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
A resident's wedding ring was reported missing by a family member, prompting an incomplete investigation by facility staff. The search included the resident's room and interviews with some staff and a roommate's family member, but did not include all staff with access or a documented timeline of the ring's disappearance. Required documentation of interviews and a thorough investigation, as outlined in facility policy, were not completed.
Staff did not consistently perform hand hygiene between glove changes during catheter and incontinence care for a resident with multiple medical conditions, and the urinary catheter drainage bag was repeatedly handled and positioned inappropriately. Additionally, the facility did not follow its own COVID-19 protocols, as symptomatic staff were not tested for COVID-19 despite policy requirements.
The facility did not ensure that the Dietary Manager held the required certification or that a full-time dietician was employed. The Operations Manager, lacking necessary training, served as both interim DM and cook, and menu substitutions were made due to improper food ordering. Dietary staff did not receive adequate training or demonstrate competency, affecting all residents receiving meals from the kitchen.
The facility did not serve meals according to the planned and approved menus, instead substituting available food items due to insufficient ordering by an untrained interim Dietary Manager. The interim manager did not consult with the Registered Dietician regarding these changes, resulting in all residents receiving meals that differed from the posted menu.
The facility did not consistently obtain or document food temperatures for meals, as required by policy, with multiple instances where hot foods were reheated and served to residents without temperature checks. Dietary staff confirmed the omission of temperature monitoring and documentation, which affected all residents receiving food from the kitchen.
A resident with complex medical needs requiring total assistance for toileting and transfers experienced significant delays in receiving care, waiting over an hour for help after activating the call light. Facility records showed repeated instances of call lights going unanswered for extended periods, and staffing schedules revealed that CNA coverage often fell below the facility's own requirements, leading to ongoing delays in resident care.
Multiple residents with significant care needs experienced prolonged delays in call light responses, with documented wait times frequently exceeding the facility's 10-minute standard. Residents dependent on staff for mobility, toileting, and hygiene reported waiting up to an hour for assistance, particularly during evening shifts. Interviews and records confirmed that insufficient staffing contributed to these delays, and grievances regarding the issue were not investigated or resolved.
Surveyors found that the facility failed to maintain a safe and sanitary bathing environment, with significant structural damage and debris present in the shower room used by multiple residents with complex medical needs. The facility was aware of the damage but had no plan to repair it, directly affecting residents' right to a safe and homelike environment.
A resident reported feeling threatened by an OM, who stated the resident would be discharged to a homeless shelter if an outstanding bill was not resolved. The resident informed the SSD, who acknowledged the concern as verbal abuse but failed to report the allegation to the State Agency or notify facility leadership, as required by policy.
A resident reported feeling threatened by an Operations Manager who stated that unresolved billing issues could result in discharge to a homeless shelter. The Social Service Director did not notify the Administrator or initiate an investigation, and the incident was not reported to the State Agency as required by policy.
Failure to Thoroughly Investigate Missing Resident Property
Penalty
Summary
The facility failed to conduct and document a thorough investigation into the misappropriation of a resident's property, specifically a wedding ring belonging to a resident who had been admitted in July 2022. The resident's personal inventory included several rings of value, and the missing wedding ring was reported by a family member after noticing its absence during a visit. The family member had last seen the ring during a previous visit and, upon discovering it missing, reported it to the nurse on duty. The facility's investigation, as documented, included searching the resident's room and the unit, and interviewing the roommate's daughter, but did not include interviews with all staff who had access to the resident or the resident's belongings. Further, the investigation did not document interviews with all potentially involved staff, nor did it establish a clear timeline for when the ring was last seen. Interviews were conducted with the nurse and aide on duty at the time of the report and the ADON, but the findings from these interviews were not documented. The facility also did not rule out the possibility that misappropriation had occurred, and interviews with other residents were not completed due to their impaired cognition. These actions and omissions are contrary to the facility's own policy, which requires all allegations of abuse or neglect to be thoroughly investigated and documented.
Infection Control Failures in Hand Hygiene, Catheter Care, and COVID-19 Protocols
Penalty
Summary
Staff failed to perform hand hygiene at appropriate intervals during the provision of care, specifically when removing soiled gloves and before donning clean gloves. Observations showed that nurse aides did not complete hand hygiene before putting on personal protective equipment or after removing gloves during catheter care and incontinence care for a resident. The urinary catheter drainage bag was repeatedly placed on bed linens and positioned above the level of the resident's bladder and head during transfers, contrary to facility policy and best practices for infection prevention. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes. The resident required total staff assistance for hygiene and had an indwelling urinary catheter. During care, the catheter drainage bag was handled inappropriately, including being placed on the bed and attached to the lift above the resident's bladder, and staff did not consistently perform hand hygiene between glove changes while managing incontinence and catheter care. Additionally, the facility failed to follow its COVID-19 protocols. The DON was observed with respiratory symptoms but had not completed a COVID-19 test and stated there was no intention to do so. It was confirmed by a registered nurse that the facility did not test staff or residents presenting with respiratory symptoms or increased temperature, despite facility policy requiring symptomatic employees to be restricted from work until COVID-19 infection was ruled out by testing.
Failure to Employ Qualified Dietary Staff and Maintain Menu Standards
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as required by regulation. Specifically, the Dietary Manager (DM) position was vacant after the previous DM left, and the Operations Manager (OM), who lacked the required certification and training, was serving as the interim DM. The OM also worked as a cook without having received any training for the DM or cook roles and had not consulted with the Registered Dietician regarding menu changes. Additionally, the facility did not employ a full-time dietician, and dietary staff had not received adequate training or demonstrated competency to serve as cooks. Record review and staff interviews revealed that the OM was responsible for ordering food and, due to insufficient ordering, the facility was unable to follow the preapproved/planned menus. Instead, available food from the freezers and storeroom was used as substitutes. The dietary schedule showed the OM frequently filled in as a cook due to staffing shortages, and the Interdisciplinary Team (IDT) assisted with dietary aide duties, receiving only limited training related to dishwasher safety and temperature logs. These deficiencies had the potential to affect all residents who consumed food prepared in the facility.
Failure to Follow Planned Menus Due to Untrained Interim Dietary Management
Penalty
Summary
The facility failed to follow its planned and preapproved menus for all residents who consumed food from the facility kitchen. On the specified date, the noon meal served to residents did not match the posted menu; instead of the listed breaded chicken patty on a bun, mini baker potatoes, cream gravy, country trio vegetables, bread with margarine, and flamingo cake, residents received Salisbury steak, au gratin potatoes, country trio vegetables, white gravy, and a cookie. This deviation occurred because the Operations Manager, who was acting as the interim Dietary Manager after the previous manager left, did not order enough food for the planned menus and substituted available items from the facility's storeroom and freezers. The interim Dietary Manager had no training for the role and did not consult with the Registered Dietician regarding these menu changes.
Failure to Ensure Hot Foods Served at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at a palatable temperature for residents, as required by policy and regulatory standards. Review of the facility's food temperature logs over several weeks revealed numerous instances where food temperatures were not obtained or recorded for breakfast, noon, and evening meals. The facility's policy required that food temperatures be taken and documented for all items prepared in the dietary department, with hot foods maintained at 135°F or higher and reheated foods reaching 165°F. However, logs showed repeated omissions in temperature documentation across multiple days and meals. Direct observations during a noon meal service showed dietary staff removing pre-cooked hot dogs and soup from the refrigerator, reheating them in the microwave, and serving them to residents without checking or recording the food temperatures. During an interview, dietary staff confirmed that temperatures were not obtained or documented for these items and acknowledged that this was a recurring issue, partly due to staffing concerns. This failure had the potential to affect all residents who consumed food from the kitchen.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the needs of all residents, specifically resulting in delayed toileting and incontinence care for a resident with significant medical needs. The resident, who had diagnoses including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes, required total staff assistance for toileting, hygiene, dressing, bed mobility, and transfers, and was frequently incontinent of bowel with an indwelling urinary catheter. On the observed morning, the resident activated the call light at 7:15 AM for assistance to use the commode, but did not receive help until 8:39 AM, resulting in an involuntary bowel movement due to the prolonged wait. Interviews confirmed that only two direct care staff were working that shift for a census of 30, and the resident was often left waiting for extended periods due to insufficient staffing. Review of the facility's Device Activity Report and call light activity logs revealed numerous instances where call light response times exceeded the facility's policy of a 15-minute response, with some calls going unanswered for up to 138 minutes. These delays were not isolated to a single day but occurred repeatedly over a two-week period, affecting multiple residents. The facility's own policy required prompt response to call lights, and staff interviews confirmed that the expectation was to answer within 15 minutes, which was not consistently met. Further review of staffing schedules showed that the facility frequently scheduled fewer CNAs than required, particularly on weekends and overnight shifts. The Director of Nursing confirmed that the number of CNAs scheduled often did not meet the facility's own standards for adequate staffing. This chronic understaffing directly contributed to the inability to provide timely care and respond to residents' needs as required by both facility policy and regulatory standards.
Delayed Call Light Responses Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple documented instances where residents waited significantly longer than the facility's expected response time of 10 minutes. The facility's Resident Call Light Policy requires staff to respond to call lights as timely as possible and to ensure all residents have access to a functional and responsive call light system. However, review of call light response logs revealed numerous occasions where call lights were left unanswered for periods ranging from over 10 minutes to more than an hour. One resident, who was cognitively intact and dependent on staff for all activities of daily living due to conditions such as quadriplegia and pressure ulcers, experienced repeated delays in call light responses, with several instances exceeding 30 minutes and some over an hour. Another resident with heart failure and dependent on staff for bathing and toileting reported waiting up to 30 minutes for assistance, particularly during evening shifts. A third resident with spina bifida and paraplegia, who required assistance with personal hygiene and dressing, also reported frequent long waits for call light responses, including a documented grievance where the call light was not answered for 56 minutes. This resident indicated that the issue persisted, especially during certain shifts, and that submitting a grievance did not result in any noticeable changes. Interviews with the affected residents confirmed their experiences of delayed responses, with particular concern for insufficient staffing during evening shifts. The administrator acknowledged that the facility's expectation was for call lights to be answered within 10 minutes and confirmed that the documented response times did not meet this standard. There was also a lack of evidence that grievances related to call light response times were investigated or addressed.
Unsafe and Unsanitary Bathing Environment Maintained for Residents
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike bathing environment for its residents. Observations of the 200 hall shower room revealed significant structural damage, including missing wall tiles, broken drywall with exposed wood studs and pipes, and an area covered with torn paper and clear tape. The floor in front of the damaged wall also had broken and missing tiles, exposing rough cement and creating uneven surfaces. Debris, unidentified powders, and discoloration were present throughout the affected areas. These conditions were directly observed while residents were being assisted with bathing, and the facility was aware of the damage but had no plan in place to repair it. This deficiency affected all six sampled residents, each with complex medical histories such as diabetes mellitus, dementia, respiratory failure, urinary tract infection, depression, anxiety, back pain, hypertension, osteoporosis, chronic kidney disease, heart failure, failure to thrive, broken ribs, and prostate cancer. On the day of the survey, multiple residents received showers in the compromised environment, as confirmed by staff interviews and the facility's bathing schedule. The lack of a safe and sanitary bathing area was evident during direct care activities, impacting the residents' right to a safe and comfortable environment.
Failure to Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of potential staff-to-resident abuse to the State Agency as required by policy and regulation. A resident reported feeling threatened by the Operations Manager (OM), who stated that if the resident did not resolve an outstanding bill, the facility would issue a 30-day notice and, if no alternate placement was found, the OM would take the resident to a homeless shelter with their medications. The resident communicated these concerns to the Social Service Director (SSD), expressing that they felt threatened and did not want to be placed at a homeless shelter. Despite the resident's report and the SSD's acknowledgment that the resident was verbally abused, the SSD did not report the allegation to the State Agency or notify anyone else at the facility. A review of facility investigations over the relevant period showed no evidence that this allegation of verbal abuse was reported as required. The OM confirmed the statements made to the resident regarding discharge and potential placement at a homeless shelter.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of potential staff-to-resident verbal abuse as required by policy and state regulations. A resident reported to the Social Service Director (SSD) that they felt threatened by the Operations Manager (OM), who stated that if the resident did not resolve an outstanding bill, the facility would issue a 30-day notice and, if no alternate placement was found, the OM would take the resident to a homeless shelter with their medications. The SSD acknowledged feeling that the resident was verbally abused but did not notify the facility Administrator or initiate an investigation into the allegation. A review of facility records showed no evidence that the allegation was reported to the State Agency or that an investigation was conducted. Interviews confirmed that the OM made the statements to the resident and that the Administrator was unaware of the allegation, resulting in no investigation or report being submitted as required. The facility's policy mandates immediate reporting and investigation of such allegations, but these steps were not followed in this case.
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