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
Two residents with complex medical needs experienced repeated delays in staff response to call lights, with documented wait times far exceeding the facility's 5-minute expectation. Both residents reported long waits, and call light logs confirmed multiple instances of extended response times, indicating staff did not meet the facility's standard for timely care.
Two residents at risk for pressure ulcers did not receive timely or appropriate interventions, including the use of pressure-relieving devices and specific care plan updates. One resident developed new pressure ulcers without the ordered Roho cushion or air mattress in place, while another was transferred without protective footwear, contributing to ulcer development. Additionally, practitioner-ordered wound care was not consistently provided or documented for a resident with a foot ulcer.
Staff did not consistently wear required masks during a COVID-19 outbreak, failed to implement Enhanced Barrier Precautions for a resident with a chronic wound, and allowed damaged recliners in a common area to remain in use despite being unable to be fully cleaned, as confirmed by direct observation and staff interviews.
Two residents with significant fall risks and physical impairments were not adequately protected from accidents. One resident experienced a fall during an attempted transfer without proper staff assistance or a thorough post-fall investigation, while another resident was repeatedly observed without access to a call light or bell as required by their care plan, leaving them unable to request help for over an hour.
The facility did not complete required neurological checks after unwitnessed falls for two residents, including one with significant cognitive impairment and another with mobility issues. Additionally, a resident was not provided with PRN bowel medications or monitored for bowel movements as required by facility policy, despite extended periods without a bowel movement. Staff interviews and documentation confirmed these deficiencies.
The facility did not notify the State Agency within the required five working days after a change in the DON, as confirmed by record review and administrator interview. This delay in notification had the potential to impact all residents in the facility.
Staff failed to consistently use Enhanced Barrier Precautions, including gowns and gloves, during high-contact care for residents with wounds, indwelling devices, or MDROs, and did not follow proper hand hygiene or equipment cleaning protocols. Observations included improper cleaning and storage of a CPAP machine, omission of gowns during catheter and toileting care, and failure to perform hand hygiene at required intervals.
Two residents with multiple chronic conditions and cognitive impairment were neither offered nor given the pneumococcal vaccine, and there was no documentation in their medical records to show the vaccine was offered, administered, or declined, as confirmed by facility staff.
A resident with dementia, bladder incontinence, and self-care deficits following a hip fracture did not receive bathing assistance at least weekly as required. Bathing records showed intervals of up to 13 days between baths, despite the resident's dependence on staff for ADLs and the facility's policy to provide bathing services based on individual needs.
The facility did not complete required post-fall assessments and documentation after a resident experienced an unwitnessed fall with injury, and also failed to consistently follow physician's orders for wound care treatments for another resident, with multiple missed or undocumented treatments confirmed by the DON.
Failure to Respond Promptly to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for two residents, resulting in unmet resident needs. For one resident with multiple complex diagnoses, including cerebral infarction, hypertensive heart disease, anxiety disorder, major depressive disorder, muscle weakness, urinary retention, bowel incontinence, and hemiplegia, both interviews and call light logs confirmed repeated delays in staff response. The resident reported that call lights took a long time to be answered, and direct observation showed a call light remaining on for 15 minutes before staff responded. Review of call light logs revealed multiple instances where the call light was left on for extended periods, ranging from 17 to 54 minutes on various dates. Another resident, diagnosed with Parkinson's disease and assessed as cognitively intact, also reported waiting up to half an hour or more for call light responses. Review of this resident's call light event log showed numerous occasions where the call light remained on for periods ranging from 18 to 46 minutes. Both residents' experiences were corroborated by documentation and interviews, confirming that staff did not meet the facility's stated expectation of responding to call lights within 5 minutes. The facility's policy, last revised in August, requires staff to respond to call lights in a timely manner, with the Executive Director and a Registered Nurse both confirming the expectation of a 5-minute response time. Despite this policy, the documented delays in responding to call lights for these two residents demonstrate a failure to meet the established standard of care.
Failure to Implement Pressure Ulcer Prevention and Wound Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions for the prevention of pressure ulcers and did not provide practitioner-ordered wound care for two residents. One resident, who was at moderate to high risk for pressure ulcer development due to limited mobility, incontinence, and cognitive impairment, experienced a decline in skin integrity. Despite worsening Braden Scale scores and the development of a stage 2 pressure ulcer and an unstageable heel ulcer, the care plan was not updated in a timely manner to reflect new interventions. Observations revealed that ordered pressure-relieving devices, such as a Roho cushion and air mattress, were not in place, and heel protectors were only implemented after the heel wound developed. Staff interviews confirmed delays in obtaining and implementing these interventions. Another resident, who had multiple comorbidities and was dependent on staff for transfers and mobility, developed an unstageable pressure ulcer on the left foot related to not wearing appropriate footwear during transfers. The care plan did not include specific interventions addressing the cause of the ulcer, such as the requirement to wear shoes during all transfers. Observations showed that staff continued to transfer the resident using a sit-to-stand lift while the resident wore only socks, and staff interviews confirmed a lack of awareness regarding the need for protective footwear during transfers. The resident also confirmed that staff had not provided instructions to change transfer practices after the ulcer was identified. Additionally, the facility failed to consistently provide and document practitioner-ordered wound care for the resident with the left foot ulcer. Review of treatment records revealed multiple missed wound care treatments on specified dates, and staff interviews confirmed that these treatments were not completed as ordered. The wound nurse acknowledged that wound care was not always documented or performed according to the physician's orders.
Failure to Follow Infection Control Protocols During Outbreak and Inadequate Equipment Maintenance
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies during a COVID-19 outbreak. Despite the facility's policy requiring all staff to wear source control (surgical mask or N-95 respirator) during outbreak status, multiple staff members, including nurse techs, an LPN, and an environmental services tech, were observed in various hallways and resident rooms without masks. This occurred even in areas with confirmed COVID-19 positive residents and in rooms with droplet precautions signage. Interviews with staff and the administrator confirmed that guidance had been provided to wear masks, but compliance was not maintained. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, as required by policy. The resident had an unstageable pressure ulcer and required EBP, including the use of gowns and gloves during high-contact care and appropriate signage outside the room. Observations revealed that no EBP signage was posted, gowns were not available, and staff, including the wound nurse, did not don gowns during wound care. Staff were observed performing wound care without proper PPE and then moving throughout the facility, and interviews confirmed that EBP was not in place as required. Additionally, six recliners in a commons area had vinyl coverings that were peeling away from the armrests and seats, making them unable to be fully cleaned. The Environmental Services Director confirmed that the damaged chairs could not be properly sanitized, increasing the potential for cross contamination in the shared area.
Failure to Prevent Accidents and Ensure Adequate Supervision for Residents at Risk of Falls
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for two residents with significant fall risks and physical impairments. One resident, admitted with multiple diagnoses including infection due to a knee prosthesis, bacteremia, myasthenia gravis, essential tremors, and gait abnormalities, was dependent on staff for transfers and had impaired range of motion. Despite these risks, the resident experienced a fall while attempting to transfer from a recliner to bed. Documentation revealed that staff were aware the resident needed assistance and instructed the resident to wait, but upon returning, found the resident on one knee at the bedside. The incident was not fully investigated, as required by facility policy, with no comprehensive documentation, staff statements, or root cause analysis completed. Progress notes did not reflect the fall, and there was no evidence of a formal review during clinical meetings. Another resident, assessed as severely cognitively impaired and at high risk for falls, required extensive assistance with activities of daily living and had a history of multiple falls. The resident's care plan included interventions such as keeping a call light and bell within reach, frequent rounding, and environmental modifications to reduce fall risk. However, multiple observations showed the resident's bell was consistently out of reach, and at times, the call light was not accessible. Staff confirmed the call light was broken and a work order was supposedly placed, but the Environmental Service Director reported no such work order had been submitted. The resident was left without access to a call light or bell for over an hour, contrary to the care plan interventions. These events demonstrate lapses in both the implementation of individualized fall prevention interventions and the facility's investigative processes following incidents. The lack of thorough documentation, failure to ensure assistive devices were within reach, and incomplete post-fall investigation contributed to the deficiencies identified for both residents.
Failure to Complete Neuro Checks and Bowel Management Interventions
Penalty
Summary
The facility failed to implement required neurological checks following unwitnessed falls for two residents. For one resident with a history of infection, myasthenia gravis, and impaired mobility, neurological checks were ordered after an unwitnessed fall, but several scheduled assessments were missed over multiple days. Documentation confirmed that these checks were not completed as expected, and there was no additional evidence of the assessments being performed. Another resident, who was severely cognitively impaired, required extensive assistance with activities of daily living, and was receiving hospice care, experienced two unwitnessed falls. Record review and staff interviews confirmed that neurological checks were not conducted after either incident, despite facility policy requiring such assessments for unwitnessed falls. Additionally, the facility did not monitor or intervene appropriately for bowel management for the same cognitively impaired resident. Bowel records showed extended periods without a bowel movement, and the Medication Administration Record indicated that no PRN bowel medications were administered during these times. Staff interviews confirmed that the resident should have received PRN bowel medications according to facility policy, but this did not occur.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the State Agency within five working days following a change in the Director of Nursing (DON), as required by licensure regulations. Record review showed that the DON was changed on 9/13/25, but the notification form was not faxed to the Department of Health and Human Services (DHHS) until 9/29/25, exceeding the required timeframe. During an interview, the Administrator confirmed that the notification was not submitted within the mandated five working days. This deficiency had the potential to affect all 68 residents residing in the facility at the time.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) and proper cleaning protocols. Observations revealed that staff did not consistently use gowns and gloves during high-contact care activities for residents who were either colonized or infected with multidrug resistant organisms (MDROs), had wounds, or had indwelling medical devices. For example, during toileting assistance for one resident and catheter care for another, staff either omitted the use of gowns or failed to perform hand hygiene at appropriate intervals. In several instances, staff were unaware of residents' EBP status or did not follow the policy for donning personal protective equipment during high-contact care. Additionally, the facility did not ensure proper cleaning and storage of resident care equipment, such as CPAP machines. Multiple observations showed a resident's CPAP mask and tubing left on the floor or improperly stored, and staff confirmed that cleaning was not performed according to facility policy or CDC guidelines. This failure to clean and store equipment as required increased the risk of cross-contamination and infection. Hand hygiene practices were also not consistently followed. Staff were observed failing to perform hand hygiene before and after glove use, after removing gloves, and between clean and soiled tasks. These lapses occurred during wound care, catheter care, and incontinent care for multiple residents. Interviews with staff and the infection preventionist confirmed that these practices were not in line with facility policy, which requires hand hygiene at specific intervals during resident care.
Failure to Offer or Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide evidence that two residents were up to date with, or had been offered, pneumococcal vaccinations as required by facility policy. According to the policy, all residents should be offered onsite pneumococcal vaccinations annually by October 1. Record review showed that one resident with heart failure, high blood pressure, kidney disease, and moderate cognitive impairment, and another resident with anemia, high blood pressure, diabetes, Alzheimer's disease, dementia, depression, chronic lung disease, and severe cognitive impairment, had not received or been offered the pneumococcal vaccine. There was no documentation in either resident's medical record indicating the vaccine was offered, administered, or declined. Interviews with facility staff confirmed that these residents were not offered the vaccination as required.
Failure to Provide Timely Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide bathing assistance to a resident with dementia, bladder incontinence, and self-care deficits following a recent hip fracture. The resident was dependent on staff for activities of daily living, including bathing, and was unable to bear weight on the left leg. According to the resident's care plan, staff were required to assist with bathing. However, a review of bathing records showed that the resident was not bathed at least weekly, with intervals of up to 13 days between baths. The Director of Nursing confirmed that there was no evidence the resident received bathing assistance at the required frequency, despite the facility's policy to provide bathing services according to individual needs and preferences.
Failure to Complete Post-Fall Assessments and Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate follow-up evaluations and condition assessments after a resident experienced a fall. Specifically, after a resident slipped and fell in their room, initial documentation indicated the resident was alert, denied hitting their head, and had no visible injuries. However, the following morning, red drainage was observed on the resident's right cheek and shirt, which the resident confirmed was related to the fall. Interviews with facility staff, including the DON and Administrator, confirmed that required neurological assessments, vital signs, and post-fall evaluations were not completed or documented as per facility policy, despite the fall being unwitnessed and resulting in an injury. Additionally, the facility did not follow physician's orders for the treatment of a foot ulcer for another resident. Review of the Treatment Administration Record (TAR) over several months revealed multiple instances where wound care treatments were not signed off as completed, and in some cases, treatments were marked as not done due to the resident sleeping, which was confirmed by the DON as not appropriate. The lack of documentation and completion of ordered treatments indicated that staff were not consistently following physician's orders for wound care.
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