Prestige Care Center Of Nebraska City
Inspection history, citations, penalties and survey trends for this long-term care facility in Nebraska City, Nebraska.
- Location
- 1420 North 10th Street, Nebraska City, Nebraska 68410
- CMS Provider Number
- 285109
- Inspections on file
- 25
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Prestige Care Center Of Nebraska City during CMS and state inspections, most recent first.
Surveyors found that the Alzheimer's care unit had a persistent strong urine odor in the hallway over multiple days, confirmed by the DON, a MA, and a NA, while records showed limited deep cleaning of a resident room over several months. Despite a written policy requiring regular cleaning of horizontal surfaces and hard flooring, one room was repeatedly observed with black, brown, and white particles on the bedside table and a brown spot with similar particles on the floor, which a MA confirmed, demonstrating a failure to maintain a clean, odor-free, and homelike environment.
A resident with dysphagia, major depressive disorder, type 2 DM, moderately impaired cognition, significant weight loss, and on mechanically altered foods had an activated medical POA, per facility records. Facility policy required notifying the resident’s representative of significant treatment changes and documenting who was notified. A new physician order directed the resident to be up in a w/c for all meals, with refusals to get up recorded as meal refusals, but there was no documentation over an extended period that the POA was informed. An RN stated an attempt to notify was made but not charted, the family member identified as the contact reported not being notified of the order change, and the IDON confirmed there was no evidence of POA notification.
Surveyors found that a resident on hospice care with multiple cognitive and psychiatric diagnoses received PRN morphine for pain or shortness of breath without documented clinical justification. Facility policy required ongoing review of drug regimens and adequate monitoring for indications and efficacy, and the resident had orders for morphine every 1–2 hours PRN with pain monitoring each shift. However, the MAR showed multiple administrations of morphine with a recorded pain score of zero, and progress notes described behaviors such as restlessness, agitation, pacing, and striking objects or attempting to hit staff without documenting any pain or shortness-of-breath indicators. The IDON confirmed the absence of documented pain or respiratory symptoms at the times morphine was given.
Surveyors found that bathroom exhaust vents in two resident rooms were not functioning, as they did not pull air in, despite facility logs indicating that one of these rooms’ vents had previously been checked and recorded as working. Review of the exhaust fan inspection log showed that only a small number of rooms in each hall were checked monthly over several months, and during an on-site observation and interview, the MD confirmed that the vents in the identified rooms were not operating.
Staff did not consistently perform hand hygiene or change gloves appropriately during care for three residents, including catheter care, perineal care, and wound care. In several instances, staff touched resident belongings, supplies, and clean surfaces with contaminated gloves, changed gloves without hand hygiene, and used items that had fallen on the floor, creating opportunities for cross contamination.
A resident with quadriplegia and multiple medical conditions, fully dependent on staff for hydration, was not provided with adequate assistance or monitoring for fluid intake. Despite a recent hospital visit for dehydration and an order to encourage fluids, staff were unaware of the diagnosis and order, and the care plan lacked a hydration focus. Facility observations confirmed the resident's water pitcher remained full and assistance was only provided during meals, contrary to facility policy.
Facility staff did not notify a pulmonary specialist of medication changes for a resident with COPD, as directed by the primary care provider. The resident refused prescribed antibiotics due to adverse reactions and reported an allergy, but staff failed to communicate these issues to the specialist. The resident eventually contacted the pulmonologist independently, leading to a new prescription.
A resident experienced multiple falls resulting in a wrist fracture, and the facility failed to submit the required five-day written investigation report on time, instead submitting it two days late as confirmed by the RDO.
A resident's comprehensive admission MDS assessment was not completed within the required 14-day timeframe, as facility records showed the assessment was finalized 13 days late, which was confirmed by the Regional Director of Operations.
The facility did not implement new interventions after a resident with severe cognitive impairment experienced multiple falls, and failed to investigate or add preventive measures after another non-ambulatory resident sustained a skin tear. Required incident reporting and care plan updates were not completed, as confirmed by record review, staff interviews, and observation.
A resident with multiple medical conditions and intact cognition reported being hit and experiencing pain. The facility's investigation did not include required staff or resident interviews, and documentation was incomplete, as confirmed by the administrator.
The facility did not send federally required transfer documentation to the receiving health care institution for two residents who were transferred to the hospital after falls. Review of records and interviews with the Administrator confirmed that essential information, such as practitioner contacts, resident status, and care plans, was not provided at the time of transfer.
A resident with severe cognitive impairment and a high risk for falls did not receive all care plan interventions intended to prevent accidents, including the absence of a fall mat, dycem in the wheelchair, a visible reminder sign, and consistent 15-minute safety checks. Staff confirmed these interventions were not in place as required by facility policy.
The facility failed to maintain a clean and safe environment in 17 resident rooms, with issues such as cracked caulking, stained floors, and dust-coated ventilation covers. The Maintenance Director confirmed these concerns, noting no active work orders, indicating a lapse in the maintenance process.
A resident with severe cognitive impairment experienced significant weight loss due to the facility's failure to timely implement nutritional interventions. Despite requests from the resident's POA, there was a delay in ordering and administering a nutritional supplement. The facility's process for monitoring and addressing weight variances was ineffective, leading to continued weight loss.
The facility failed to conduct trauma-based assessments for two residents diagnosed with PTSD. One resident with severe cognitive impairment did not receive a PTSD assessment, and another resident's care plan lacked PTSD-related information despite receiving medication for the condition. The absence of trauma-informed care assessments was confirmed by facility staff.
The facility failed to implement practitioner's orders for medications, lab tests, and weight monitoring for two residents. One resident with congestive heart failure had inconsistent weight documentation and unimplemented orders for Zaroxlyn and a lab test. Another resident with heart failure and kidney disease had incomplete weight monitoring, despite orders. The facility's procedures for processing orders were not effectively followed, leading to these deficiencies.
A resident with congestive heart failure experienced a 6 lbs weight gain over four days, but the facility staff failed to notify the practitioner as required. The resident's care plan included daily weight monitoring, yet weights were not recorded for three days, and the practitioner was not informed of the significant weight change. Communication records showed that requested updates were not provided, contrary to facility policy.
Persistent Odor and Inadequate Cleaning in Alzheimer's Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in the Alzheimer's care unit by not preventing persistent urine odors in the hallway and not ensuring routine cleaning of a resident room. Record review showed that the Alzheimer's unit had 12 occupied beds, and the deep cleaning schedule indicated that one resident's room was deep cleaned only once in January, with no deep cleaning scheduled for February and the next deep cleaning not planned until the second Wednesday in March. On three separate observations on 03/02/2026, 03/04/2026, and 03/05/2026, surveyors noted a strong urine odor in the hallway of the Alzheimer's care unit. The DON/RN, a medication aide, and a nursing assistant each confirmed the presence of the urine odor during interviews on those dates. The facility's Routine Cleaning and Disinfection policy, revised 12/2025, required that horizontal surfaces with infrequent hand contact, such as window sills and hard surface flooring in routine resident-care areas, be cleaned on a regular basis, when soiling and spills occur, and when a resident is discharged. Despite this policy, observations of one resident room on 03/02/2026 and again on 03/03/2025 revealed black, brown, and white particles on the bedside table and a brown spot with white and brown particles on the floor. During the 03/03/2025 observation, a medication aide confirmed the presence of these particles and the brown spot on the floor, indicating that the room had not been cleaned in accordance with the facility’s stated cleaning and disinfection procedures.
Failure to Notify Medical POA of New Physician Order and Care Plan Change
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s activated medical power of attorney (POA) of a new physician order and change in the plan of care. Facility policy on Change of Condition, revised 09/2025, required nursing staff to notify the resident’s attending physician and family or representative of changes in medication or treatment, significant alterations in medical treatment, and to document in the record who was notified and any new orders. The resident, admitted on 02/28/2025, had diagnoses including dysphagia, major depressive disorder, and type 2 diabetes mellitus, and an annual MDS showing moderately impaired cognition (BIMS score of 11), need for partial assistance with eating, significant weight loss, and receipt of mechanically altered foods. The resident’s durable health care POA, effective immediately upon signing on 12/02/2025, was documented as invoked in the comprehensive care plan. Record review showed a physician order dated 01/01/2026 directing that the resident be up in a wheelchair for all meals, and that if the resident refused to get up, this would be charted as refusing meals. From 01/01/2026 to 03/02/2026, there was no documentation in the progress notes that the POA was notified of this new order. An RN reported attempting to notify the POA but stated they probably did not document the attempt in the progress notes. The resident’s family member, identified as the point of contact for order changes and communication, reported they were not contacted or notified of the new order regarding being out of bed for all meals and having refusals considered meal refusals. The Interim DON confirmed there was no evidence that the POA was notified of the new physician order and acknowledged that the POA should have been notified.
Failure to Document Pain Indicators for PRN Opioid Use
Penalty
Summary
Surveyors identified a deficiency related to unnecessary drugs when staff failed to document signs and symptoms of pain to justify the continued PRN use of opioid pain medication for one resident. Facility policy on unnecessary drugs required the attending physician to lead medication management and for each resident’s drug regimen to be reviewed on an ongoing basis, including indications, clinical need, and adequate monitoring for efficacy and adverse consequences. The resident, who had dementia, metabolic encephalopathy, schizoaffective disorder, and major depressive disorder, was admitted to hospice and had active orders for morphine solution 10 mg by mouth/sublingually every 1–2 hours PRN for pain or shortness of breath, along with an order to monitor pain every shift. The comprehensive care plan included an intervention to administer all medications as ordered. Record review of the resident’s MAR showed morphine was administered multiple times with a documented pain rating of zero, despite the order requiring a pain evaluation for administration. On several occasions, progress notes documented behaviors such as restlessness, agitation, pacing, pushing chairs, sitting on another resident’s bed, refusing cues, being “everywhere,” hitting tables with a walker, and attempting to hit staff, but did not document any indicators of pain or shortness of breath. Additional administrations of morphine were recorded with no accompanying documentation of pain or shortness of breath, including doses given late at night and one dose given specifically for restlessness without pain indicators. The Interim DON confirmed that the MAR reflected a pain rating of zero at the time of morphine administration and that there were no documented indicators of pain or shortness of breath in the progress notes.
Nonfunctioning Bathroom Exhaust Vents in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of adequate outside ventilation in resident bathrooms, as required by licensure regulation 175 NAC 12-007.04(D). Review of the facility’s “Exhaust Fan Annual Inspection Log For All Resident Room Restrooms Throughout Facility” dated from 10/15/2025 through 2/10/2026 showed that only three rooms per month were checked in various halls, and that one of the affected rooms in the 300 hall had been checked in December and logged as working. However, during observation on 03/02/2026 at 1:00 PM, the bathroom exhaust vents in two sampled rooms (one in the 300 hall and room 325) were found not to be functioning, as they did not pull air in. In a subsequent observation and interview on 03/03/2025 at 12:25 PM, the Maintenance Director confirmed that the bathroom vents in these rooms were not functioning and were not pulling air in. No information was provided in the report about the medical conditions or histories of the residents occupying the affected rooms at the time of the deficiency.
Failure to Perform Proper Hand Hygiene and Gloving During Resident Care
Penalty
Summary
Staff failed to perform proper hand hygiene and gloving procedures during care for three residents, as observed and documented in the facility. The facility's policies required hand hygiene before and after glove use, after contact with potentially contaminated surfaces, and between clean and soiled tasks. However, multiple instances were observed where staff did not follow these protocols, leading to opportunities for cross contamination. For one resident with quadriplegia and multiple complex medical conditions, a registered nurse and a nurse aide provided catheter and perineal care. During the procedure, the nurse touched various surfaces and assisted the resident with a drink without changing gloves or using hand sanitizer between tasks. The nurse also handled supplies and resident belongings with contaminated gloves, and only performed hand hygiene at the end of the procedure. The nurse confirmed during an interview that these actions could have led to cross contamination. In another case, two nurse aides provided perineal care to a resident with heart failure, diabetes, and other chronic conditions. One aide changed gloves without performing hand hygiene and used a brief that had fallen on the floor, placing it under the resident. The aide acknowledged these actions could have resulted in bacterial contamination. Additionally, during wound care for a resident with Parkinson's disease and suspected MRSA, a nurse donned gloves without hand hygiene, touched the light switch and other surfaces, and moved between clean and soiled areas without sanitizing hands. The nurse confirmed these lapses in infection control during an interview.
Failure to Prevent Dehydration in Dependent Resident
Penalty
Summary
The facility failed to prevent dehydration for a resident who was dependent on staff for all care due to quadriplegia and other significant medical conditions, including autonomic dysreflexia, neuromuscular bladder dysfunction, acute cystitis with hematuria, and moderate protein calorie malnutrition. The resident was cognitively intact but unable to independently access fluids due to physical limitations, requiring assistance for all eating and drinking needs. Despite these needs, the care plan did not include a focus area for hydration, and there were no orders to monitor fluid intake and output or to observe for signs and symptoms of dehydration. The resident was sent to the emergency room with a high fever and dark, cloudy urine, where they were diagnosed with a urinary tract infection and dehydration, and received intravenous fluids. Upon return to the facility, the after-visit summary included an order to encourage increased fluid intake, which was acknowledged by a facility nurse. However, this order was not implemented, as there were no subsequent orders or documentation to monitor the resident's hydration status or fluid intake and output. Observations confirmed that the resident's water pitcher remained full throughout the day, and the resident reported receiving assistance with fluids only during meals, with no routine staff visits to help with drinking. Interviews with the DON and nursing staff revealed they were unaware of the dehydration diagnosis and the order to push fluids, and confirmed that the expected monitoring and assistance were not provided. The facility's own hydration policy, which requires systematic assessment, monitoring, and documentation of hydration status, was not followed for this resident.
Failure to Notify Pulmonary Specialist of Medication Changes
Penalty
Summary
Facility staff failed to notify a resident's pulmonary specialist of medication changes as directed by the primary care provider. The resident, who had chronic obstructive pulmonary disease (COPD) and a history of antibiotic resistance, was admitted with intact cognition and had recently experienced increased shortness of breath and a productive cough. The primary care provider ordered doxycycline and other medications for a suspected COPD exacerbation, but the resident repeatedly refused the antibiotic, citing adverse reactions and later reporting an allergy. Despite the resident's requests and the primary care provider's explicit direction to notify the pulmonary specialist, facility records and electronic health records showed no evidence that the pulmonary specialist was contacted by staff regarding the medication changes or the resident's refusals. Communication logs indicated that the APRN repeatedly asked if the pulmonary specialist had been notified and if there was any response, but staff reported no contact or response from the specialist. The resident ultimately contacted the pulmonologist independently, resulting in a new prescription being faxed to the facility. The deficiency was identified through record review and interviews, which confirmed that the facility did not follow its own policy requiring notification of changes in treatment to the appropriate physician or specialist. The lack of timely communication with the pulmonary specialist occurred despite clear instructions from the primary care provider and ongoing documentation of the resident's medication refusals and reported allergy.
Late Submission of Five-Day Written Investigation Report Following Resident Falls
Penalty
Summary
The facility failed to complete and submit a five-day written investigation report regarding an allegation of potential neglect for one resident. The facility's policy requires the administrator or designee to report the results of an investigation within five working days of an incident. Record review showed that a resident experienced multiple falls over several days, resulting in a right wrist fracture. Documentation indicated that the resident was found on the floor, had been using a cane instead of a walker, and was not wearing non-skid socks. Although assessments were completed and the interdisciplinary team reviewed the falls, the facility submitted the required five-day written report two days late, on the seventh day after the incident, rather than within the mandated five-day period. This delay was confirmed by the Regional Director of Operations.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive admission Minimum Data Set (MDS) assessment within the required 14-day timeframe for one resident. According to facility policy and the MDS User's Manual, the admission MDS must be completed no later than the 14th calendar day after admission, except in certain readmission scenarios. Record review showed that a resident was admitted on 9/9/2025, but the admission MDS was not signed as completed until 10/11/2025, which was 13 days past the required deadline. This was confirmed by the Regional Director of Operations during an interview.
Failure to Implement and Update Interventions for Falls and Skin Tears
Penalty
Summary
The facility failed to implement new interventions to prevent falls for a resident with severe cognitive impairment and multiple risk factors, despite the occurrence of three falls within a short period. The resident, who had diagnoses including Alzheimer's disease, dementia, unsteadiness, and difficulty walking, required supervision and assistance for mobility. The care plan listed several fall prevention interventions, but after the resident experienced multiple falls, no new interventions were added, and the existing interventions were simply repeated. Observations confirmed that some interventions, such as the use of a wheelchair, were not consistently in place, and staff interviews revealed that a wheelchair was not regularly used or available for the resident. Additionally, the facility did not investigate or implement interventions to prevent further skin tears for another resident who was non-ambulatory, dependent on staff for care, and receiving anticoagulant therapy. After the resident sustained a skin tear to the forearm, staff provided immediate wound care but did not complete an incident report or update the care plan with new interventions to prevent recurrence. The facility's policy required incident reporting and the implementation of preventive measures based on assessment, but these steps were not followed. Interviews with facility leadership confirmed that required post-incident assessments, care plan updates, and preventive interventions were not completed for either resident following their respective incidents. The failures were identified through record review, staff interviews, and direct observation, demonstrating noncompliance with facility policies and regulatory requirements for accident prevention and skin integrity management.
Failure to Complete Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse made by a resident. According to the facility's abuse policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying responsible staff, interviewing all involved parties, and documenting the process. In this case, a resident reported pain under the right breast and stated that someone had hit them, prompting an assessment by a licensed nurse, which found no visible injury. However, the subsequent investigation did not include interviews with staff or other residents, and there was a lack of documentation regarding these critical steps. The resident involved had a history of chronic obstructive pulmonary disease, schizophrenia, and osteoporosis, and was assessed as cognitively intact with a BIMS score of 13/15. The resident also exhibited some behavioral symptoms according to recent assessments. The facility administrator confirmed that the investigation was incomplete, as required interviews and documentation were not performed, resulting in a failure to meet regulatory requirements for responding to alleged violations.
Failure to Provide Required Transfer Documentation to Receiving Facility
Penalty
Summary
The facility failed to provide federally required transfer documentation to the receiving health care institution for two of three sampled residents. According to the facility's own policy, when a resident is transferred to another provider, specific information must be sent, including practitioner contact information, resident representative details, advance directives, current status, diagnoses, medications, recent labs, special instructions, and the resident's care plan goals. For both residents in question, record reviews showed that after each sustained a fall and was transferred to the hospital for evaluation and treatment, there was no evidence in the electronic health record or scanned documents that the required transfer information was sent to the hospital. Interviews with the facility Administrator confirmed that the necessary documentation was not provided at the time of transfer for either resident. The deficiency was identified through review of progress notes, assessments, and other records, which lacked the federally mandated information transfer. The facility's failure to send this information was acknowledged by the Administrator during the surveyor's interview.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement required fall prevention interventions for a resident identified as high risk for falls. The resident had multiple diagnoses, including neurocognitive disorder with Lewy bodies, Parkinson's disease, dementia, a history of falling, osteoarthritis of the right shoulder, and difficulty walking. The resident's assessments indicated severe cognitive impairment and a high risk for falls, with care plan interventions specifically outlined to address these risks. Despite the care plan listing several interventions such as the use of a fall mat, dycem in the wheelchair, a visible sign reminding the resident to call for assistance, and 15-minute safety checks, these were not consistently implemented. Observations revealed the absence of a fall mat at the bedside, no dycem in the wheelchair, and no sign displayed in the resident's room. Additionally, review of the 15-minute check documentation showed missing or incomplete records on several dates, indicating lapses in the required monitoring. Interviews with staff confirmed that the interventions listed in the care plan were not in place at the time of observation. The facility's policy required individualized interventions based on risk assessments and ongoing monitoring for effectiveness, but these were not fully carried out for the resident in question. The administrator confirmed that care plan interventions are expected to be implemented, yet several were not, resulting in a deficiency related to accident hazard prevention and supervision.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple environmental concerns observed in 17 out of 28 occupied resident rooms. These concerns included cracked and broken caulking around toilets, stained and brown areas around toilet bases and on linoleum, pulled away baseboards, scraped drywall and wood on doors, and dust-coated ventilation covers. Additionally, some bathroom doors would not close, carpets were stained, and caulking between sinks and walls was cracked, with sinks pulled away from walls. Fall stop strips were also pulled away from the floor, creating non-cleanable surfaces, and there were holes in the brick around electrical outlets and loose transition strips covered with duct tape. During an environmental tour with the Maintenance Director, these issues were confirmed, and it was noted that there were no active work orders for the identified concerns. The facility's assessment indicated that all rooms are inspected monthly by the Maintenance Director, and issues are supposed to be reported and addressed through the TELS system or verbally. However, the lack of active work orders suggests a failure in the reporting and maintenance process, leading to the persistence of these environmental deficiencies.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility failed to initiate timely interventions to prevent further weight loss for a resident with severe mental cognition impairment. The resident was admitted with a weight of 171 pounds and experienced a significant weight loss over a short period. Despite the resident's Power of Attorney (POA) requesting a nutritional supplement, there was a delay in ordering and administering the supplement, resulting in continued weight loss. The resident's care plan initially indicated a goal for meal and supplement consumption, but no new interventions were added when weight loss was noted. The facility's process for monitoring weights involved alerts for weight variances, but the Registered Dietician's (RD) recommendations for nutritional supplements were not promptly implemented. The RD's recommendations were delayed in being communicated to the physician and subsequently entered into the electronic medical record. Interviews with facility staff revealed systemic issues in the communication and implementation of nutritional interventions. The Director of Nursing (DON) and Corporate Nurse (CN) acknowledged delays in addressing the resident's nutritional needs, and the facility's process for handling weight variances was identified as a contributing factor to the deficiency. The facility's Nutrition Policy outlined responsibilities for maintaining residents' body weight, but these were not effectively executed in this case.
Failure to Conduct Trauma-Based Assessments for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-based assessments for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). Resident 24, who was admitted with a diagnosis of PTSD, had severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3. Despite this, the facility did not conduct a PTSD/trauma assessment for Resident 24, as confirmed by both the Corporate Nurse and the Social Service Director during interviews. This lack of assessment was noted despite the resident's active diagnosis of PTSD. Similarly, Resident 34, who was also admitted with a diagnosis of PTSD, did not have a trauma-informed care assessment conducted prior to the survey date. The resident's care plan, last revised in August 2024, lacked any information related to PTSD, even though the resident was receiving medication for the condition. The Social Service Director confirmed the absence of a trauma-informed care assessment for Resident 34 before the survey, highlighting a deficiency in the facility's approach to trauma-informed care for residents with PTSD.
Failure to Implement Practitioner's Orders for Medications and Weight Monitoring
Penalty
Summary
The facility staff failed to implement practitioner's orders for medications, laboratory testing, and weight monitoring for two residents. Resident 3, diagnosed with congestive heart failure, had orders for daily weights, which were inconsistently recorded. Despite having multiple orders for weight monitoring, several days in August 2024 lacked documented weights. Additionally, orders for Zaroxlyn and a Basic Metabolic Panel were not implemented, even after significant weight gain and worsening symptoms were reported to practitioners. Resident 1, with a history of heart failure and chronic kidney disease, also had orders for daily weight monitoring. However, the resident's MAR indicated that weights were not consistently recorded, with several instances of refusal or other codes noted. The facility's administrator confirmed that the daily weights for Resident 1 had not been completed as required, despite being checked off in the MAR. The facility's policy for using the Tele Doc application was reviewed, which outlined procedures for contacting providers and processing orders. However, the failure to implement orders for both residents suggests a breakdown in following these procedures. The administrator acknowledged the lack of documentation and completion of required orders, highlighting a deficiency in ensuring that practitioner's orders were consistently followed and documented.
Failure to Notify Practitioner of Resident's Weight Gain
Penalty
Summary
The facility staff failed to notify a resident's practitioner of a significant change in the resident's condition, specifically a weight gain of 6 lbs over a four-day period. The resident, who was admitted with a diagnosis of congestive heart failure, had an order for daily weight monitoring as part of their care plan. However, the electronic medical record did not show any weights recorded for three consecutive days, and there was no documentation of the practitioner being informed of the weight increase. Additionally, communication records indicated that the practitioner had requested updates on the resident's condition, which were not provided as requested. The facility's policy requires notifying the physician of significant changes in a resident's condition, such as a weight increase of over 5 lbs, which was not adhered to in this case. The administrator confirmed the expectation that the practitioner should have been notified of the weight gain and updated on the resident's condition as requested.
Latest citations in Nebraska
Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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