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 with Alzheimer’s disease and CKD experienced progressive, significant weight loss over several months, during which multiple new treatments were initiated, including a nutritional supplement, KCL for hypokalemia, metformin for prediabetes, mirtazapine for dementia with depression and weight loss, and orders for prealbumin labs, weekly weights, and a renal ultrasound. Although the facility’s policy required notifying the resident’s representative of significant condition changes and new treatments, documentation showed no evidence that the POA was informed of the ongoing weight loss or these new orders, and the POA reported only being told once that the resident would start a supplement and then not hearing more until hospice was discussed.
A resident with Alzheimer’s disease and CKD stage 3 experienced progressive weight loss despite being on a mechanical soft diet, med pass supplement, and snacks as requested, and being care planned for significant weight loss. Facility policy required weekly weights for residents with weight loss, but weekly weights were not initiated, resulting in a large gap between recorded weights during which the resident lost over 10% of body weight, followed by an additional significant loss in one week. A prealbumin lab was ordered due to unintended weight loss, but no result for the initial order was found in the record, even though a later prealbumin level was low and could indicate malnutrition. These omissions show that the resident’s nutritional status and weight loss were not adequately monitored after interventions were implemented.
A resident with a history of stroke, hemiplegia, moderate cognitive impairment, and chronic constipation repeatedly refused multiple ordered bowel medications over an extended period, as documented on the MAR and in nursing progress notes. RNs educated the resident several times about the importance of the bowel regimen while noting prolonged absence of BM and episodes of vomiting, but the refusals continued. Facility policy required notifying the physician when treatment needed to be significantly altered, using an SBAR tool for communication. Record review showed no evidence that the provider was notified of the ongoing medication refusals, and there were no documented parameters for notification in the orders or care plan; the RN team lead and DON confirmed that no SBAR or other provider notification was found.
Surveyors found that the facility did not maintain several occupied rooms in a safe, clean, and well-functioning condition. During an environmental tour with the Maintenance Supervisor and Administrator, they observed missing bathroom call strings, very low sink water pressure in multiple rooms, cobwebs on walls and ceilings, and ventilation covers coated with dust-like buildup. They also noted a non-functioning bathroom light, stained bathroom ceilings, light covers and floors, a deeply gouged bathroom door, and cracked or broken call light and phone outlet covers. The Maintenance Supervisor confirmed these problems, stated they required cleaning or repair, and reported there were no active work orders for them and that staff were inconsistent in submitting work orders.
The facility failed to report two separate serious incidents to the State Survey Agency as required by its own abuse and incident reporting policy. One resident with a history of TBI, mood disorder, falls, behavioral symptoms, and wandering left the building twice without notifying staff; during the second elopement, staff were unaware of the resident’s whereabouts, the wheelchair was later found outside, and the resident returned with abrasions, shoulder pain, and required hospital evaluation. The resident’s care plan noted impulsivity and a preference for walking outside but lacked interventions for wandering. In a separate event, another resident sustained a ground-level fall resulting in a facial laceration that required suturing in the hospital. A clinical consultant and the Administrator confirmed that neither the elopement with injury nor the fall with significant injury was reported to the State Agency.
A resident was transferred to the hospital on multiple occasions, but the facility did not provide the required written bed-hold information or written reasons for transfer at the time of each hospitalization. Facility policy requires that residents and their representatives receive written information on State bed-hold duration and payment amounts before hospital transfer or therapeutic leave, and that this information be provided at admission and prior to each transfer. Record review showed no bed-hold notices or transfer-reason documentation for any of the resident’s hospital leaves, and the Social Service Director confirmed that no such forms were completed, despite the policy and staff education requirements.
A resident admitted for surgical aftercare following circulatory system surgery did not receive ordered wound care to a left fourth toe because nursing staff did not enter the hospital AVS wound treatment orders into the TAR at admission. As a result, the prescribed twice-daily regimen of cleansing, Betadine application, gauze placement between toes and in the fifth toe crease, and use of a Rooke boot was not documented or performed for several days, which was confirmed by review of the MAR/TAR and by interviews with the IDON and DON.
A resident with quadriplegia, amputations, a Stage III sacral pressure ulcer, multiple venous ulcers, and a surgical wound was care planned for a low air loss mattress, but there was no corresponding physician order or usage parameters. The mattress alarm beeped for weeks, indicating malfunction, yet staff, including an LPN and the IDON, did not know how to correct or calibrate it and key personnel were not notified of the problem. Observations showed the mattress set at the highest weight setting despite the resident’s much lower recorded weight, and the mattress was calibrated based on comfort rather than manufacturer-recommended weight-based settings, contrary to the device instructions.
A resident with TBI, mood disorder, history of falls, inattention, disorganized thinking, depression, and documented wandering behaviors was not provided with appropriate elopement or fall prevention interventions. The care plan noted impulsivity, poor redirectability, and a preference for walking outside, yet contained no elopement or wandering interventions, and the resident’s Wanderguard was removed after being assessed as low risk. The resident left the facility multiple times without signing out, and on one occasion staff only realized the resident was gone after finding the resident’s wheelchair outside, leading to a search by staff and law enforcement before the resident was returned with abrasions and complaints of pain. Despite multiple documented falls, the care plan lacked updated fall interventions, and observations showed environmental hazards in the resident’s room, including scattered paper towels, multiple beverage cases and boxes on the floor, and a urinal out of reach, with no fall prevention measures in place.
Two residents experienced significant medication errors when ordered drugs were not available or not initiated as required. One resident with dental pain and infection had an antibiotic ordered by a dentist and faxed to the pharmacy, but the order was never entered into the electronic record, and the first dose was not given as scheduled. Another resident with Type 2 DM had a standing weekly Ozempic injection order, but the last administering nurse did not reorder the medication after the prior dose, leaving no dose available on the next due date. These failures occurred despite facility policies requiring timely initiation of new medications and reordering when supplies were low.
Failure to Notify Resident Representative of Significant Weight Loss and Treatment Changes
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s legal representative of significant changes in condition and treatment, as required by facility policy and state licensure regulations. The facility’s written policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there were accidents, significant changes in physical, mental, or psychosocial condition, or circumstances requiring alteration of treatment, including new treatments. Resident 3 was admitted with Alzheimer’s disease with late onset and stage 3 chronic kidney disease, and the admission record identified a family member as POA. The POA reported being told months earlier at a care conference that the resident was losing weight and would start a supplement, but reported receiving no further information about the resident’s weight loss until the resident was placed on hospice. The social service note for that care conference did not document weight loss as a concern. Weight records showed a progressive and significant weight loss over several months, with multiple documented 5–10% or greater changes from prior comparison weights. During this period, several new clinical interventions and orders were initiated in response to the resident’s condition, including starting a nutritional supplement (med pass 60 cc three times daily) for slow weight loss, potassium chloride for hypokalemia, metformin for prediabetes, and mirtazapine for dementia with depression and weight loss, as well as orders for a prealbumin lab, weekly weights, and a renal ultrasound due to a history of mass and significant weight loss. A handwritten note indicated the family declined the ultrasound. However, a review of progress notes and medical professional notes between late October and early January did not show documentation that the POA was notified of the resident’s weight changes or the new orders for potassium chloride, metformin, mirtazapine, or the prealbumin lab. The registered dietitian confirmed not speaking with the family about the weight loss, and the ADON confirmed that nurses are expected to notify the POA of changes in condition, including weight loss and medication changes, and that no additional documentation of POA notification could be found.
Failure to Monitor Nutritional Status and Weight Loss After Interventions
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and follow up on a resident’s nutritional status and weight loss after nutritional interventions were implemented. Facility policy required that residents with weight loss be monitored with weekly weights and that interventions be identified, implemented, monitored, and modified as appropriate. The resident, who had Alzheimer’s disease with late onset and stage 3 chronic kidney disease, was care planned for significant weight loss and was receiving a mechanical soft diet, med pass supplement, and snacks as requested. Dietary notes documented progressive weight loss, including a 3.5% loss in 30 days and an 8.9% loss in 90 days, with plans for the RD to monitor oral intake, diet status, weight trends, and skin integrity. Despite these interventions and plans, the facility did not obtain weekly weights as required for a resident with weight loss, as confirmed by the RD. The weight and vital summary showed a weight of 134.8 lbs. on one date and then no further recorded weight until a later date when the resident’s weight had dropped to 121 lbs., reflecting a 10.2% loss over that period, followed by another recorded weight of 114 lbs. one week later, a 5.79% loss in that week. Additionally, a prealbumin lab was ordered due to unintended weight loss, but no result was found in the record for that order, and the regional nurse consultant confirmed that no result could be located. A later prealbumin result showed a level of 14, which could indicate malnutrition. These gaps in weight monitoring and lack of documented follow-up on the initial prealbumin order occurred despite the resident being identified with significant weight loss and having nutritional interventions in place.
Failure to Notify Provider of Ongoing Refusal of Bowel Regimen
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the medical practitioner of ongoing refusals of prescribed bowel medications for one resident. The facility’s policy, last reviewed on 08/27/2018, required notification of the physician or designee and the resident’s legal representative when there was a need to significantly alter treatment, including discontinuation of existing treatment due to ineffectiveness or adverse consequences, or initiation of new treatment. The policy specified use of an SBAR tool for non-emergent notifications, with documentation to be filed in the physician’s order section of the chart. Despite this policy, the facility did not notify the provider when the resident repeatedly refused bowel regimen medications over a series of days. The resident involved had a history of cerebral infarction with right-sided hemiplegia/hemiparesis, difficulty walking, moderate cognitive impairment (BIMS score of 7), and constipation. The comprehensive care plan included monitoring for constipation, monitoring bowel and bladder patterns every shift, and ongoing education about bowel management, noting that the resident often stated it was normal to go a lengthy time between bowel movements and that the resident sometimes refused bowel protocol due to past work circumstances. Physician orders included multiple bowel regimen medications (prune products PRN, milk of magnesia PRN, senna, bisacodyl suppository PRN, Motegrity, Miralax, and an order to document bowel sounds and abdominal characteristics daily). Medication Administration Records showed that over a 10-day period the resident refused docusate sodium 15 of 20 scheduled doses, refused Motegrity and Miralax 8 of 10 scheduled doses, and refused senna on 2 occasions. Progress notes documented repeated refusals despite RN education on the importance of bowel medications and more frequent bowel movements, and noted the resident had gone 7 and then 8 days without a bowel movement while continuing to refuse bowel protocol, though bowel sounds were active in all quadrants at those times and the resident denied pain or discomfort. Additional notes documented vomiting episodes and changes in bowel sounds on one day. A physician dictation later acknowledged the resident had not been taking the bowel regimen because of dislike of the medications. However, review of progress notes, scanned documents, and the physical chart revealed no evidence that the medical practitioner had been notified of the repeated refusals, and there were no documented parameters for notification of medication refusals in the physician’s orders or care plan. The RN Team Lead and DON confirmed there was no evidence of SBAR communication or provider notification for these refusals during the period reviewed.
Environmental Maintenance and Call System Deficiencies in Multiple Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment in 11 of 42 occupied rooms during an environmental tour conducted with the Maintenance Supervisor and Administrator. Observations included missing call strings in at least one resident bathroom, very low water pressure in multiple room sinks, cobwebs along the walls and ceiling in one room, and multiple ventilation covers coated with a gray, fuzzy dust-like substance in several rooms (301, 304, 305, 306, 316, 502, 505, 511, 512, 514). Additional issues included a non-functioning bathroom light in one room, reddish-brown stains on the bathroom ceiling and light cover and dark stains on the bathroom floor in another room, scratches and a deep gouge in a bathroom door, a cracked and broken call light outlet on a wall, and a broken phone outlet cover on a wall. In an interview, the Maintenance Supervisor confirmed all of these issues, acknowledged they needed cleaning and/or repair, and stated there were no active work orders for the identified concerns and that staff were inconsistent in submitting work orders. No specific resident medical histories or clinical conditions were described in relation to these environmental deficiencies.
Failure to Report Elopement and Fall With Major Injury to State Agency
Penalty
Summary
The facility failed to timely report to the State Survey Agency an elopement and a fall with major injury involving two residents, as required by its Abuse, Neglect, and Exploitation policy. The policy required all allegations of abuse, neglect, exploitation, and injuries of unknown source to be reported within 2 hours for serious bodily injury and within 24 hours if no injury, with investigation results submitted within 5 working days. One resident, with a history of traumatic brain injury, mood disorder, history of falling, inattention, disorganized thinking, depression, verbal behaviors that interfered with care and put others at risk, and documented wandering behaviors, left the facility twice on the same day without signing out or notifying staff. Progress notes showed that the resident’s care plan included preferences for walking outside and described the resident as very impulsive and not easily redirectable, but did not include interventions addressing wandering behaviors. On the second elopement, staff did not know where the resident was going, the resident’s wheelchair was later found near the drive-up area, and the resident ultimately returned with abrasions, complaints of shoulder pain, and required hospital evaluation for hypothermia and injuries from a fall. The Administrator confirmed this elopement incident was not reported to the State Agency. A second resident experienced a ground-level fall resulting in a right facial laceration that required transport to the hospital. The hospital discharge summary documented a right upper eyelid laceration with sutures, indicating a significant injury. Interview with a clinical consultant confirmed that this fall with significant injury was not reported to the State Agency, despite the facility’s policy requiring reporting of such events. These two unreported incidents, an elopement with injury and a fall with major injury, occurred among a sample of four residents in a facility with a census of 62 and constituted the basis for the cited deficiency under the licensure requirement to timely report suspected abuse, neglect, or theft and the results of investigations to proper authorities.
Failure to Provide Bed-Hold Information and Written Transfer Reasons for Hospital Transfers
Penalty
Summary
The facility failed to provide required bed-hold information and written reasons for transfer for a resident on multiple occasions. The facility’s “Bed Hold and Return to Facility Policy and Procedure,” created in May 2017 and revised in January 2024, states that residents who are transferred to the hospital or go on therapeutic leave are to be provided written information about the State’s bed-hold duration and payment amount before the transfer. The policy also states that residents and their representatives will be provided with bed-hold and return information at admission and before a hospital transfer or therapeutic leave, and that nursing and social work staff are educated on these requirements. Record review showed that one resident, admitted on an unspecified date, was listed on hospital leave on five separate occasions: 11/30/25, 12/01/25, 12/09/25, 12/18/25, and 01/02/26. Progress notes from 11/30/25 at 2:12 AM documented that the doctor’s office was notified and the resident was sent to the emergency room. However, review of the resident’s medical record, including progress notes and miscellaneous documents, revealed no bed-hold information or written reason for transfer for any of the five hospital transfers. In an interview on 1/20/26 at 9:50 AM, the Social Service Director confirmed that the facility had no completed bed-hold forms or reason-for-transfer forms for this resident and acknowledged that one should have been completed with each transfer to the hospital.
Failure to Initiate and Provide Ordered Surgical Wound Care
Penalty
Summary
Facility staff failed to provide ordered surgical wound care for one resident following admission. The facility’s new/re-admission process required a licensed nurse to review admission orders and input wound treatment orders into the system. The resident was admitted with a diagnosis of encounter for surgical aftercare following surgery on the circulatory system. The hospital after visit summary (AVS) included detailed wound care orders for the left fourth toe, specifying cleansing with soap and water, application of povidone (Betadine), placement of gauze between each toe space and in the crease of the fifth toe, and use of a Rooke boot, to be performed twice daily. Record review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed that the wound care order from the AVS was not activated on the TAR until several days after admission, and no wound care was charted during that period. Interviews with the Interim Director of Nursing and the Director of Nursing confirmed that staff should have used the wound care orders from the AVS and that the wound care was not initiated or completed during the identified dates.
Failure to Ensure Proper Functioning and Calibration of Low Air Loss Mattress for Resident With Pressure Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure proper functioning and calibration of a low air loss mattress for a resident with significant skin integrity issues. The resident had spastic hemiplegia, quadriplegia, amputations of the left foot and right leg above the knee, a history of wounds, and at the time had a Stage III sacral pressure ulcer, multiple venous ulcers on the left leg and stump, and a surgical wound on the right stump. The resident’s care plan included an intervention for a low air loss mattress, but there was no corresponding physician order or parameters for its use in the order summary. The manufacturer’s instructions for the Med Aire Plus 8 Alternating Pressure and Low Air Loss Mattress specified that the mattress should be kept in alternating pressure mode when the patient is lying down and that pressure should be set according to the patient’s weight using the weight setting buttons. Multiple observations showed the resident’s mattress alarm beeping on more than one occasion, indicating a malfunction, and later showed the mattress set at the highest weight setting despite the resident’s last recorded weight of 190.4 lbs. An LPN acknowledged the alarm indicated the mattress was not working correctly, admitted not knowing how to correct or calibrate it, and could not provide evidence of having contacted the equipment company as claimed. The resident and a medication aide both reported that the mattress had been beeping for weeks, and the interim DON and maintenance director stated they had not been informed of the issue until the survey date. The interim DON and maintenance director also reported not knowing how to calibrate the air mattress according to manufacturer instructions, and the mattress was instead adjusted based on the resident’s comfort rather than the resident’s weight, despite the presence of active wounds and the manufacturer’s specified weight-based settings.
Failure to Implement Elopement and Fall Prevention Interventions for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify and care plan a resident’s elopement risk and fall risk, and to implement interventions to prevent accidents. The facility had an Elopement/Exit Seeking policy stating it would provide a safe and secure environment and be proactive in preventing elopement. The resident involved had a history of traumatic brain injury, unspecified mood disorder, history of falling, inattention, disorganized thinking, depression, and exhibited wandering behaviors that significantly interfered with care and put others at risk for physical injury. The resident’s care plan documented impulsivity, poor redirectability, irritability with safety reminders, and a preference for walking outside, but did not include interventions related to wandering or elopement despite these behaviors and diagnoses. The resident’s MDS showed a BIMS score of 13, indicating cognitive awareness, and documented that the resident required supervision or touching assistance with all mobility and assistance with several ADLs. The resident had a wander/elopement alarm noted on the MDS, but the facility’s Audit of Wanderguards did not list the resident as having a Wanderguard. Progress notes showed that an elopement risk assessment was completed and the resident was deemed to have no active elopement attempts, and the Wanderguard safety device was documented as no longer applicable. Later, the resident left the facility multiple times without signing out or notifying staff, including two exits on the same day without using the sign-out book, and continued to exit seek after being educated on sign-out procedures. On one occasion, staff became aware the resident was missing only after finding the resident’s wheelchair outside near the drive-up area, and documentation showed that staff and law enforcement had to search the surrounding area before the resident was returned by police and the Administrator. The facility also failed to implement and update fall interventions for this resident despite multiple falls. Progress notes and fall data collection forms documented falls on several dates, including in-facility falls and an out-of-facility fall, but the resident’s care plan did not show fall interventions to prevent recurrence of the falls on those dates. Root cause documentation for some falls noted factors such as spilled pop on the floor and nighttime medications causing drowsiness, but there were no documented interventions to prevent similar events in the future or after the resident returned from the hospital. Observations of the resident’s room showed paper towels scattered on the floor, multiple boxes and cases of soda and other items on the floor near the bedside table and between the bed and restroom, and the resident’s urinal hanging on a trash can by the door and not within reach. No fall interventions were observed in the room. Facility staff, including the Clinical Consultant, confirmed that interventions were not put in place following the resident’s falls and that no interventions were implemented to protect the resident from eloping because the resident was considered cognitively aware and able to make their own decisions.
Failure to Ensure Timely Initiation and Continuation of Ordered Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to timely initiation and continuation of ordered medications. Facility policy required that medications be obtained and administered in a timely manner, with new orders to be started within 24 hours unless otherwise specified, and that nurses reorder medications when six or fewer doses remained. Despite this, the process for entering and obtaining medications from the pharmacy did not function as intended, resulting in missed doses for two residents. For one resident admitted with dental pain and infection, a dentist evaluated the resident and prescribed Augmentin to be given twice daily for 10 days, with the medication to be delivered by the pharmacy. The LPN on duty documented faxing the new antibiotic order to the pharmacy on the day of the dental visit. The following morning, when the resident complained of significant jaw pain and stated they had not received the antibiotic, the LPN confirmed there was no antibiotic listed in the resident’s electronic orders and contacted the pharmacy. The pharmacy reported the medication was at the facility, but the order had not yet been entered into the medical record, and the resident had not received the first dose the day it was ordered. For another resident with a primary diagnosis of Type 2 Diabetes Mellitus, the Medication Administration Record showed an ongoing order for Ozempic 2 mg to be injected once weekly at 7:00 AM. On the scheduled administration date, the LPN was unable to locate the Ozempic on the medication cart or in the medication storage room and confirmed that the injection due that morning could not be given. The LPN later verified that the last person who administered the weekly Ozempic dose had not reordered the medication when the previous dose was given, contrary to facility practice for once-weekly medications. The DON confirmed that the last nurse to administer the Ozempic was responsible for reordering it and that this had not occurred, resulting in a missed scheduled dose.
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