Care Unit
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and memory care unit, which had the potential to affect 81 of 82 residents who consumed food prepared by the facility. Observations revealed unsanitary conditions, including a reach-in refrigerator with liquid splashes and a utility cart with breadcrumbs and food debris. Additionally, food containers were placed directly on the floor without a barrier, and open, unsealed bags of cereal were found in the memory care unit. These actions were confirmed by the Certified Dietary Manager (CDM), who acknowledged the presence of unsanitary conditions and the lack of adherence to the cleaning schedule. The facility's sanitation policy required daily inspections of food service areas, including refrigerators and storage areas, and weekly inspections by the dietary manager to ensure compliance with sanitation regulations. However, the CDM confirmed that the cleaning schedule had not been filled out, indicating a failure to adhere to the established sanitation program. The Nebraska Food Code also mandates that nonfood-contact surfaces be designed for easy cleaning, which was not observed in the facility's practices.
Facility Deficiencies in Maintenance and Safety
Penalty
Summary
The facility failed to ensure a functional doorbell at the north entrance, which had the potential to affect 32 residents identified as independent with mobility. During an observation, it was noted that the doorbell at the main entrance did not sound when pushed, confirmed by the Receptionist and the Administrator in Training, who stated that the doorbell chime was not plugged in. This deficiency was observed on a day when the temperature outside was 26 degrees Fahrenheit, potentially impacting residents' ability to re-enter the facility safely. Additionally, the facility did not maintain the cleanliness and repair of various areas, including wallpaper, walls, light covers, and fixtures in nine resident rooms. Specific issues included holes in walls, stained toilet bases, cracked caulking, and missing light covers. In the memory care unit, the utility sink was in disrepair, and the wallpaper was torn. Furthermore, the handrail to the exterior steps beside the south entrance was rusted and not secured, affecting 12 residents identified as self-mobile without assistive devices. The Maintenance Director confirmed these issues and acknowledged that there were no active work orders to address them.
Failure to Follow Wound Treatment Orders
Penalty
Summary
The facility failed to ensure that wound treatment orders were followed according to the practitioner's instructions for a resident with wounds. The resident, who had wounds on the right lower leg and required assistance for transfers, had a diagnosis of heart disease and seizures. The practitioner's order specified that betadine should be applied to the second digit of the left foot and the bottom of the right foot daily. However, during an observation of wound care, a registered nurse applied betadine only to the left foot's second toe and neglected to treat the bottom of the right foot. Interviews with the registered nurse and the wound nurse confirmed that the order was not fully executed as prescribed. The facility's policy on wound treatment management emphasized the importance of providing evidence-based treatments in accordance with physician orders, which was not adhered to in this instance.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 0. The resident required extensive assistance with toileting and showering, and moderate assistance with dressing, transfers, and bed mobility. The resident's care plan, dated January 6, 2025, specified the use of Dycem on the wheelchair seat to prevent falls. However, observations on February 5 and 6, 2025, revealed that Dycem was not present on the resident's wheelchair. Interviews with facility staff, including a Nursing Assistant (NA) and the Director of Nursing (DON), confirmed that the intervention of Dycem was not implemented as per the care plan. The NA reported alternative fall interventions, such as gripper socks and non-skid strips, but did not acknowledge the need for Dycem in the wheelchair. The facility's fall prevention policy requires individualized care and services based on each resident's risk assessment, but the lack of Dycem in the wheelchair indicates a failure to adhere to the resident's comprehensive care plan.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to provide nutritional supplements as ordered for Resident 54, who was assessed with severe cognitive impairment and required assistance with daily activities. The resident had a physician's order for Med Pass 2.0, a nutritional supplement, to be given four times a day due to weight loss. However, the supplement was not administered on the evening of February 5, 2025, because it was reportedly unavailable, despite the facility having it on hand. Further investigation revealed that on the morning of February 6, 2025, the supplement was again not given because the RN on duty was unaware of what Med Pass 2.0 was. Interviews with the Certified Dietary Manager and the Director of Nursing confirmed the oversight, and an observation showed that the supplement was available in the refrigerator at the nurse's station. The facility's policy on weight monitoring emphasized maintaining residents' nutritional status, but the failure to administer the supplement as ordered indicated a lapse in following this policy.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as evidenced by a 7.14% error rate resulting from 2 errors out of 28 opportunities. This deficiency affected one resident, identified as Resident 328, out of a sample of three residents, with a total facility census of 82. During an observation, Medication Aid (MA) J administered medications to Resident 328, including levothyroxine, Tylenol, and lansoprazole. However, the administration of levothyroxine and lansoprazole did not comply with the physician's orders. Levothyroxine was supposed to be given on an empty stomach, 30 minutes before a meal, but was administered after the resident had already eaten breakfast. Lansoprazole was to be given with breakfast, but the timing of its administration was not aligned with this requirement. An interview with MA J confirmed the errors in the timing of medication administration. The facility's medication administration policy, dated January 2025, requires medications to be administered as ordered by the physician and in accordance with professional standards of practice. The policy emphasizes verifying the resident's name, medication name, form, dose, route, and time against the medication administration record. The failure to adhere to these guidelines resulted in the observed medication errors, contributing to the facility's non-compliance with the required medication error rate.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during the care of a resident, identified as Resident 49, who required wound care. The facility's policy mandates the use of gowns and gloves during high-contact resident care activities, which was not followed by Registered Nurse (RN) A. During an observation, RN A entered the resident's room without wearing a gown, despite signage indicating the requirement for gown and glove use. Additionally, RN A placed a stack of washcloths directly on the bed linens and a basin of soapy water on the floor without any barrier, which is against the facility's infection control policy. Resident 49, who had unclear speech and cognitive impairments, was dependent on staff for care and had an open lesion requiring daily wound treatment. The resident's physician orders specified cleaning the left shoulder open area with soap and water and applying a border gauze daily. Despite these orders and the resident's condition, RN A did not follow proper infection control procedures, as confirmed by both RN A and the Director of Nursing (DON). The DON acknowledged that wound supplies should be placed on a barrier and that a gown should have been worn during the wound treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Glen Haven Village | 9.2 mi | ★★★★★ | 2 | 0 |
| Hillcrest Health & Rehab | 9.4 mi | ★★★★★ | 5 | 0 |
| Hillcrest Country Estates-cottages | 10.9 mi | ★★★★★ | 0 | 0 |
| Hillcrest Shadow Lake Llc | 11.8 mi | ★★★★★ | 4 | 0 |
| Brookestone Of Papillion | 12.8 mi | ★★★★★ | 0 | 0 |
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