Citations in Nebraska
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Nebraska.
Statistics for Nebraska (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Nebraska
The facility did not ensure that the posted Daily Nurse Staffing Form accurately reflected the actual census, as the form consistently displayed a higher number than the true census confirmed by administrative staff. Staff interviews revealed a lack of policy and procedure for completing the form, and the form was not updated daily as required.
The facility did not complete or document required care plan conferences for three residents, including those with Multiple Sclerosis and varying cognitive statuses. Residents reported not being involved in care planning, and staff confirmed that care conferences were delayed or missing, with no consistent scheduling or notification process in place.
Two residents requiring CPAP therapy for conditions such as sleep apnea and respiratory failure had physician orders that lacked specific settings, including pressure, ramp time, and humidity. The DON confirmed that the orders were incomplete and that staff could not identify the intended settings, despite facility policy requiring verification of such details before initiating CPAP therapy.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
The facility did not complete required nurse aide registry checks before three staff members began working with residents, and failed to report an adverse event involving a resident who fell during a transfer due to malfunctioning equipment. The incident resulted in soreness and bruising for the resident, and the event was not reported to the appropriate agencies as required by facility policy.
A resident with schizophrenia and bipolar disorder, identified as high risk for elopement, repeatedly exited the facility without staff knowledge. Despite a physician order for a wander guard and documented incidents of the resident leaving the building, there were no incident reports or changes to interventions to prevent further unauthorized exits. The DON confirmed that no new measures were implemented during this period.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The facility did not ensure that water temperatures for bathing and showering remained at or below 110°F, as required to prevent accidents. Multiple logs and direct observations showed water temperatures in excess of this limit in several bathhouses and tubs. Over twenty cognitively impaired residents regularly used these bathing areas, and staff confirmed the facility lacked a specific policy for tub bathing.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Staff did not obtain daily weights as ordered for a resident with heart failure, missing multiple days of required documentation. Additionally, after an unwitnessed fall, neurological checks were not performed for another resident with moderate cognitive impairment, despite facility policy requiring such assessments.
Inaccurate Posting of Daily Nurse Staffing Census
Penalty
Summary
The facility failed to ensure that the posted Daily Nurse Staffing Form accurately reflected the actual facility census. Observations on multiple days revealed that the posted census was consistently listed as 78, while interviews with the Administrator and Assistant Director of Nursing confirmed the actual census was 74 or 75 on those days. The Staffing Coordinator acknowledged that the form should display the actual daily census and noted that the forms are printed on Mondays for the past weekend. Additionally, the Regional Nurse Consultant stated there was no facility policy or procedure for completing the Daily Nurse Staffing Form, and the Administrator confirmed the inaccuracy of the posted census information. The Administrator also stated that the form should be printed and posted before the day and updated as needed.
Failure to Complete and Document Timely Care Plan Conferences
Penalty
Summary
The facility failed to complete and document comprehensive care plans and conduct interdisciplinary care conferences for three sampled residents, as required by regulatory guidelines. Record reviews for these residents showed an absence of care plan meeting notes, care conference summaries, or care plan acknowledgment forms over the past six months. Interviews with residents confirmed that they had not participated in care plan conferences for an extended period, and staff interviews corroborated that care conferences were behind schedule and not consistently documented. For one resident, the Minimum Data Set (MDS) assessment indicated a moderate cognitive impairment and a primary diagnosis of Multiple Sclerosis, yet there was no evidence of care plan meetings or documentation. Another resident, also with Multiple Sclerosis and a high cognitive function score, similarly lacked documentation of care plan conferences. A third resident, who was cognitively intact, had some care plan meetings documented, but there were missing records for required quarterly and annual conferences, and the resident reported no involvement or awareness of such meetings. Staff interviews revealed that there was no current system for scheduling care plan conferences, and notifications to families were not consistently sent in a timely manner. The facility's electronic health record system was intended to trigger the care plan process, but this was not reliably followed. Additionally, there was no facility policy on care planning, and the social services staff did not have a process for tracking care conferences, contributing to the ongoing deficiency.
Incomplete Physician Orders for CPAP Therapy
Penalty
Summary
The facility failed to ensure that physician orders for CPAP (Continuous Positive Airway Pressure) therapy included complete and specific settings for two residents. For both residents, the care plans indicated the use of CPAP as an intervention for conditions such as chronic respiratory failure with hypoxia, obstructive sleep apnea, and ALS. However, a review of the clinical physician orders revealed that the orders lacked essential details such as pressure, ramp time, and humidity settings. In one case, the order simply stated 'CPAP when sleeping - every night shift' without specifying any settings, and in another, the order referenced 'current settings' or 'per home settings' without documentation of what those settings were. The facility's policy required verification of the practitioner's order, including all necessary settings, before initiating CPAP therapy. During interviews, the DON confirmed that the physician orders for both residents did not include the required specifications and acknowledged that staff could not identify or interpret 'per home settings.' The lack of complete and specific physician orders for CPAP therapy was observed for both residents, despite their documented need for this respiratory intervention.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete Registry Checks and Report Adverse Event
Penalty
Summary
The facility failed to complete nurse aide registry checks prior to staff having possible or probable contact with residents for three of six sampled staff members. Specifically, a nurse aide and a business office manager both began working before their registry checks were completed, with the checks occurring 10 and 12 days after their respective start dates. Additionally, a housekeeper worked multiple days without any evidence of a completed registry check. The facility administrator confirmed that these staff members worked prior to the completion of the required registry checks. The facility also failed to report an adverse event involving a resident who was admitted with spinal stenosis. The resident experienced a fall during a transfer from a wheelchair to a bed using a full body lift, when the sling strap broke, causing the resident to fall partially onto the bed and partially onto the floor. The incident resulted in soreness and bruising, and was attributed to malfunctioning equipment. The director of nursing confirmed that this event was an unusual, unanticipated event with the potential to cause serious injury, and acknowledged that it was not reported to the appropriate agencies as required by facility policy.
Failure to Prevent Elopement and Inadequate Supervision for High-Risk Resident
Penalty
Summary
The facility failed to prevent accidents and incidents for a resident with a high risk of elopement. The resident, who had diagnoses of schizophrenia and bipolar disorder with psychotic features, was assessed as cognitively intact but had a history of wandering, episodes of disorientation, and confusion. Despite being identified as high risk for elopement on a risk assessment, documentation inconsistently described the resident as only a moderate risk, and a wander guard was removed. The resident had a physician order for a wander guard to be in place and functioning, with staff directed to check its placement and function every shift. Multiple incidents occurred where the resident exited the building without staff knowledge, including being found outside by therapy staff and being brought back inside on two separate occasions after exhibiting aggressive behaviors. On another occasion, the resident exited the building by following another resident who had entered the security code to the front door, and was only noticed and assisted back inside by an LPN after about a minute. There was no documentation of incident reports or changes to interventions following these events, and the DON confirmed that no new interventions were implemented to prevent further unauthorized exits during this period.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Safe Bathing Water Temperatures
Penalty
Summary
The facility failed to ensure that bathing and showering water temperatures did not exceed 110 degrees Fahrenheit, as required to prevent potential accidents. Multiple records and logs reviewed showed that water temperatures in various bathhouses and tubs consistently ranged from 111.4 to 116.4 degrees Fahrenheit, exceeding the facility's stated maximum safe bathing temperature. Observations conducted with the Regional Lead Maintenance confirmed that water temperatures in both the 100-hall and 200-hall bathhouses were above the 110-degree threshold. The facility's policies referenced a safe water temperature range of 98.6 to 120 degrees Fahrenheit, but staff interviews confirmed that the maximum for bathing should be 110 degrees Fahrenheit, and this standard was not met. The Resident Listing Report indicated that out of 45 residents, 22 were cognitively impaired and bathed in the bathhouses where the elevated water temperatures were recorded. Staff interviews confirmed that these residents, due to cognitive impairment, would be particularly vulnerable to the effects of excessively hot water. The facility did not have a policy specific to bathing in a tub, and the maintenance staff was responsible for checking and logging water temperatures, which were found to be above the safe limit on multiple occasions.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Obtain Daily Weights and Perform Neurological Checks After Fall
Penalty
Summary
Facility staff failed to obtain daily weights as ordered for a resident with a diagnosis of heart failure. The resident's Medication Administration Record (MAR) for July and August showed multiple days where daily weights were not recorded, despite a physician's order requiring daily weights and notification if the resident gained more than 3 pounds in a day or 5 pounds in a week. The resident required varying levels of assistance with activities of daily living and was assessed as cognitively intact. The Corporate Nurse confirmed that daily weights were not conducted as required. Additionally, the facility did not implement neurological evaluations after an unwitnessed fall for another resident who had moderate cognitive impairment and required substantial to total assistance with mobility and personal care. The resident's care plan documented an unwitnessed fall, but there was no evidence in the health record that neurological checks were performed following the incident. The Corporate Nurse confirmed that neurological evaluations were not completed as per facility policy, which requires such assessments after unwitnessed falls where a head injury is suspected.
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