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)
Some of the Latest Corrective Actions taken by Facilities in Nebraska
Latest Citations in Nebraska
The facility did not maintain the minimum required number of nurse aides per shift, resulting in prolonged call light response times and missed resident care, such as regular bathing for a resident with a wound. Staff and leadership confirmed that inadequate staffing led to delays in answering call lights and providing essential care, with no formal tracking or action plans in place to address these issues.
Staff failed to follow infection control protocols during wound care for a resident with a stage 2 pressure ulcer, including not wearing a gown, not changing gloves, and not performing hand hygiene between tasks. The LPN used the same gloves for wound care and peri care, and exposed the wound to a soiled brief, contrary to facility policy and best practices.
Two residents did not receive bathing according to their preferences, with one resident not having a bath for at least a month and another unable to recall their last bath, both due to staff shortages and lack of proper documentation. Care plans lacked bathing interventions or preference assessments, and staff confirmed that regular weekly baths were not consistently provided. The facility did not have a formal bathing policy, and documentation of baths and refusals was incomplete.
A resident was not given the required SNF ABN and NOMNC at least two days before the end of Medicare Part A coverage, as both notices were signed on the last covered day instead. The Social Services Director confirmed the notices were not provided within the required timeframe.
Two residents' care plans did not address all required needs: one resident's plan omitted prescribed antidepressant medications despite a diagnosis of major depressive disorder, and another resident's plan failed to include discharge planning even though a discharge order was present. The DON and SSD confirmed these omissions during interviews.
A resident with a history of falls and moderate cognitive impairment experienced a fall and was sent to the ER, but the facility did not update the Comprehensive Care Plan (CCP) with new fall interventions as required by policy. The DON confirmed that no new interventions were added to the CCP following the incident.
A resident who was dependent for ADLs and had a pressure ulcer was not repositioned or provided incontinence care as required by their care plan and facility policy. Observations showed the resident remained in the same position for extended periods and wore heavily saturated briefs, with staff confirming lapses in care and the DON acknowledging the lack of a wound care policy.
Surveyors found black buildup on both ovens, food debris on the kitchen mixer, and missing grout with food debris between floor tiles, indicating that cleaning procedures were not followed as required by facility policy and the Nebraska Food Code. These unsanitary conditions had the potential to affect all residents receiving food from the kitchen.
The facility's QAPI program did not effectively identify or address ongoing issues with environmental cleanliness, kitchen sanitation, dental appointment follow-up, and infection control, resulting in repeated deficiencies. Despite regular committee meetings and some performance improvement efforts, problems such as unclean resident rooms, lack of dental follow-up, unsanitary kitchen conditions, and improper infection control practices persisted, affecting all residents.
Surveyors identified multiple environmental deficiencies in 17 resident rooms, including cracked caulking, damaged walls and doors, broken fixtures, strong urine odors, soiled floors, and non-functioning lights. The Maintenance Director confirmed these issues had not been previously identified or addressed, and no work orders were in place for repairs.
Failure to Maintain Minimum Nurse Aide Staffing and Timely Call Light Response
Penalty
Summary
The facility failed to provide the minimum required number of nurse aides on each shift as outlined in its own facility assessment, which specified a minimum of three nurse aides per shift. Staffing records revealed that on several occasions, including the entire month of May and into June, only two nurse aides were scheduled and present on night shifts, and on at least one day shift, there were no nurse aides present. This staffing shortfall resulted in prolonged call light response times, with multiple documented instances of call lights remaining unanswered for over 30 minutes, and in some cases, exceeding an hour. Observations and interviews confirmed that call lights were not answered within the facility's expected timeframe of 5-15 minutes, and staff acknowledged that the lack of adequate staffing contributed to these delays. Additionally, the insufficient staffing impacted resident care, as evidenced by a resident who did not receive weekly baths as preferred and required, with documentation and interviews confirming that the resident had not been bathed for at least a month. The resident also had a wound on the leg and was informed by staff that bathing would help, but the lack of available staff prevented this care from being provided. Staff interviews further corroborated that baths were not being completed regularly due to staffing shortages. The Director of Nursing confirmed that the facility did not track call light response times or have action plans to address the delays, and both the Administrator and DON acknowledged that the staffing levels and response times were not acceptable.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency was identified when staff failed to follow proper infection prevention and control protocols during wound care for a resident. Specifically, an LPN did not don a gown prior to providing wound treatment, despite facility policy requiring the use of gowns and gloves for high-contact care activities such as wound care under Enhanced Barrier Precautions. The LPN also failed to change gloves and perform hand hygiene at appropriate times during the procedure, including after cleaning stool from the resident's buttocks and peri area, and before handling clean dressings and briefs. The resident involved had significant medical complexities, including Type 2 Diabetes Mellitus, hypothyroidism, bilateral above-knee amputations, mild cognitive impairment, peripheral vascular disease, and was dependent on staff for all care. The resident had a stage 2 pressure ulcer on the left buttock, which was acquired in the facility, and was at risk for further skin breakdown. The care plan required regular turning and repositioning, as well as adherence to wound care protocols to prevent infection and promote healing. During the observed wound care, the LPN removed a soiled brief and dressing, exposed the wound to a dirty brief, and used the same gloves for multiple tasks, including wound cleaning, dressing application, and peri care, without changing gloves or performing hand hygiene between steps. Both the LPN providing care and another LPN present confirmed in interviews that proper gown use and hand hygiene protocols were not followed, and that the wound should not have been exposed until after peri care and cleaning were completed.
Failure to Provide Bathing per Resident Preference Due to Staffing and Documentation Issues
Penalty
Summary
The facility failed to honor and facilitate resident self-determination regarding bathing preferences for two residents. For one resident with polyneuropathy and restless leg syndrome, who was cognitively intact and required maximum assistance for bathing, there were no care plan interventions or social service assessments addressing bathing preferences. Bathing logs and schedules showed infrequent baths, and the resident confirmed not having a bath for at least a month, attributing this to staff shortages. Staff interviews corroborated that baths were not being provided weekly as expected, and the Director of Nursing confirmed that bath logs were discarded after documentation in the electronic medical record. The facility also lacked a specific bathing policy. Another resident, who required supervision or touching assistance with activities of daily living and had a moderate cognitive impairment, was observed with oily hair and could not recall the last time they had a bath or washed their hair. Bathing logs indicated only one or two baths per month, and there was no documentation of bed baths or refusals in the progress notes. The resident's care plan did not include bathing interventions or preferences, and staff interviews confirmed that there was not a daily bath aide scheduled and that staffing shortages impacted the ability to provide regular baths. Throughout the review, it was confirmed by multiple staff, including the Administrator and DON, that the facility did not have a formal bathing policy and that resident preferences for bathing were not consistently assessed or care planned. Documentation of bathing and refusals was inconsistent, and staffing limitations were cited as a reason for not meeting the expected frequency of weekly baths based on resident preferences.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a resident with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) at least two days prior to the end of Medicare Part A covered services. Record review showed that the resident's last covered day for Medicare Part A was 04/30/2025, and the facility initiated discharge from Medicare Part A services before benefit days were exhausted. Both the SNF ABN and NOMNC were signed electronically by the resident on the last covered day, with no date recorded for the Social Services Director's initials. An interview with the Social Services Director confirmed that the required notices were not provided within the mandated timeframe.
Care Plans Lacked Psychotropic Medication and Discharge Planning
Penalty
Summary
The facility failed to ensure that individualized care plans addressed all of the residents' needs, specifically omitting psychotropic medication management and discharge planning for two residents. For one resident with multiple diagnoses including major depressive disorder, hypertension, diabetes, and acute kidney failure, the care plan did not include the prescribed antidepressant medications, despite physician orders for Celexa and Remeron. The Director of Nursing confirmed that medications were not addressed in the care plan as required. For another resident with diagnoses such as hypertension, low back pain, muscle weakness, and unsteadiness, the care plan did not include the resident's discharge plan, even though there was a physician order for discharge to an assisted living facility. The Social Service Director confirmed that the discharge plan was not documented in the care plan. These omissions were identified through record review and staff interviews, and were not in accordance with the facility's care planning policy.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the Comprehensive Care Plan (CCP) to accurately reflect new fall interventions for a resident following a fall incident. According to the facility's Fall Prevention and Response Policy, the care plan should be updated with any new or revised fall interventions after a fall occurs. Record review showed that the resident, who had a history of falls and moderate cognitive impairment, experienced a fall on 5/7/2025, resulting in being sent to the emergency room. Despite this incident, no new fall interventions were identified or added to the resident's CCP. Further review of the resident's records indicated that the most recent fall intervention documented in the CCP was dated nearly a year prior to the incident, and the fall prevention focus had not been updated since before the fall. The Director of Nursing confirmed during an interview that the CCP lacked new fall interventions after the recent fall and acknowledged that updates should have been made in accordance with facility policy.
Failure to Provide Timely Repositioning and Incontinence Care
Penalty
Summary
Facility staff failed to provide timely repositioning and incontinence care for a resident who was dependent on staff for activities of daily living. Multiple observations over several days showed the resident lying in bed in the same position, with no evidence of being repositioned or having incontinence care provided for extended periods, sometimes up to five hours. Staff interviews confirmed that the resident was not checked, changed, or repositioned during these intervals, despite facility policy and the resident's care plan requiring repositioning at least every two hours and peri care after each incontinence episode. The resident in question had a history of cerebral infarction, dementia, mood disturbance, and anxiety, and was assessed as severely cognitively impaired and fully dependent for ADLs. The resident also had a pressure ulcer related to immobility and was at risk for further skin breakdown, as indicated by a Braden Scale score of 13 and frequent skin moisture. Observations documented the resident wearing heavily saturated briefs with foul odor, and staff acknowledged that the care provided did not meet the required frequency. The Director of Nursing confirmed the expectation for two-hourly checks and repositioning, and that refusals of care should be documented, but also stated there was no facility wound care policy.
Unsanitary Kitchen Equipment and Surfaces
Penalty
Summary
Surveyors observed that the facility failed to maintain the dual ovens, kitchen stand mixer, and kitchen floor in a clean and sanitary condition, as required by professional standards and the Nebraska Food Code. Specifically, there was black buildup on the bottom of both ovens, food debris accumulation on the arm and stand of the kitchen mixer, and missing grout between two rows of tiles near the stove top and ovens, with food debris present in the unfilled space. These findings were confirmed during observations with both the Certified Dietary Manager (CDM) and the Registered Dietitian (RD), who acknowledged the presence of buildup and missing grout. Interviews with the CDM and RD confirmed that the facility had a cleaning checklist in place, which required weekly cleaning of the ovens and cleaning of the mixer after each use. The facility's policy outlined that the CDM was responsible for oversight and that kitchen staff were assigned daily, weekly, and monthly cleaning tasks. Despite these policies, the observed conditions indicated that cleaning procedures were not being followed as required, resulting in unsanitary kitchen equipment and surfaces that could potentially affect all 69 residents who consumed food prepared in the facility kitchen.
QAPI Program Fails to Address Repeat Deficiencies in Environment, Kitchen, and Infection Control
Penalty
Summary
The facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively identified and addressed concerns related to deficient practices found during the annual survey, as well as repeat deficiencies from previous surveys. Specifically, the QAPI program did not maintain correction for issues such as environmental cleanliness and maintenance (F 584), dental appointment follow-up (F 791), kitchen sanitation (F 812), and infection control practices (F 880). The QAPI committee was responsible for reviewing survey results, internal audits, infection control data, grievances, accidents, clinical outcomes, dietary performance, and performance improvement plans (PIPs), but failed to implement effective interventions for recurring issues. The facility's policy required regular meetings and data-driven interventions, but these were not successful in preventing repeat citations. During the most recent survey, deficiencies included failure to protect residents' property and maintain cleanliness in resident rooms, lack of follow-up on dental appointments, inadequate maintenance of kitchen appliances and floors, and improper infection control practices such as not disinfecting glucometers between uses and improper handling of catheter bags. These deficiencies had the potential to affect all 69 residents in the facility. Interviews confirmed that environmental and kitchen sanitation issues had been cited in previous years, and while a PIP was initiated for the kitchen, it was not effective in maintaining correction, and no PIP was implemented for environmental concerns.
Widespread Environmental Deficiencies in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for residents, as required by regulation. During an environmental tour with the Maintenance Director and Housekeeping Supervisor, multiple deficiencies were identified in 17 out of 41 occupied resident rooms. These included cracked and stained caulking around toilets, scrapes and holes in drywall and doors, cracked and bubbled ceiling tiles, pulled-away baseboards, food and water stains on ceilings, broken or missing fixtures such as nightlight covers, kick plates, toilet paper holders, towel bars, and window blinds. Additionally, there were strong urine odors, soiled and sticky floors, loose or torn fall stop strips, missing light covers, non-functioning lights, broken beds, and missing call light cords. Some rooms also had dried tube feeding solution on fall mats and peeling floor finishes. The Maintenance Director confirmed during the interview that the identified areas required cleaning or repair and acknowledged that there were no existing work orders for these issues. The concerns had not been previously identified by facility staff prior to the surveyors' environmental tour. The report does not mention any specific residents' medical histories or conditions at the time of the deficiency, nor does it indicate any corrective actions taken following the findings.
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