Emerald Nursing & Rehab Legacy Pointe llc
For profit - Limited Liability company
108 Beds
EMERALD HEALTHCARE
Data: November 2025
Trust Grade
30/100
#146 of 177 in NE
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Emerald Nursing & Rehab Legacy Pointe in Omaha, Nebraska has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranked #146 out of 177 facilities in Nebraska, they are in the bottom half overall and #18 of 23 in Douglas County, meaning there are only a few local options that perform better. The facility's situation is worsening, with the number of issues increasing from 7 in 2024 to 14 in 2025. Staffing is rated below average at 2 out of 5 stars, with a turnover rate of 42%, which is slightly better than the state average but still concerning. Additionally, the facility has accumulated $60,671 in fines, which is higher than 94% of Nebraska facilities, suggesting ongoing compliance problems. Recent inspection findings revealed serious issues, such as a failure to properly sanitize dishes and maintain food safety standards, putting residents at risk of foodborne illness. They also did not follow a plan to prevent Legionella growth, which could lead to serious health risks. While there is some RN coverage, it is below average compared to most facilities in Nebraska, meaning that residents may not receive the level of attention needed for early problem detection. Overall, families should weigh these serious concerns against any strengths when considering this facility for their loved ones.
- Trust Score
- F
- In Nebraska
- #146/177
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 42% turnover. Near Nebraska's 48% average. Typical for the industry.
- Penalties ○ Average
- $60,671 in fines. Higher than 64% of Nebraska facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 25 minutes of Registered Nurse (RN) attention daily — below average for Nebraska. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
30/100
Bottom 18%
Needs review
7 → 14 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 14 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (42%)
6 points below Nebraska average of 48%
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Nebraska average (2.9)
Significant quality concerns identified by CMS
Staff Turnover: 42%
Near Nebraska avg (46%)
Typical for the industry
Federal Fines: $60,671
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: EMERALD HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
Jul 2025
14 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Nebraska Licensure Reference 175 NAC 12-006.05(E)Based on interview and record review, the facility failed to evaluate resident food preferences related to religious beliefs for 1 (Resident 20) of 1 s...
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Nebraska Licensure Reference 175 NAC 12-006.05(E)Based on interview and record review, the facility failed to evaluate resident food preferences related to religious beliefs for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 63.The findings are:An interview on 7-16-2025 at 10:32 AM with Resident 20 revealed [gender] does not eat pork due to Seventh Day Adventist beliefs and revealed the facility staff offer meals containing pork.An interview on 7-17-2025 at 1:59 PM with the Food Services Director (FSD) revealed the facility performed a food preferences interview at the time of admission and the results of that interview are recorded on the resident's tray card. The FSD confirmed Resident 20's dietary preferences were not listed on the tray card.A record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified Resident 20 had diagnoses which included chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), diabetes mellitus (DM) type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), heart failure, and major depressive disorder a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 20's Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4-21-2025 identified Resident 20 found religious services or practices somewhat important. Further review of the MDS revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score for Resident 20 was not assessed.Record review of Resident 20's Physician's Orders printed 7-17-2025 revealed a controlled carbohydrates diet (CCHO, low concentrated sweets) with a regular texture and thin fluids.Record review of Resident 20's Social Services Quarterly Data Collection dated 4-22-2025 identified religious preference of Seventh Day Adventist.Record review of Resident 20's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed no interventions related to Resident 20's religious preferences.Record review of Resident 20's Tray Card dated 7-17-2025 revealed a CCHO diet with a regular texture. The tray card did not include the resident's religious dietary preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview the facility failed to notify the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)Based on record review and interview the facility failed to notify the resident's practitioner of omitting the administration of insulin for 3 (Residents 5, 31, and 39) of 3 residents sampled. The facility census was 63. The findings are:
A.
Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident:
-Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact.
-had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus.
-was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood).
-was receiving insulin injections.
-required partial assistance with toileting, bathing, dressing and transfers.
Record review of the facility policy titled Notification of Changes Policy revealed the following:
-it is the policy of this facility that changes in a resident’s condition or treatment are immediately shared with the resident and/or resident representative and reported to the attending physician or delegate.
-the objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician when there is a change in the resident’s condition.
-requirements for physician notification include a need to alter treatment such as a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.
Record review of Resident 5’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed on 06-30-2025(a Monday) at 12:00PM the facility staff documented OF (Out of Facility) for the administration for of the Lispro insulin at 12:00 PM because Resident 5 was at dialysis.
Record review of Resident 5’s MAR for July 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00PM the facility staff documented OF on the following dates:
-07-02-2025(Wednesday),
-07-04-2025 (Friday),
-07-07-2025 (Monday),
-07-09-2025 (Wednesday),
-07-11-2025 (Friday),
-07-14-2025 (Monday)
-07-16-2025 (Wednesday).
An interview conducted on 07-17-2025 at 2:46 PM with the Agency Nurse (AN) G for the [NAME] Wing of the facility revealed (gender) was unaware of who was responsible to administer insulin while residents were out of the facility for dialysis. Furthermore, AN revealed the resident’s practitioner should be notified any time insulin is not given.
An interview conducted on 07-17-2025 at 2:50 PM with Licensed Practical Nurse (LPN) H for the East Wing of the facility revealed (gender) was unaware of any residents with orders for insulin to be administered while residents were out of the facility for dialysis, and confirmed the resident’s practitioner should be notified if a dose of insulin was missed for any reason.
B.
Record review of Resident 39’s MDS dated [DATE] revealed the facility staff assessed the following about the resident:
-BIMS was scored at an 11. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment.
-had a diagnosis of ESRD and Diabetes Mellitus.
-was receiving hemodialysis.
-was receiving insulin injections.
-required substantial assistance with upper body dressing and bathing.
-required total assistance with toileting, lower body dressing, bed mobility and transfers.
Record review of Resident 39’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed an OF was documented at 12:00PM on the following dates:
-06-02-2025 (Monday)
-06-03-2025 (Tuesday)
-06-04-2025 (Wednesday)
-06-13-2025 (Friday)
-06-16-2025 (Monday)
-06-18-2025 (Wednesday)
-06-20-2025 (Friday)
-06-23-2025 (Monday)
-06-25-2025 (Wednesday)
-06-27-2025 (Friday)
-06-30-2025 (Monday)
Record review of Resident 39’s MAR for July 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00PM the facility staff documented OF on the following dates:
-07-02-2025(Wednesday),
-07-04-2025 (Friday),
-07-07-2025 (Monday),
-07-09-2025 (Wednesday),
-07-11-2025 (Friday),
-07-14-2025 (Monday)
-07-16-2025 Wednesday.
An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed OF on the MAR meant the resident was not given the medication because the resident was out of the facility and the facility staff did not notify Resident 5’s practitioner that the Lispro Insulin at 12:00 PM was not given on dialysis days.
An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed the facility staff did not notify Resident 39’s practitioner that the Lispro Insulin at 12:00 PM was no given on dialysis days.
C.
Record review of Resident 31's Order Summary Report on 7/17/25 revealed Resident 31 admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Ischemic Cardiomyopathy, Chronic Kidney Disease Stage 5, End Stage Renal (Kidney) Disease, Type 2 Diabetes Mellitus with other Diabetic Kidney Complication, Dependence on Renal Dialysis.
Record review of Resident 31's Electronic Medication Administration Record (MAR) for July 2025 revealed a practitioner's order for Lispro Insulin, inject 13 units daily before breakfast related to diagnosis of Type 2 Diabetes Mellitus. Further review of July 2025 MAR's for Resident 31 revealed OF (indicating resident is out of facility) on July 2,4,11,14,16. The review further of Resident 31's medical record revealed the facility staff did not notify the practitioner of omitted (not given) insulin orders on days the resident went to dialysis. Resident 31 has dialysis every Monday, Wednesday, and Friday.
An Interview on 07/17/2025 3:58 PM The Infection Preventionist (IP) confirmed, Resident 31 had not received scheduled insulin and the Medical Provider had not been notified of the omitted (not given) insulin on dialysis days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.05Based on record review and interview, the facility failed to provide notice of transfer in writing to the resident or resident's representative for 2 (Resid...
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Licensure Reference Number 175 NAC 12-006.05Based on record review and interview, the facility failed to provide notice of transfer in writing to the resident or resident's representative for 2 (Resident 20 & 64) of 4 residents sampled. The facility staff identified a census of 63.The findings are:Record review of facility policy entitled Transfer and Discharge from the Facility dated 1-2024 revealed: -The facility will provide proper and timely notice to a resident who will be discharged as required by regulations and laws. -C. Contents of the notice: -Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language in which is understood. -At a minimum the notice will include: -a. The reason for transfer/discharge -b. The effective date of the transfer/dischargeA.A record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified Resident 20 had diagnoses which included chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway obstruction resulting in a slowed rate of exhalation), diabetes mellitus (DM) type 2 (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia (high blood sugar) resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), heart failure, and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).A record review of Resident 20's Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) dated 4-21-2025 revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score for Resident 20 was not assessed.A record review of Resident 20's Change in Condition Evaluation dated 5-6-2025 revealed the resident experienced abdominal pain, diarrhea, and was tired, weak, confused, or drowsy.A record review of Resident 20's Progress Notes (PN) dated 5-6-25 showed the facility transferred the resident to an emergency department due to chronic diarrhea and abdominal pain.A record review of Resident 20's Bed Hold/Therapeutic Leave Form (BHTLF) showed the resident wished to bed hold with the hold beginning on 5-6-2025. There was no reason for transfer listed on the form.Further review of Resident 20's electronic health record (EHR), including progress notes and scanned documents, revealed there was no notice of transfer in writing to the resident or resident representative.An interview on 7-22-2025 at 9:36 AM with the Director of Nursing (DON) confirmed the facility did not provide the resident or resident's representative with the reason for transfer in writing and should have.B.A record review of Resident 64's admission Record printed 7-21-2025 revealed the facility admitted the resident on 2-20-2019 and identified Resident 64 had diagnoses which included hemiplegia (total or partial paralysis on one side of the body that results from disease or injury to the motor centers of the brain) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body), systemic inflammatory response syndrome (SIRS, a severe systemic response to a condition [such as trauma, an infection, or a burn] that provokes an acute inflammatory reaction indicated by the presence of two or more of a group of symptoms including abnormally increased or decreased body temperature, heart rate greater than 90 beats per minute, respiratory rate greater than 20 breaths per minute or a reduced concentration of carbon dioxide in the arterial blood, and the white blood cell count greatly decreased or increased), and COPD.A record review of Resident 64's Discharge MDS identified the resident was transferred to the hospital on 5-13-2025 and was expected to return to the facility. Further review of the MDS identified the resident had intact short-term memory and had severely impaired skills for daily decision making.A record review of Resident 64's BHTLF showed the resident wished to bed hold with the hold beginning on 5-12-2025. There was no reason for transfer listed on the form.Further review of Resident 64's electronic health record (EHR), including progress notes and scanned documents, revealed there was no notice of transfer in writing to the resident or resident representative.An interview on 7-21-2025 at 7:56 AM with the DON confirmed the facility transferred the resident to the hospital on 5-13-2025.An interview on 7-22-2025 at 9:36 AM with the DON confirmed the facility did not provide the resident or resident's representative with the reason for transfer in writing and should have.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observation, interview and record review the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The ...
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Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observation, interview and record review the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The facility census was 63. The findings are:Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation and interview the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The facility census was 63. The findings are:Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-11-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 4. According to the MDS Manual a BIMS score of 0-7 indicates severe cognitive impairment. -had quadriplegia (a condition characterized by paralysis of all 4 limbs and torso).-required total assistance with eating, hygiene, dressing, toileting, bathing, transfers and bed mobility. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 03-06-2024 revealed Resident 2 had a functional deficit with activities of daily living (ADL) due to quadriplegia. The CCP also indicated Resident 2 was dependent on staff for personal hygiene.An observation on 07-21-2025 at 6:15 AM revealed Resident 2 revealed fingernails on both hands were approximately 1 centimeter in length. An observation was conducted on 07-22-2025 at 6:30 AM with Nursing Assistant (NA) A providing care for Resident 2 revealed fingernails to both hands were long. During the observation an interview was conducted with NA A which confirmed Resident 2's fingernails were long and revealed Resident 2 was scheduled for a bath and the bath aid would trim the fingernails. An interview was conducted with NA B on 07-22-2025 at 9:00 AM revealed NA B had given Resident 2 a shower earlier that morning. An observation on 07-22-2025 at 9:30 AM revealed Resident 2 had returned from the bath house and the fingernails had not been trimmed. An interview with the Director of Nursing (DON) on 07-22-2025 confirmed nail care was provided with showers. An observation of Resident 2 with NA B on 07-22-2025 at 9:40 AM revealed Resident 2's fingernails were not trimmed. An interview was conducted with NA B during the observation which confirmed Resident 2's fingernails were long and confirmed fingernails were not trimmed during the bath. During the interview with NA B about the length of the fingernails, Resident 2 clearly stated cut them.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(vi)(2). Based on observation, interview and record review the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(vi)(2). Based on observation, interview and record review the facility failed to implement an individualized activity program for Resident 5. The findings are: Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a BIMS score of 13 to 15 indicates a person is cognitively intact. -had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus. -was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood).-required partial assistance with toileting, bathing, dressing and transfers. An interview conducted on 07-16-2025 at 9:45 AM with Resident 5 revealed Resident 5 had recently started going to dialysis on Mondays, Wednesdays and Fridays and does not return to the facility until around 4:00 PM. Resident 5 also reports there are no activities offered in the evening or on the weekends. Record review of the facility activity calendar for July 2025 revealed no activities scheduled in the evening or on the weekends. Record review of Resident 5's Electronic Health Record (EHR) under Clinical Census revealed resident was on hospital leave from 06-13-2025 to 06-26-2025. Record review of Resident 5's Progress Note (PN) dated 06-27-2025 revealed Resident 5 returned to the facility from the hospital and would be going to dialysis 3 days a week. Record review of Resident 5's Activities readmission Data Collection (ARDC) dated 06-30-2025 revealed Resident 5's recreational interests included animals/pets, arts/crafts, bingo, family/friend visits, movies, music, and special events. The ARDC also indicated Resident 5 preferred to have activities 2-5 times a week. Record review of Resident 5's Comprehensive Care Plan (CCP) dated 11-09-2023 revealed Resident 5 was dependent on staff with activity participation, would express satisfaction with the type of activities and level of activity involvement when asked through the review date. The CCP also indicated to provide Resident 5 with materials for individual activities as desired. The resident likes the following independent activities: coloring and family visits. Record review of Resident 5's EHR revealed Resident 5 actively participated in activities on 06-06-2025, 06-10-2025 and 06-11-2025 for the month of June and no participation in activities was documented for July 2025. An interview with the Administrator (ADM) on 07-2025 at 12:33 PM confirmed Resident 5 did not participate in any activities since readmission on [DATE] and confirmed the activity calendar did not indicate any activities in the evenings or on weekends.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Nebraska Licensure Reference 175 NAC 12-006.09(H)(iv)(5)Based on interview and record review, the facility failed to evaluate bowel function and failed to implement interventions to manage bowel funct...
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Nebraska Licensure Reference 175 NAC 12-006.09(H)(iv)(5)Based on interview and record review, the facility failed to evaluate bowel function and failed to implement interventions to manage bowel function for 1 (Resident 8) of 5 sampled residents. The facility staff identified a census of 63.The findings are:Record review of Resident 8's admission Record printed 7-21-2025 revealed the facility admitted the resident on 6-21-2021 and identified Resident 8 had diagnoses which included dementia with behavioral disturbance (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia [a language disorder that affects a person's ability to communicate], and the inability to plan and initiate complex behavior), hypertension (high blood pressure), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 8's quarterly Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 6-25-2025 revealed the facility staff assessed the resident to have a short-term and long-term memory problem. Further review of the MDS identified the resident was dependent upon staff for assistance with toileting.Record review of Resident 8's Physician's Orders dated 7-21-2025 revealed bowel management orders which included PEG3350 (polyethylene glycol, an osmotic laxative medication that works by drawing water into the colon which softens the tool and makes it easier to pass) to be administered daily for constipation and Senexon-S (a combination of stimulant laxative and stool softener) to be administered twice daily as needed (PRN) for constipation.Record review of Resident 8's Bowel Elimination POC Response History from 6-22-2025 through 7-21-2025 revealed the response No Bowel Movement was recorded on each of the following six consecutive dates: 7-12-2025, 7-13-2025, 7-14-2025, 7-15-2025, 7-16-2025, and 7-17-2025.Record review of Resident 8's Electronic Medication Administration Record (eMAR) dated July 2025 revealed the resident was administered polyethylene glycol daily as ordered. Further review of Resident 8's July 2025 eMAR revealed the Senexon-S medication was not administered at any time in the month of July including from 7-12-2025 through 7-17-2025.Further review of Resident 8's Electronic Medical Record (EMR) including progress notes, forms, and scanned documents showed neither a record of administration of PRN Senexon-S, nor an evaluation of the resident's bowel function.Record review of Resident 8's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) showed no interventions for constipation.An interview on 7-22-2025 at 11:55 AM with the Unit Manager (UM) confirmed Resident 8 had not had a bowel movement for six consecutive days from 7-12-2025 through 7-17-2025. The UM further confirmed there was no documentation of an assessment being performed and no documentation of the PRN laxative being administered. An interview on 7-22-2025 at 1:30 PM with the Director of Nursing (DON) revealed the facility has no policy on bowel and bladder elimination. The DON further revealed that when a resident has had no bowel movement for six consecutive days, facility staff should utilize PRN laxative medications if available, perform an evaluation of the resident's bowel function, or notify the provider.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Nebraska Licensure Reference Number 175 NAC 12-006.09(H)(v)Based on observation, interview, and record review; the facility failed to implement interventions to prevent further decrease in range of mo...
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Nebraska Licensure Reference Number 175 NAC 12-006.09(H)(v)Based on observation, interview, and record review; the facility failed to implement interventions to prevent further decrease in range of motion for 1 (Resident 20) of 1 resident sampled. The facility staff identified a census of 63.The findings are:Record review of a facility policy entitled Activities of Daily Living (ADLs) dated 1-2024 revealed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. -Tips for improving or maintaining ADL skills: involvement of therapy or restorative nursing personnel to retrain resident.Record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified the resident had diagnoses which included pain, type 2 diabetes mellitus (a common form of diabetes mellitus that develops especially in adults and most often in obese individuals and that is characterized by hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production), heart failure, and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 20's Annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 4-21-2025 revealed the Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score for Resident 20 was not assessed. Further review of Resident 20's MDS revealed no restorative nursing program was offered.Record review of Resident 20's Therapy Screening (TS) dated 1-21-2025 revealed: - Pt [patient] would benefit from skilled services due to lack of mobility, however pt adamantly refuses OOB [out of bed] activity. Will continue to monitor, encourage/discuss, and screen PRN [as needed].Record review of Resident 20's TS dated 4-21-2025 revealed: - Resident on OT caseload, no noted ST [speech therapy] or OT [occupational therapy] needs, will cont [continue] to monitor and screen PRN.Record review of Resident 20's electronic health record (EHR) including physician's orders, treatment administration records, and comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed a lack of intervention to prevent further decrease in range of motion.Observation on 7-17-2025 at 9:45 am revealed the fingers of Resident 20's left hand with nodules and decrease range in motion.An interview on 7-17-2025 at 9:45 AM with Resident 20 revealed facility staff did not perform interventions to prevent further decrease in range of motion.An interview on 7-22-25 at 1:07 PM with the Director of Nursing (DON) confirmed there were no identified interventions to prevent further decrease in range of motion for Resident 20.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to identify and implement a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to identify and implement a plan to manage medications for residents on dialysis services for 3 (Residents 5, 31 and 39) of 4 residents sampled. The facility census was 63. The findings are:
A.
Record review of the facility policy titled Special Needs dated 01-2024 revealed the following:
-to address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician’s orders, the comprehensive person-centered care plan, and the resident’s goals and preferences.
-this policy pertains to the following needs-dialysis
-the facility will communicate relevant information with outside providers to ensure safe, continuous care of the resident.
-medical conditions will be monitored and managed to prevent complications.
-Registered Nurses (RN) and Licensed Practical Nurses (LPN) will participate in the management of medical conditions by following physician orders, assessment of the resident, and reporting changes in condition to the resident’s physician.
-interventions will be modified in the resident’s care plan as needed.
-policies and procedures related to special needs will reflect current standards of practice.
Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident:
-Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a BIMS score of 13 to 15 indicates a person is cognitively intact.
-had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus.
-was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood).
-was receiving insulin injections.
-required partial assistance with toileting, bathing, dressing and transfers.
Record review of Resident 5’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed on 06-30-2025(a Monday) at 12:00PM the facility staff documented OF (Out of Facility) for the administration for of the Lispro insulin at 12:00 PM because Resident 5 was at dialysis.
Record review of Resident 5’s MAR for July 2025 revealed an order for Lispro Insulin inject 8 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00 PM the facility staff documented OF on the following dates:
-07-02-2025(Wednesday),
-07-04-2025 (Friday),
-07-07-2025 (Monday),
-07-09-2025 (Wednesday),
-07-11-2025 (Friday),
-07-14-2025 (Monday)
-07-16-2025 (Wednesday).
An interview conducted on 07-17-2025 at 2:46 PM with the Agency Nurse (AN) G for the [NAME] Wing of the facility revealed (gender) was unaware of who was responsible to administer insulin while residents were out of the facility for dialysis. Furthermore, AN G revealed the resident’s practitioner should be notified any time insulin is not given.
An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed OF on the MAR meant the resident was not given the medication because the resident was out of the facility. Furthermore, staff did not notify Resident 5’s practitioner that the Lispro Insulin at 12:00 PM was not given in order to modify the insulin regimen.
B.
Record review of Resident 39’s MDS dated [DATE] revealed the facility staff assessed the following about the resident:
-BIMS was scored at an 11. According to the MDS Manual a BIMS score of 8-12 indicates moderate cognitive impairment.
-had a diagnosis of ESRD and Diabetes Mellitus.
-was receiving hemodialysis.
-was receiving insulin injections.
-required substantial assistance with upper body dressing and bathing.
-required total assistance with toileting, lower body dressing, bed mobility and transfers.
Record review of Resident 39’s Medication Administration Record (MAR) for June 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed an OF was documented at 12:00PM on the following dates:
-06-02-2025 (Monday)
-06-03-2025 (Tuesday)
-06-04-2025 (Wednesday)
-06-13-2025 (Friday)
-06-16-2025 (Monday)
-06-18-2025 (Wednesday)
-06-20-2025 (Friday)
-06-23-2025 (Monday)
-06-25-2025 (Wednesday)
-06-27-2025 (Friday)
-06-30-2025 (Monday)
Record review of Resident 39’s MAR for July 2025 revealed an order for Lispro Insulin inject 5 units 3 times a day with meals and an order to complete a pre and post dialysis assessment on Mondays, Wednesdays, and Fridays. The MAR also revealed for the administration of the Lispro insulin at 12:00PM the facility staff documented OF on the following dates:
-07-02-2025(Wednesday),
-07-04-2025 (Friday),
-07-07-2025 (Monday),
-07-09-2025 (Wednesday),
-07-11-2025 (Friday),
-07-14-2025 (Monday)
-07-16-2025 Wednesday.
An interview conducted on 07-17-2025 at 2:50 PM with Licensed Practical Nurse (LPN) H for the East Wing of the facility revealed (gender) was unaware of any residents with orders for insulin to be administered while residents were out of the facility for dialysis, and confirmed the resident’s practitioner should be notified if a dose of insulin was missed for any reason.
An interview conducted on 07-17-2025 with the Unit Manager (UM) at 3:58 PM confirmed the facility staff did not notify Resident 39’s practitioner that the Lispro Insulin at 12:00 PM was not given on dialysis days and confirmed the facility had not notified the resident’s practitioner to modify the insulin regimen for dialysis residents.
C.
Record review of Resident 31's Order Summary Report on 7/17/25 revealed Resident 31 admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease (plaque buildup on arterial walls), Ischemic Cardiomyopathy (a condition when the heart muscle is unable to effectively pump blood), Chronic Kidney Disease Stage 5 (most severe stage of kidney impairment), End Stage Renal (Kidney) Disease, Type 2 Diabetes Mellitus with other Diabetic Kidney Complication (occurs when the body cannot use insulin correctly and sugars builds up), Dependence on Renal Dialysis.
Record review of Resident 31's Electronic Medication Administration Record (MAR) for July 2025 revealed a practitioner's order for Lispro Insulin, inject 13 units daily before breakfast related to diagnosis of Type 2 Diabetes Mellitus. Further review of July 2025 MAR's for Resident 31 revealed OF (indicating resident is out of facility) on July 2,4,11,14,16. The review further of Resident 31's medical record revealed the facility staff did not notify the practitioner of omitted (not given) insulin orders on days the resident went to dialysis. Resident 31 has dialysis every Monday, Wednesday, and Friday.
An Interview on 07/17/2025 3:58 PM The Infection Preventionist (IP) confirmed, Resident 31 had not received scheduled insulin and the Medical Provider had not been notified of the omitted (not given) insulin on dialysis days. Dialysis days are Monday, Wednesday, and Friday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Nebraska Licensure Reference 175 NAC 12-006Based on record review and interview, the facility failed to evaluate the use of a la...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Nebraska Licensure Reference 175 NAC 12-006Based on record review and interview, the facility failed to evaluate the use of a laxative medication for 1 (Resident 8) of 5 residents sampled. The facility staff identified a census of 63.The findings are:Record review of a facility policy entitled Unnecessary Drugs-Without Adequate Indication for Use dated 1-2024 revealed: -2. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regime in collaboration with residents and/or representatives, other professionals, and the interdisciplinary team. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: a. Dose b. Duration of use c. Indications for use d. Adequate Monitoring e. Presence of adverse consequences which indicate the dose should be reduced or discontinued. f. Any combination of the reasons above.Record review of Resident 8's admission Record printed 7-21-2025 revealed the facility admitted the resident on 6-21-2021 and identified Resident 8 had diagnoses which included dementia with behavioral disturbance (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia [language disorder], and the inability to plan and initiate complex behavior), hypertension (high blood pressure), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or loss, feelings of worthlessness or guilt, and sometimes suicidal tendencies).Record review of Resident 8's Physician's Orders dated 7-21-2025 revealed an order dated 8-05-2023 for PEG3350 (polyethylene glycol, an osmotic laxative medication that works by drawing water into the colon which softens the stool and makes it easier to pass) to be administered daily for constipation. There was no stop date listed on the order.Record review of Resident 8's Electronic Medication Administration Record (eMAR) dated June and July 2025 revealed the resident refused polyethylene glycol on 6-8-2025 but was otherwise administered the medication as ordered.Further review of Resident 8's Electronic Health Record (EHR) showed no documentation that the medication had been reevaluated by the prescriber for continued use. Record review of polyethylene glycol Drug Facts dated 11-01-2021 and accessed at www.miralax.com revealed: -Directions adults and children [AGE] years of age and older: -do not use more than seven daysAn interview on 7-22-2025 at 12:23 PM with the Unit Manager (UM) confirmed the resident received polyethylene glycol daily. The UM further confirmed there was no evidence that the prescriber had evaluated the continued use of the medication.The facility was unable to produce further documentation regarding the evaluation of polyethylene glycol at survey exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(D) Based observations, record reviews and interviews; the facility staff failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(D) Based observations, record reviews and interviews; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 28 medications administered revealed 3 errors resulting in a medication error rate of 10.71%. The medication errors affected 3 (Resident 11, 22 and 37) of 7 sampled residents. The facility staff identified a census of 63. Findings are: A. Record review of a Order Summary Report (OSR) printed on 7-22-2025 revealed Resident 22's practitioner ordered a Advair Diskus inhaler (medication used to help with breathing) to be used every 12 hours on 7-14-2022. Instruction on the order was to inhale 1 puff and then to rinse the mouth after use.Observation on 7-17-2025 at 6:54 AM revealed Certified Medication Assistant (CMA) A obtained the Advair Diskus, a cup of water and went into the resident's room. CMA A handed the Advair Diskus to the resident and instructed Resident 22 to take a puff. Further observation on 7-17-2025 at 6:54 AM revealed CMA A handed Resident 22 a cup of water and did not instruct Resident 22 to rinse the mouth resulting in Resident 22 drinking the water without rinsing the mouth.On 7-17-2025 at 7:01 AM an interview was conducted with CMA A. During the interview CMA A confirmed Resident 22 was not cued to rinse the mouth as ordered with Resident 22 drinking the water. B. Record review of Resident 37's OSR printed on 7-22-2025 revealed Resident 37's practitioner ordered 15 units of Lispro insulin to be given three times a day and additional Lispro insulin be given based upon blood sugar level. Observation on 7-17-2025 at 8:20 AM of administration of insulin to Resident 37 revealed Licensed Practical Nurse (LPN) C obtained Resident 37 insulin pen. LPN C reported Resident 37's blood sugar level was 242 resulting in Resident 37 would receive an additional 6 units of Lispro insulin, for a total of 21 units of Lispro to be given. LPN C dialed Resident 37's insulin pen to 1unit and pushed the button to prime the insulin pen. After completing the priming of 1unit ,LPN C dialed the pen to 21 units and administered the insulin. On 7-17-2025 at 8:32 AM an interview was conducted with LPN C. During the interview LPN C confirmed Resident 37's insulin pen was primed with 1 unit of insulin. C.Record review of Resident 11's OSR printed on 7-22-2025 revealed Resident 11's practitioner ordered Resident 11 to have 10 units of Lantus insulin every morning. Observation on 7-17-2025 at 8:30 AM revealed LPN C obtained Resident 11's Lantus insulin pen. LPN C dialed Resident 11's insulin pen to 1unit and pushed the button to prime the insulin pen. LPN C dialed the insulin pen to 10 and administered the 10 units of Lantus insulin.On 7-17-2025 at 8:55 AM an interview was conducted with LPN C. During the interview LPN C confirmed Resident 11's insulin pen was primed with 1 unit of insulin. D. Record review of the manufacturers' instruction for using the Lispro insulin pen revised on 7-2023 found at [NAME] Lilli.com revealed the following information:-Prime before each injection: -Priming your pen mean removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly.-If you do not prime before each injection, you may get to much or to little insulin.Step 6: To prime the pen turn the dose knob (dial) to select 2 units. E. Record review of the Manufactures instruction for use of the Lantus insulin pen found at Lantus.com revealed the following information:Step 3. Perform safety test-Dial a test dose of 2 units. Press the injection button all the way in and check to see that insulin comes out of the needle.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.15(A) & (B). Based on observation, interview and record review the facility failed to ensure dental services were provided for 2 (Resident 5 and 56) of 2 resi...
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Licensure Reference Number 175 NAC 12-006.15(A) & (B). Based on observation, interview and record review the facility failed to ensure dental services were provided for 2 (Resident 5 and 56) of 2 residents sampled. The facility census was 63. The findings are:
A.
Record review of the facility policy titled Dental Services Policy revealed the following:
-it is the policy of this facility in order to meet the needs of the residents, to assist all residents in obtaining routine and emergency dental care to the extent covered under the State plan and 24-hour emergency dental care.
-the facility will provide or obtain from an outside resource, routine and emergency dental services to meet the needs of each resident.
-the facility will assist the resident with making dental appointments and arranging transportation to and from the dental service location.
Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident:
-Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact.
- had an obvious or likely cavity or broken natural teeth.
-required partial assistance with toileting, bathing, dressing and transfers.
An interview conducted with Resident 5 on 07-16-2025 at 10:11 AM revealed Resident 5 had seen a dentist that recommended extraction of the upper teeth.
An observation of Resident 5 on 07-16-2025 at 10:15 AM revealed 3 broken discolored teeth to the front of the upper jaw.
Record review of an Oral Surgery Referral form dated 01-25-2024 revealed the following for Resident 5:
-resident resides in a nursing facility and has been referred for dental care that exceeds the capability of the facilities mobile dental services.
-resident had residual root tips needing removal.
-resident had multiple teeth that need to be removed.
-resident’s treatment plan included extractions that are surgical in nature.
-resident needs evaluated for extractions where diagnostic x-rays and oral access can be obtained.
An interview conducted with the Assistant Director of Nursing (ADON) on 07-17-2025 confirmed Resident 5 had not seen a dentist since 01-25-2025 and confirmed Resident 5 did not have any dental services currently scheduled.
B.
Observation on 07/16/2025 10:00 AM revealed Resident 56 is missing multiple teeth and has several broken teeth. Resident 56’s only complaint of pain is in the back and legs.
Interview on 7/21/25 8:45 AM Assistant Director of Nursing (ADON) provided documents from 360 Care of Nebraska with dates of service. Resident 56 has not been seen by a dentist since 6/20/2024.
Interview with the Director of Nursing (DON) on 07/22/2025 08:52 AM Confirmed Resident 56 has not been seen by a dentist since 05/13/2024 and last seen by the dental hygienist 07/24/2024.
Record review of the 360 care of Nebraska revealed notes from the Dentist dated 05i14/2024, Resident 56 needs to be referred to Oral Surgeon due to surgical case and the referral was sent to the facility.
Record review of the care plan confirmed awareness of Resident 56’s poor dentition.
Focus: The resident has oral/dental health problems r/t Poor oral hygiene Date Initiated: 05/23/2024,
Revision on: 05/23/2024
Goal: The resident will be free of infection, pain or bleeding in the oral cavity through review
period. Date Initiated: 05/23/2024, Revision on: 03/03/2025
Target Date: 05/22/2025
Interventions: Monitor/document/report PRN (as needed) any signs and symptoms of of oral/dental problems needing attention: Pain (gums, toothache), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Date Initiated: 05/23/2024.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Licensure Reference Number 175 NAC 12-006.11(A)Based on observations, record review and interview, the facility kitchen staff failed to follow the menu serving sizes for 48 resident who have a regular...
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Licensure Reference Number 175 NAC 12-006.11(A)Based on observations, record review and interview, the facility kitchen staff failed to follow the menu serving sizes for 48 resident who have a regular textured diet. The facility staff identified a census of 63. Findings are: Record review of a undated Menu at a Glance revealed the lunch meal for 7-17-2025 was as follows:-BBQ meat balls-Smashed red potatoes-Green Beans-Corm bread with margarine-BeverageRecord review of of the Diet Spreadsheet for the 7-17-2025 noon meal revealed the following information:-Regular texture portion sizes:-BBQ meatballs, 3- 1 ounce (oz) size meat balls.-Smashed Red Potatoes, #8 scoop size.-Green Beans #8 scoop size.-Cornbread with margarine, 1 each.Observations on 7-17-2025 at 11:56 AM revealed Dietary Assistant (DA) E began serving and setting up room trays to be given to resident in their rooms or secured unit dinning room. Further observations on 7-17-2025 revealed DA E did not use dietary card (informational cards that identify diet type, portion, consistency of foods, food preferences and allergies). DA E served 5 meat balls to residents who were on regular textured diets.An interview was completed with DA E on 7-17-2025 at 11:56 AM . During the interview DA E reported residents on regular textured diets received 5 meat balls. Observation on 7-17-2025 at 12:14 PM of meal service in the east dining room revealed DA F serving random portion of 5 to 12 meat balls to residents on regular textured diets. On 7-17-2025 at 12:30 PM an interview was conducted with DA F. During the interview DA F reported not knowing the serving sizes of the meat balls to be given to the residents.On 7-21-2025 at 10:10 AM an interview was conducted with the Food Service Director (FSD). During the interview the FSD reported each meat ball served on 7-17-2025 noon meal was 1/2 ounces and that each resident on regular textured meals should have received 6 meat balls. The FSD confirmed the menu for portion sizes had not been followed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observations and interviews; the facility kitchen staff failed to ensure foods were at temperatures that was appetizing and palatable. The deficient practice had the potential to effect all r...
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Based on observations and interviews; the facility kitchen staff failed to ensure foods were at temperatures that was appetizing and palatable. The deficient practice had the potential to effect all residents who eat food from the kitchen. The facility staff identified a census of 63. Findings are: Record review of the current Nebraska Food Code found at 81-2,272.01 for hot and cold holding temperatures revealed the following information:-1. Except during preparation, cooking or cooling or when time is used as a public health control, time/temperature control for safety shall be maintained.-a. At 135 degrees Fahrenheit or above, for hot foods.-41 degrees or less for cold food. Record review of of a facility grievance log from 1-1-2025 through 7-14-25 revealed the following information:-1-01-2025, Multiple Residents , resident not happy with choices for breakfast and complained of cold food.-2-17-2025, Multi resident reported food was cold when they received it in their rooms. -4-4-02-2025, resident unhappy with food. Stated it looked as if it was just thrown on the plate.-6-05-2025, Resident reported did not like diner. The cucumbers were hot and zuchini was cold.On 7-16-2025 at 8:40 AM an interview was conducted with Resident 29. During the interview Resident 29 reported the food doesn't taste good. Record review of a undated Menu at a Glance revealed the lunch meal for 7-17-2025 was as follows:-BBQ meat balls-Smashed red potatoes-Green Beans-Corm bread with margarine-Beverage-PuddingObservation on 7-17-2025 from 12:14 PM to 12:32 PM in the East Dining room revealed Dietary Assistant (DA) C served resident their noon meals. DA C completed the meal service in the East Dining room and began to prepare meal room trays for residents, in addition, a requested meal test tray (meal tray used to evaluate the taste and temperatures of foods served to residents). Further observation on 7-17-2025 from 12:14 PM to 12:32 PM revealed the last room tray was delivered. DA C using the facility thermometer revealed the following information on the evaluation of the meal test tray:-Meat balls 129.0 degrees. -Diced potatoes 107.6.-Ground Meat 110.0.-Green beans 121.4 degrees. -Hot dog alternate 96.0 -Mashed potatoes 120.8, -Pudding 67.8, On 7-17-2025 at 12:32 PM a interview was conducted with DA C. During the interview DA C confirmed hot food were cold and the pudding was too hot. DA C further reported the food did not taste good.On 7-21-2025 at 10:10 AM an interview was conducted with the Dietary Service Manager (DSM). During the interview the DSM reported the facility follows the Nebraska Food code for holding temperatures.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18, 12-006.18 (C)Based on observation, interview, record review, the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18, 12-006.18 (C)Based on observation, interview, record review, the facility failed to implement a plan to mitigate the potential growth of Legionella, and failed to implement Enhanced Barrier Precautions (EBP) for Residents 8 and 61. Findings are:
A.
An interview on 07/22/2025 10:15 AM with the Maintenance Director (MD) confirmed no documentation of flushing holding tanks or areas that have the potential for stagnant water which could promote potential growth of Legionella.
Record review of the facility policy titled “Environmental-Infection Control-Legionella Surveillance & Detection”, dated 1/2024.
Legionella Surveillance and Detection
Policy Statement:
Our facility is committed to prevention, detection, and control of water-borne contaminants, including Legionella. Legionnaire’s disease will be included as part of our infection surveillance activities.
Legionella Water Management Program
Policy Interpretation:
Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella.
Policy Interpretation and Implementation:
5. The water management program includes the following elements:
c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including:
- Storage tanks;
-Water heaters;
-Filters;
-Aerators;
-Shower heads and hoses;
-Misters, atomizers, air washers and humidifiers;
-Hot tubs;
-Fountains; and
-Medical devices such as CPAP machines, hydrotherapy equipment; etc.
7. Water stagnation and;
8. Inadequate disinfection.
e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants);
f. The control limits or parameters that are acceptable and that are monitored;
g. A diagram of where control measures are applied;
h. A system to monitor control limits and the effectiveness of control measures;
i. A plan for when control limits are not met and or control measures are not effective; and
j. Documentation of the program.
B.
Record review of Resident 61’s MDS dated [DATE] revealed the facility staff assessed the following about the resident:
-required total assistance with toileting and bathing.
-required extensive assistance with lower body dressing.
-required limited assistance with upper body dressing and transfers.
Record review of Resident 61’s Comprehensive Care Plan (CCP) dated 08-22-2024 revealed Resident 61 had an active Multi Drug Resistant Organism (MDRO: an infection caused by bacteria that have developed resistance to multiple classes of antibiotics) or MDRO colonization in the urine. The CCP also revealed the staff were to utilize EBP and wear gowns and gloves during high-contact resident activities.
An observation on 07-22-2025 at 8:30 AM revealed a sign on Resident 61’s door indicating EBP was to utilized when caring for the resident.
An observation conducted on 07-22-2025 at 9:00 AM of Nursing Assistant (NA) B giving Resident 61 a shower revealed NA B transferred Resident 61 into the bath chair, assisted with the removal of clothes and assisted with incontinence care without wearing a gown.
An interview with NA G on 07-22-2025 at 9:45 AM confirmed Resident 61 was on EBP and a gown was not worn during the shower and should have been.
C.
Record review of Resident 8’s “admission Record” identified the facility admitted the resident on 6-21-2021 and the resident had diagnoses which included extended spectrum beta lactamase resistance (ESBL resistance, a type of antibiotic resistance in bacteria).
Record review of Resident 8’s quarterly MDS dated [DATE] identified the resident was dependent upon staff for toileting and the use of an indwelling urinary catheter (a flexible tube inserted through the urethra and into the bladder to drain urine).
Record review of Resident 8’s CCP (Care Plan) identified the resident has an active multidrug-resistant organism (MDRO) or MDRO colonization and enhanced barrier precautions were to be utilized during high contact resident care activities.
Observation on 7-21-25 at 11:43 AM revealed EBP signage was hung at the door.
Observation on 7-21-2025 at 11:50 AM of NA-D performing Resident 8’s catheter care revealed catheter care supplies prearranged on a bedside table with a barrier between the table and supplies. NA-D washed hands with soap and water for 22 seconds and donned (applied) gloves. Without donning a gown, NA-D assisted Resident 8 to roll side-to-side to remove the brief. NA-D doffed (removed) gloves, performed hand hygiene, and donned new gloves. NA-D completed urinary catheter care, doffed gloves, performed hand hygiene, donned new gloves, and applied a clean brief.
During an interview on 7-21-2025 at 12:02 PM, NA-D confirmed Resident 8 was on EBP and that EBP included the use of gown. NA-D further confirmed that a gown was not worn during urinary catheter care and should have been.
Record review of a facility policy entitled “MDRO PPE-Enhanced Barrier Precautions” dated revised 1-2024 revealed:
-Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.
-Framework for applying EBP in this facility is the application of EBP to routine care of residents with wounds or indwelling medical devices. The facility requires that staff participate in initial and on-going training on the facility’s expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage or similar dressing.
-Examples of chronic wounds include, but are not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous stasis ulcers.
-Indwelling medical device examples: central lines, urinary catheters, feeding tubes, tracheostomies.
-For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care (any skin opening requiring a dressing).
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1)
Based on observations, record review and interview; the facility staff f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1)
Based on observations, record review and interview; the facility staff failed to implement interventions to prevent potential development of pressure ulcers for 1 (Resident 7) of 5 residents. The facility staff identified a census of 60.
Findings are:
Record review of a Order Summary Report (OSR) printed on 11-18-2024 revealed Resident 7 admitted to the facility on [DATE] with the diagnoses of, Pain, Hypertension and Hemiplegia (paralysis) and Hemiparesis weakness) related Cerebral Infarction (stroke) that effected the left side of the body. Further review of the OSR printed on 11-18-2024 revealed Resident 7's practitioner ordered a treatment to be completed to a wound on Resident 7's buttock/coccyx (tail bone area) three times a day.
Record review of Resident 7's Minimum Data set (MDS, a federally mandated assessment tool used for care planning) dated 9-26-2024 revealed the facility staff assessed the following about the resident:
-Brief interview of Mental Status (BIMS) was 11. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition.
-Was dependent for eating, toilet use, dressing, personal hygiene and rolling left to right.
-Identified Resident 7 was at risk for pressure ulcer development.
Record review of Resident 7's CCP revised on 11-29-2023 revealed Resident 7 had a pressure ulcer and had the potential for pressure ulcer development. The goal identified on Resident 7's CCP was Resident 7 would have intact skin. Interventions to meet this goal with a revision date of 10-04-2024 was to provide pressure reducing/relieving device to bed that was a low loss air mattress (type of speciality mattress).
Observation on 11-18-2024 at 11:44 AM revealed Resident 7 was in bed with heels were against the mattress and not elevated.
Observation on 11-18-2024 at 12:52 PM revealed Resident 7 was in bed and heels were against the mattress and not elevated.
Observation on 11-19-2024 at 5:10 AM revealed Resident 7 was in bed with feet sticking out of their blanket revealing Resident 7's heels were not elevated.
Observation on 11-19-2024 at 7:06 AM of personal care with Nursing Assistant (NA) A and Licensed Practical Nurse (LPN) B revealed Resident 7 was in bed with heels on mattress and not elevated.
On 11-19-2024 at 7:48 AM an interview was conducted with LPN B. During the interview LPN B reported Resident 7's heels should be off the mattress and elevated, such as on a pillow. LPN B confirmed Resident 7's heel were on the mattress and not elevated.
Record review of the facility Prevention of Pressure revised on 6-07-2024 revealed the following:
-Support Surfaces and Pressure Redistribution:
-Select appropriate support surfaces based on the residents risk factors in accordance with current clinical standards.
Record review of the National Pressure Injury Advisory Panel at NPIAP.com revealed the following information:
-Page 145:The heel is one of two most common sites for pressure ulcers.
-The reduction of pressure and shear at the heel is an important interest in clinical practice.
-Page 147: Ensure the heels are free from the surface of the bed.
-Page 148: Heel elevation,
-Pressure can be relieved by elevating the lower leg and calf from the mattress. Ideally, heels should be free of all pressure- a state sometimes called floating heels.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18
Based on observations record review and interview; the facility staff failed to imp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18
Based on observations record review and interview; the facility staff failed to implement Enhanced Barrier Precaution (EBP,an infection control intervention designed to reduce transmission of resistant organisms that employs gown and glove use during high contact resident care activities) for 1(Resident 7) of 1 sampled resident. The facility staff identified a census of 60.
Findings are:
Record review of a Order Summary Report (OSR) printed on 11-18-2024 revealed Resident 7 admitted to the facility on [DATE] with the diagnoses of, Pain, Hypertension and Hemiplegia (paralysis) and Hemiparesis weakness) related to a Cerebral Infarction (stroke) that effected the left side of the body. Further review of the OSR printed on 11-18-2024 revealed Resident 7's practitioner ordered a treatment to be completed to a wound on Resident 7's buttock/coccyx (tail bone area) three times a day. In addition Resident 7's OSR revealed Resident 7 received tube feedings.
Record review of Resident 7's Minimum Data set (MDS, a federally mandated assessment tool used for care planning) dated 9-26-2024 revealed the facility staff assessed the following about the resident:
-Brief interview of Mental Status (BIMS) was 11. According to the MDS [NAME] a score of 8 to 12 indicates a person has moderately impaired cognition.
-Was dependent for eating, toilet use, dressing, personal hygiene and rolling left to right.
-Identified Resident 7 was at risk for pressure ulcer development.
-Received tube feedings.
Record review of Resident 7's Treatment Administration Record (TAR) for November 2024 revealed Resident 7 had a treatment to feeding tube insertion site to be completed every shift.
Observation on 11-18-2024 at 10:30 AM revealed Resident 7 was in their room. Further observations of Resident 7's room, including the door and walls revealed there were no indications to indicate Resident 7 was on EBP.
Observation on 11-18-2024 at 12:21 PM of Resident 7's room including the entrance to the room revealed there was no indications Resident 7 was on EBP.
Observation on 11-19-2024 at 5:10 AM revealed Resient 7 was in bed. Further observations of Resident 7's room and entrance revealed there was no indications Resident 7 was on EBP.
Observations on 11-19-2024 at 7:06 AM of treatment to the buttock/coccyx and feeding tube insertion site by Licensed Practical Nurse (LPN) B revealed LPN B completed both treatments and had not gowned.
On 11-19-2024 at 7:48 AM an interview was conducted with LPN B. During the interview LPN B confirmed they did not wear a gown while doing Resident 7's treatments. LPN B further reported not knowing what EBP was.
On 11-19-2024 at 10:34 AM an interview was conducted with the Director Of Nursing (DON). During the interview the DON reported Resident 7 should have been on EBP.
Record review of the facility Infection Control for EBP revised on 3-20-2024 revealed the following:
-Framework for applying EBP in this facility is the application of EBP to routine care of residents with wounds or indwelling medical devices. The facility requires that staff participate in initial and on-going training on the facility's expectation about hand hygiene and gown and glove use.
-Examples of chronic wounds include, but not limited to Pressure ulcers, diabetic foot ulcers.
-unhealed surgical wound and venous stasis ulcers.
-Indwelling medical devices examples:
-Central lines.
-Urinary catheters.
-feeding tubes.
May 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility staff failed to investigate and submit their written investigation of alleged misappropriations to the state agency within 5 working days for 1 (Resi...
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Based on record review and interview, the facility staff failed to investigate and submit their written investigation of alleged misappropriations to the state agency within 5 working days for 1 (Resident 31) of 3 residents reviewed. The facility identified a census of 64.
Findings are:
Record review of an Adult Protective Services (APS) report dated 1/2/24 revealed APS was notified Resident 31 alleged a family member had stolen Resident 31's Net Spend card (similar to a debit card).
Record review of Resident 31's Progress Notes dated 1/02/2024 revealed the facility staff had notified APS at 11:57 AM of the allegation of Resident 31's Net Spend card being stolen.
A interview on 5/22/2024 at 10:02 AM was conducted with the Director of Nursing (DON). During the interview the DON confirmed a investigation and the results of the investigation being sent to the required state agency had not been completed.
Record review of a facility Policy dated 1/2024 titled Abuse Protection revealed the following information:
-Misappropriation is defined as the deliberate misplacement, exploitation, or wrongful (temporary or permanent) use of a resident's belongings or funds without the resident's consent.
-Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to; facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our resident, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.
-Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals.
-Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum:
-Reporting/response-The reporting and filing of accurate documents relative to incidents of abuse; reporting to State and Local agencies as required analyze and implement necessary changes to prevent future occurrences of abuse. The facility will follow the Elder Abuse Act which includes Reporting Abuse. The reports must be made both to the DHHS and to local law enforcement within twenty-four hours after a reasonable suspicion is formed. However, if the events causing reasonable suspicion could result in serious bodily injury, the reporting must be done within two hours after forming the suspicion.
-483.12(c)(1)Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.095D5
Based on interviews and record reviews, the facility failed to evaluate and implement interventions to manage triggers for 1 (Resident 7) of 1 resident ...
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Licensure Reference Number 175 NAC 12-006.095D5
Based on interviews and record reviews, the facility failed to evaluate and implement interventions to manage triggers for 1 (Resident 7) of 1 resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility staff identified a census of 64.
Findings are:
Record review of Resident 7's Census revealed Resident 7's admission date was 9/20/23.
Record review of Resident 7's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 3/26/24 revealed Resident 7's Brief Interview of Mental Status (BIMS, a test to determine cognition) had a score of 15. According to the MDS manual a score of 13-15 indicated a person was cognitively intact. Further review of Resident 7's MDS revealed Resident 7 had the diagnosis of Post Traumatic Stress Disorder (PTSD).
Record review of Resident 7's Comprehensive Care Plan (CCP) initiated on 9/20/23 revealed no indication of PTSD or interventions staff were to use to mitigate triggers for Resident 7's PTSD.
Interview with Resident 7 on 5/20/24 at 9:43 AM, Resident 7 stated, I see a therapist outside of the facility. I have PTSD, and I don't think the staff understand. I have a lot of trouble at night. I like to have the TV on and a soft voice to wake me up. When the staff come around the curtain, it can scare me.
Interview on 5/23/24 at 6:42 AM with the Director of Nursing (DON), revealed there were no triggers or interventions within Resident 7's medical record for PTSD.
Interview with the Social Worker (SW) on 5/23/24 at 8:54 AM, revealed there was no interview, assessment, or interventions completed for Resident 7's PTSD. The SW confirmed Resident 7 had never been asked for specific triggers or interventions directly related to the diagnosis of PTSD.
Record review of the facility Mood and Behavior Policy and Procedure dated 1/2024 revealed the following:
The facility promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding mood and behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident whole emotional and mental well-being, therefore an individualized approach to care is essential. It is the policy of the facility that each resident must receive, and the facility must provide the necessary behavioral health care and services and medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the resident assessment instrument (RAI) specified by CMS.
The objective of the Mood and behavior policy and procedure identified the facility is to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the Interdisciplinary Team (IDT). This plan of care will include medically related social services to address mood and behavioral health service to attain or maintain the highest practicable well-being.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18B3
Based on observation and interview, the facility failed to maintain walls, floors...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18B3
Based on observation and interview, the facility failed to maintain walls, floors, resident equipment, fixtures, air conditioning and ventilation covers in a clean, safe and functional manner in 7 rooms (116, 122, 123, 126, 127, 128 and 130) and in the east and west shower rooms, which had the potential to affect 55 of 64 residents that utilized those rooms. The total number occupied resident rooms was 42. The facility census was 64.
Finding are:
Observations on 05/20/24 between 7:30 AM and 12:30 PM revealed:
- Multiple scrapes on the wall by the air conditioning unit in room [ROOM NUMBER] that has removed the painted surface leaving several dark marks.
- A 1/2 inch irregular shaped opening (hole) around the air conditioner power intake cover for room [ROOM NUMBER].
- The ventilation covers in resident bathrooms were covered with a gray substance resembling dust in rooms 116,122, 123,126,127,and 128.
- The left armrest on Resident 31's wheelchair was broken exposing a sharp edge.
-The bathroom door to room [ROOM NUMBER] had a several long horizontal scrapes approximately 3 feet long and 1/2 inch wide that removed the top surface of the wood leaving superficial dark marks on the lower third of the door.
- The baseboards in room [ROOM NUMBER] had a built up of gray fuzzy substance resembling dust and floor near the airconditioning unit had an oily, greasy substance buildup.
- The bathroom faucet had poor water pressure with only a trickle of water present in room [ROOM NUMBER].
- Gouges/holes approximately 1/4 inches leaving an opening in the drywall around soap dispenser in rooms [ROOM NUMBERS].
Observation on 5/23/24 between 8:00 AM and 9:15 AM during the environmental tour with the facility Maintenance Director and Administrator revealed the following:
- Multiple scrapes on the wall by the air conditioning unit in room [ROOM NUMBER] that has removed the painted surface leaving several dark marks.
- A 1/2 inch irregular shaped opening (hole) around the air conditioner power intake cover for room [ROOM NUMBER].
- The ventilation covers in resident bathrooms were covered with a gray substance resembling dust in rooms 116,122, 123,126,127,and 128.
- The left armrest on Resident 31's wheelchair was broken exposing a sharp edge.
-The bathroom door to room [ROOM NUMBER] had a several long horizontal scrapes approximately 3 feet long and 1/2 inch wide that removed the top surface of the wood leaving superficial dark marks on the lower third of the door.
- The baseboards in room [ROOM NUMBER] had a built up of gray fuzzy substance resembling dust and floor near the airconditioning unit had an oily, greasy substance buildup.
- The bathroom faucet had poor water pressure with only a trickle of water present in room [ROOM NUMBER].
- Gouges/holes approximately 1/4 inches leaving an opening in the drywall around soap dispenser in rooms [ROOM NUMBERS].
- Rusty (oxidation of iron in the presence of air and moisture), brown discolored ceramic tiles in shower stalls in east and west shower rooms.
Interview with the Maintenance Director 5/23/24 at 9:29 AM confirmed the above identified concerns were present and agreed that issues need to be addressed and corrected. The Maintenance Director confirmed that there were no previous or current work orders for any of the identified concerns listed above.
Interview with Director of Nursing (DON) on 05/23/24 at 9:26 AM confirmed 55 residents utilize the east and west shower room for bathing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.12E1
Based on observations and interviews, the facility failed to ensure the east medi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12.006.12E1
Based on observations and interviews, the facility failed to ensure the east medication room was secure. This had the potential to affect 22 of 64 residents who were self-mobile and resided in the facility and 2 (Nursing Assistant A and B) of 3 unauthorized staff.
Findings are:
An observation on 05/23/2024 at 4:10 AM revealed the keys were in the lock of the medication storage room door on the east side of the building beside the nurses' station. The door was clearly visible by anyone who passed in the hallway. There were no staff present at the nurses' station at that time.
An observation on 05/23/2024 at 4:10 AM revealed Registered Nurse (RN)-A at the end of the east hall outside room [ROOM NUMBER].
An observation on 05/23/2024 at 4:10 AM revealed Resident 27 was in a wheelchair beside the nurses' station. A record review of Resident 27's Electronic Health Record confirmed Resident 27 had a BIMS (Brief Interview of Mental Status - a federally mandated tool used to screen and identify the cognitive condition of residents.) score of of 5 which indicated the resident had severe cognitive impairment.
An observation on 05/23/2024 at 4:40 AM revealed RN-A entered the medication room and removed the keys from the door at that time.
An interview on 05/23/2024 at 4:43 AM with RN-A revealed the keys that were left in the lock of the medication storage room also contained the key for the padlock for the medication fridge located in the medication storage room. RN-A confirmed the keys should not have been within the lock.
An interview on 05/23/2024 at 10:00 AM with the Director of Nursing (DON) confirmed the medication storage rooms are to be locked at all times. The DON confirmed the keys should not have been left in the door lock and that the east medication room was unsecured when the keys were left in the lock.
An interview with the DON on 5/23/2024 at 12:45 PM revealed there were 22 of the 64 residents who resided in the facility which had the ability to open the medication room door if the keys were left in the lock. An interview with the DON confirmed two of three unauthorized staff members, Nurse Assistant (NA) NA-A and NA-B could have opened the medication room door when the keys were left in the lock.
A record review of the Storage of Medications Policy from the Nursing Services Policy and Procedure Manual for Long-term care, copyright 2001 MED PASS, Inc. (Revised November 2020) revealed the following information:
(6) Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.
(7) Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or other secured location. Medications are stored separately from food and are labeled accordingly.
(8) Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.
Jan 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.04C3a(6)
Based on record review and interview, the facility failed to ensure responsible par...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure reference: 175 NAC 12-006.04C3a(6)
Based on record review and interview, the facility failed to ensure responsible party was notified of weight loss for 2 [Residents 1 and 3] of 4 sampled residents. The facility had a total census of 63 residents.
Findings are:
A. A review of Resident 1's admission record revealed Resident 1 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in hemisphere subcortical [stroke] and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side [paralysis on one side of the body following stroke]. Resident 1 has a legal guardian according to admission record.
A review of Resident 1's admission MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 9/26/23 revealed a BIMS [Brief Interview for Mental Status] score of 9 indicating moderate cognitive impairment.
A review of Resident 1's weights recorded in weight section of electronic medical record revealed a weight of 187 lbs. [pounds] on 9/20/23.
Record review of Resident 1's bath record dated 12/20/2023 revealed a weight of 178.4 lbs. This reflected a weight loss of 8.6 lbs., or a 4.6% weight loss in 3 months.
A review of Progress Note dated 11/20/23 for Resident 1 revealed Resident 1 had a 3.4% weight loss from last weight identified on 9/20/2023. According to Resident 1's Progress Note dated 11/20/2023, Resident 1 was refusing enteral nutrition as well as meals with recommendation to start oral supplement of 120 cubic centermeters (cc) per day with the Advanced Practitioner Registered Nurse being notified of weight loss.
A review of Resident 1's 1/2024 MAR [Medication Administration Record] revealed an order dated 11/21/23 for Boost nutritional supplement one time a day.
A review of 12/25/23 Nutrition Quarterly Data Collection revealed Resident 1 remained on a regular, pureed, honey thickened diet with oral intakes of 60-65% and Boost supplement one time per day. Resident 1 has orders for Nepro [enteral nutrition] via tube feeding 4 times per day with refusal of enteral nutrition 1/3 of time. The Nutritional Note dated 12/25/2023 identified a current body weight of 177 lbs. which is a 10 lb. loss since admission.
A review of Resident 1's Progress Notes from did not reveal any evidence of Resident 1's responsible party being notified of weight loss.
In an interview on 1/2/24 at 3:17 PM, the Director of Nursing reported being unable to find any evidence of responsible party being notified of Resident 1's weight loss. The Director of Nursing indicated notification requirements would be based on facility policy.
B. A review of Resident 3's admission Record revealed an admission dated of 12/24/2018 with a diagnosis of longstanding persistent Atrial Fibrillation [irregular heartbeat].
A review of Resident 3's significant change in status MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment.
A review of Resident 3's weights recorded in the vitals section of the electronic medical record revealed a weight of 130.6 lbs. on 9/22/23 and a weight of 120.4 lbs. on 12/29/23 which reflects a 10.2 lbs., 7.8% weight loss in 3 months.
A review of 10/22/23 Nutrition note revealed the following:
-A weight loss of 10 lbs. in the past month for Resident 3
-Weight loss in 6 months possibly secondary to diuretic
-Recent COVID positive with possible contributor to weight loss
-Oral intake average 75-80%
-Advanced Practitioner Registered Nurse notified of weight loss
-Initiation of Ensure plus 120 cc every day
A review of Resident 3's 1/2024 MAR revealed an order for ensure Plus 120cc one time per day dated 10/23/23.
A review of Resident 3's Nutrition Quarterly Data Collection sheet dated 12/19/23 revealed the following:
-Current body weight of 120.6 lbs.
-Weights stable since mid-October
-Weight loss of 14 lbs./10.4% x 6 months
-Weight loss of 10 lbs./7.6% x 3 months
A review of Resident 3's Progress Notes from did not reveal any evidence of Resident 1's responsible party being notified of weight loss.
In an interview on 1/2/24 at 3:17 PM, the Director of Nursing reported being unable to find any evidence of responsible party being notified of Resident 3's weight loss. The Director of Nursing indicated notification requirements would be based on facility policy.
-A review of Weight Monitoring and Weight Loss Intervention policy dated 7/2/2020 revealed for weight losses/gain of 5% in 30 days, 7.5% in 90 days, and 10% in 180 days resident's physician and responsible party is to be notified.
Nov 2023
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12-006.05(4)
Based on record review and interview, the facility failed to ensure baths were given according to preferences for 3 residents (Resident 57, 35 and 29) o...
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Licensure Reference Number 175 NAC 12-006.05(4)
Based on record review and interview, the facility failed to ensure baths were given according to preferences for 3 residents (Resident 57, 35 and 29) of 3 sampled residents. The facility census was 62.
Findings are:
A. Record review of Resident 57's Comprehensive Care Plan dated 8/14/23 revealed, Resident 57 had a functional deficit with activities of daily living (ADL) related to a femur fracture and required extensive assistance of one staff member for transfers out of the wheelchair.
An interview on 11/27/23 at 11:05 AM with Resident 57 revealed, [gender] had not recieved a bath in 2 weeks.
A record review of Resident 57's electronical health record (EHR) revealed, Resident 57 recieved a shower on 11/3 and a bed bath on 11/23/23.
An interview on 11/30/23 at 9:35 AM with Resident 57 revealed, [gender] preferred to have a bath at least 2 times a week.
A record review of Resident 57's EHR revealed, that Resident 57's daily preferences were not asessed or completed.
An interview on 11/30/2023 at 4:00 PM with the facility Director of Nursing (DON) revealed, that the daily preferences for bathing was not completed for Resident 57. The DON further revealed, that Resident 57 had not recieved a bath betweeen 11/3-11/23/23.
B. A record review of Resident 35's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 09/13/23 revealed, that Resident 35 did not have bathing activity in the 7 days prior to 09/13/2023.
A record review of Resident 35's active Care Plan revealed, that Resident 35 required assistance with ADLs related to weakness, impaired physical mobility and impaired cognition.
A record review of Resident 35's EHR revealed, that Resident 35 had not recieved a bath between 11/17-11/30/23.
An interview on 11/30/23 at 4:05 PM with the DON revealed, that bathing was not completed between 11/17/2023 and 11/30/2023.
C. A record review of Resident 29's active Care Plan revealed, that Resident 29 was to receive 3 showers a week.
A record review of Resident 29's EHR for November 2023 revealed, that Resident 29 recieved a shower on 11/10/23 and 11/23/23.
An interview on 11/30/23 at 9:21 AM with Resident 29 revealed, that [gender] did not recieve a shower in the last week. Resident 29 further revealed, [gender] wanted 3 showers a week.
An interview on 11/30/23 at 11:30 AM with the facility DON revealed, that Resident 29 had not recieved 3 showers a week.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C3a(6)
Based on record review and interview; the facility staff failed to notify the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04C3a(6)
Based on record review and interview; the facility staff failed to notify the practitioner of an abnormal laboratory result for 1 (Resident 19) of 5 sampled residents. The facility staff identified a census of 62.
Findings are:
Record review of an Order Summary Report (OSR) printed on 11-30-2023 revealed Resident 19 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus.
Record review of Resident 19's laboratory results dated [DATE] revealed Resident 19's A1C ( a blood test that measures your average blood sugar levels over the past 3 months) was 8.5 as compared to the reference range of 5.7 or less.
Record review of Resident 19's electronical medical record revealed there was no indication Resident 19's practitioner had been notified the the laboratory results of the A1C dated 9-26-2023.
On 11-30-2023 at 12:41 PM an interview was conducted with the Director of Nursing (DON) which revealed Resident 19's practitioner was not notified of the abnormal A1C result dated 9-26-2023.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review, observation and interview, the facility failed to obtain a rationale from the medical practitioner for the continued use of a psychotropic medication for 1( Resident 50) of 5 s...
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Based on record review, observation and interview, the facility failed to obtain a rationale from the medical practitioner for the continued use of a psychotropic medication for 1( Resident 50) of 5 sampled residents. The facility identified a census of 62.
Findings are:
A record review of the Medication Regimen Review (MRR) for Resident 50 completed between 9/1/23 and 9/8/23 revealed, the facility Pharmacy Consultant gave a recommendation on 9/7/23 for the physician to give a clinical rationale to continue the use of lorazepam (a medication to treat anxiety) prn (as needed) for duration of six months.
A record review of a MRR completed between 11/01/2023 and 11/8/2023 for Resident 50 revealed the Pharmacist Consultant gave a recommendation on 11/09/2023 for the physician to give a clinical rational to continue the use of as needed lorazepam.
On 11/30/2023 at 12:20 PM an interview was conducted with the Director of Nursing (DON). During the interview review of the pharmacist recommendation dated 9/07/2023 and 11/09/2023 was completed with the DON. The DON confirmed during the interview that Resident 50's physician had not responded to the recommendation made by the pharmacist.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
B. An observation on 11/29/23 at 7:31 AM of medication administration to Resident 59 by CMA-D revealed medications were administered to Resident 59 including Quetiapine (antipsychotic medication) tab ...
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B. An observation on 11/29/23 at 7:31 AM of medication administration to Resident 59 by CMA-D revealed medications were administered to Resident 59 including Quetiapine (antipsychotic medication) tab 25 mg, take 1 tablet by mouth three times daily.
A record review a physican summary sheet for November 2023 revealed, the order for Quetiapine Tab 25 mg - take 1 tab by mouth three times daily was discontinued on 11/28/2023.
On 11/29/2023 at 7:40 AM a interview was conducted with CMA-D. During the interview CMA-D confirmed Resident 59 had been given the discontinued Quetiapine medication.
ON 11-29-2023 at 7:40 AM an interview was conducted with Registered Nurse (RN)-E. During the interview RN-E confirmed Resident 59's Quetiapine had been discontinued.
LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D
Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. Observation of 30 medications administered revealed 2 errors which resulted in an error rate of 6.67%. The errors affected 2 of 5 residents (Resident's 7 and 59) observed during medication administration. The facility identified a census of 62.
Findings are:
A. Observation on 11/30/2023 at 7:35 AM of a medication administration for Resident 7 revealed Certified Medication Assistant (CMA)-B prepared medications that included a Advair Diskus (bronchodilator) inhaler, 100/50 mcg 1 puff to be taken 2 times a day and for Resident 7 to rinse the mouth after use. CMA-B prepared the medication, including the Advair Diskus inhaler to be given to Resident 7. CMA-B after administering oral medication to Resident 7, primed and handed the Advair Diskus to Resident 7. Resident 7 inhaled the metered dose of the medication and handed the inhaler back to CMA-B. CMA-B did not have Resident 7 rinse the mouth after use.
An interview on 11/30/2023 at 11:35 AM with Resident 7 revealed, that they had not been told that they should rinse their mouth after using the Advair inhaler.
An interview on 11/30/2023 at 12:09 PM with CMA-B revealed, that the CMA-B was aware the resident should have rinsed their mouth after using the inhaler. CMA-B revealed, [gender] had not instructed the resident to rinse their mouth after using the inhaler.
On 11/30/2023 at 12:09 PM an interview was conducted with CMA-B. During the interview CMA-B confirmed Resident 7 did not rinse the mouth after using the Advair Diskus inhaler.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Licensure Reference Number NAC 175 12-007.01A
Based on record review, observation and interview, the facility failed to date opened food items to prevent the potential for food borne illness. This had...
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Licensure Reference Number NAC 175 12-007.01A
Based on record review, observation and interview, the facility failed to date opened food items to prevent the potential for food borne illness. This had the potential to affect all residents in the building. The facility staff identified a census of 62.
Findings are:
A record review of an undated Facility Food safety Requirement policy revealed, the following; Paragraph b) #4, Proper labeling and dating of each item.
An observation on 11/27/23 at 6:57 AM of 4 packages of Sysco drink mixes are open and placed in an open zip lock bag with no date of opening. 1) Sysco fruit punch drink mix, 2) Sysco Orange Drink Mix, 3) Sysco Lemonade drink Mix, 4) Sysco Grape Drink Mix.
An observation on 11/29/23 at 6:05 AM of the Sysco fruit punch drink mix was open and dated 12/27/23 (a month later). Sysco orange drink mix was opened and dated 12/27/23. Malt O Meal (on spice rack) opened with no date. Hamburger buns opened and not dated.
A interview on 11/29/23 at 6:10 AM with DM (Dietary Manager) revealed, that the packages were opened on 11/28/23. The DM reported during the interview that when packages are opened, they are to be dated with the open date. DM also revealed, that the drink mixes were marked with the wrong date. DM further revealed, the Malt O Meal should have been dated with the date the package was opened and placed in a storage container.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(6)
Based on record review and interview; the facility staff failed to ensure a Volu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.05(6)
Based on record review and interview; the facility staff failed to ensure a Voluntary Arbitration Agreement ( According to www.alabar.org a Arbitration agreement requires that persons who signed them resolve any disputes by binding arbitration, rather than in court before a judge and/or jury) was explained and understood for 3( Resident 8, 57 and 58) of 3 sampled residents. The facility staff identified a census of 62.
Findings are:
A. Record review of Resident 58's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 8-20-2023 revealed Resident 58 admitted to the facility on [DATE]. Further review of Resident 58's MDS dated [DATE] revealed the facility staff assessed Resident 58 with a Brief Interview of Mental Status (BIMS) of a 7. According to the MDS [NAME] a BIMS of 0-7 indicates severe cognitive impairment.
Record review of Resident 58's MDS dated [DATE] revealed the facility staff assessed Resident 58 with a BIMS of 3.
Record review of a Nebraska Voluntary Agreement for Arbitration (NVAA) revealed Resident 58 had signed the NVAA on 8-14-2023 consenting to the agreement.
On 11-30-2023 at 2:39 PM an interview was conducted with a Family Member (FM) of Resident 58. During the interview Resident 58's FM reported being present when Resident 58 signed the NVAA on 8-14-2023. During the interview Resident 58's FM reported the facility staff did not explain what the NVAA was and reported Resident 58 would not have understood what Resident 58 was signing.
B. Record review of a admission Record sheet printed on 11-30-2023 revealed Resident 8 was admitted to the facility on [DATE].
Record review of Resident 8's MDS dated [DATE] revealed the facility staff assessed Resident 8's BIMS as a 15. According to the MDS [NAME], a BIMS of 13 to 15 indicates a person is cognitively intact.
Record review of a NVAA revealed Resident 8 signed a NVAA on 9-20-2023.
An interview was conducted with Resident 8 on 11-30-2023 at 1:20 PM. During the interview Resident 8 reported signing a a lot of papers on admission. Resident 8 reported not being aware of signing the NVAA and the NVAA being explained.
C. Record review of a admission Record sheet printed on 11-30-2023 revealed Resident 57 admitted to the facility on [DATE].
Record review of Resident 57's MDS dated [DATE] revealed the facility staff assessed Resident 57 BIMS as a 15.
Record review of Resident 57's medical record revealed Resident 57 signed a NVAA on 8-14-2023.
On 11-30-2023 at 1:20 PM an interview was conducted with Resident 57. During the interview Resident 57 reported the facility staff did not review the NVAA with Resident 57. Resident 57 stated I would not have signed it if they would have gone over it with me.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record Review of the Facility Infection Control Policy and Procedure for Cleaning and Disinfecting dated 01/02/2019 revealed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Record Review of the Facility Infection Control Policy and Procedure for Cleaning and Disinfecting dated 01/02/2019 revealed the following:
- Purpose:
-to prevent infectious spread from items or environment to residents and/or staff.
-Process:
-Clean and disinfect items/environment according to risk of infection category.
-1.3 Non-critical items are objects that do not come into contact with the mucous membranes, but do come into contact with intact skin.
-4. Perform routine disinfection of items used in daily care practices.
-4.2 Disinfect these non-critical items after direct contact with the resident's environment and before use on another resident.
Observation on 11/29/2023 at 7:30 AM of Certified Medication Aid (CMA) B leaving room [ROOM NUMBER] with sit-to-stand lift (type of mechanical lift). and pushed the lift to room [ROOM NUMBER] without disinfecting the lift. Further observation revealed CMA B then took the un-disinfected lift into room [ROOM NUMBER] and used the lift with the resident.
An interview on 11/29/2023 at 7:45 AM was conducted with CMA B. During the interview CMA B confirmed that the sit-to-stand lift was not disinfected in between resident use and should have been.
C. Record Review of an undated Facility Hand Hygiene policy revealed the following:
-Purpose:
-To decrease spread of infection
Definition:
Hand Hygiene- a general term that applies to hand washing, antiseptic hand wash, antiseptic hand rub or surgical hand antisepsis.
When to wash hands or use an alcohol-based hand rub:
-Before applying and after removing gloves.
-After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
Observation on 11/28/2023 at 8:30 AM of Nurse Assistant (NA) J exiting room [ROOM NUMBER] with gloves on walked down the hallway removed the soiled gloves and put them into the trash. NA J did not complete hand hygiene after removing the soiled gloves.
An interview was conducted with NA J on 11/28/2023 at 8:35 AM. During the interview NA J confirmed that hand hygiene was not completed after removing gloves.
An interview with the DON on 11/30/23 confirmed that staff are to perform hand hygiene after removing gloves.
LICENSURE REFERENCE NUMBER 175 NAC 12-006.17
Based on observations, record review and interview; the facility staff failed to implement interventions to prevent the spread of Covid-19 in the secured unit, this had the potential to effect 13 out of 17 residents in the secured unit), failed to sanitize a mechanical lift before resident use between 2 rooms and failed to utilize handwashing and gloving techniques to prevent the potential cross contamination from resident to resident. The facility staff identified a census of 62.
Findings are;
A. A record review of the list of residents who tested positive for Covid-19 revealed the following information:
- Residents 24, 47 and 58, who resident on the secured unit, tested positive for Covid-19 on 11/27/2023.
An observation on 11/28/2023 at 9:00 AM revealed Residents 24, and 58 have remained in their original rooms with their roommates who had tested negative for Covid-19.
Observations of the dining room on 11/28/2023 at 11:15 AM revealed Resident 24 and 58 to be on the unit without facemask's.
An observation on 11/28/2023 at 10:45 AM of Resident 58 wandering up and down the hallway of the unit without a facemask.
An interview on 11/28/2023 at 1:57 PM with Certified Medication Assistant (CMA) A confirmed the Covid-19 positive residents were on the special care unit. CMA A reported the residents will not wear masks correctly and will usually take them off or pull them down. CMA A reported not receiving education or guidance on how to separate Covid-19 positive dementia residents from Covid-19 negative dementia residents.
An observation on 11/28/2023 at 11:42 AM revealed Resident 24 and Resident 58 sitting at the dining room table with Resident 44 and not wearing a mask.
O 11/28/2023 at 11:50 AM a interview was conducted with the Infection Preventionist (IP) and the Director of Nursing (DON). During the interview the DON reported were 17 residents on the memory care unit. The DON confirmed Covid-19 negative residents are exposed to Covid-19 positive residents and an attempt to separate positive residents from negative residents was not completed. The DON confirmed the facility has not discussed the outbreak with any of the National Standards.
An observation on 11/29/2023 at 9:45 AM of Residents 24 and 58 in dining room with other residents and not wearing a mask.
An interview on 11/30/23 at 2:28 PM with Licensed Practical Nurse / Infection Preventionist (LPN C/IP) confirmed the facility would not be moving the Covid-19 positive residents into other rooms away from their Covid-19 negative rooms mates.
A record review was conducted of the facility's Covid-19 facility policy and procedure dated 9/28/2023 which stated if cohorting, only patients with the same respiratory pathogen should be housed in the same room.
Nov 2022
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Licensure Reference Number 175 NAC 12.006.10
Based on observation, record review and interview, the facility failed to maintain an error rate of less than 5%. The error rate was 35.29%. The facility s...
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Licensure Reference Number 175 NAC 12.006.10
Based on observation, record review and interview, the facility failed to maintain an error rate of less than 5%. The error rate was 35.29%. The facility staff identified a census of 64.
Findings are:
Observation of medication administration on 11/16/22 at 07:30 AM by MA G (Medication Aide) to Resident 30. MA G removed the medication cards from the medication drawer and checked the medications individually against Resident 30's information in the computer prior to placing the medication in a medication cup. MA G then separated the capsules from the tablets and crushed the tablets. MA G donned gloves, opened the capsules and poured the contents of the capsules into the medicine cup containing the crushed tablet medications. MA G opened a container of chocolate pudding and mixed some of it with the crushed medications. MA G entered Resident 30's room and informed Resident 30 that they had some medication for the resident. Resident 30 allowed MA G to give the medications by mouth and MA G asked Resident 30 to open their mouth so MA G could make sure the medication had been swallowed. MA G returned to the medication cart, removed their gloves and charted the administration. Medications given were as follows:
-Amlodipine 2.5mg (milligrams) Take 1 tablet by mouth once daily.
-Aspirin 81mg chew tablet. Take 1 tablet by mouth once daily.
-Losartan 50mg. Take 2 tablets by mouth once daily.
-Tradjenta 5mg. Take 1 tablet by mouth once daily.
-Carbamazapine 100mg chew tablet. Chew and swallow 1 tablet twice a day.
-Metformin 500mg. Take 1 tablet twice daily with meals. Take with food.
-Trazadone 50mg. Take 1/2 tablet by mouth twice daily.
-Vitamin D3. 2000u (units). Take 1 tablet by mouth daily.
-Omeprazole 20mg. Take 1 capsule by mouth daily.
-Tamsulosin 0.4mg capsule. Take one capsule by mouth once daily. Do not crush or chew.
An interview on 11/16/22 at 08:35 AM with MA G revealed Resident 30 is unable to swallow whole tablets or capsules. MA G confirmed that as the reason the tablets were crushed and the capsules were opened and their contents were mixed with the crushed medications. MA G stated Resident 30 does not have a physician's order to crush the medications. MA G confirmed Resident 30 does not have a physician's order to open the capsules and mix the contents with food for administration. MA G confirmed there is a do not crush addendum to the Tamsulosin order.
An interview on 11/16/22 at 02:51 PM with LPN (Licensed Practical Nurse) E confirmed Resident 30 does not have a physician's order to crush their medications.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Licensure Reference Number: 175 NAC 12-006.10D
Based on record review and interview, the facility failed to ensure medications were available to administer for 1 of 5 residents reviewed (Resident 64)...
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Licensure Reference Number: 175 NAC 12-006.10D
Based on record review and interview, the facility failed to ensure medications were available to administer for 1 of 5 residents reviewed (Resident 64) as ordered by the physician resulting in a significant medication error. The facility census was 64.
Findings are:
Review of Resident 64's progress notes revealed Resident 64 was admitted to the facility at 6:00 PM on 9/1/2022.
Review of Resident 64's MAR revealed Resident 64 was to receive Eliquis (clot prevention) and metaprolol (blood pressure) daily.
Review of Resident 64 MAR dated for September 2022 revealed resident did not receive medications until the morning of 9/3/2022 related to not being available from pharmacy.
Review of Resident 64's progress notes revealed no documentation regarding medications not being available for administration or attempts to contact the pharmacy.
Review of an email from the pharmacy dated 11/17/2022 revealed they did not receive the fax regarding Resident 64's medications until 9/2/22 and the request was not marked urgent so medications were filled and delivered at the routine evening delivery, arriving at the facility at 8:57 PM resulting in the resident not receiving medications on the day of 9/2/22.
Interview on 11/17/22 at 8:49 AM with the Director of Nursing (DON) revealed medications should be available no later than the following morning for residents that are admitted in the evening hours and the healthcare practitioner should have been notified that Resident 64's medications were not available.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A
Based on observations, record review and interview; the facility staff failed to provide the portion size of 8 ounces of ham for 28 residents who ate regu...
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LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A
Based on observations, record review and interview; the facility staff failed to provide the portion size of 8 ounces of ham for 28 residents who ate regular textured meals from the west dining room and failed to follow the menu for for 2 residents who receive pureed meals who ate from the west dining room. The facility staff identified a census of 64.
Findings are:
Record review of a week at a Glance Menu for the facility residents revealed on 11-16-2022 facility residents were to receive baked ham, Augratin potatoes, Brussels sprouts, dinner roll with margarine and peach cobbler for lunch.
Record review of a Diet spread sheet revealed residents on regular textured diets were to receive 3 ounces of ham in addition to the other menu items for 11-16-2022 at lunch. Further review of the Diet Spread sheet for 11-16-2022 for the lunch meal revealed residents on pureed textured meals were to have pureed peach cobbler and pureed Augratin potato's.
Observation on 11-16-2022 starting at 12:00 PM through 12:58 PM with Register Dietician (RD) J revealed [NAME] I served 1 half slice of ham to residents on regular texture diets. Observation of the ham sliced revealed the ham was sliced thin. Further observation revealed residents on pureed texture did not receive pureed Augration potato's or pureed peach cobbler.
Observation on 11-16-2022 at 12:58 PM revealed that RD J weighed a slice of ham revealing the weight to be 1.5 ounces. RD J confirmed the slice of ham that was served was not the correct portion size and further confirmed residents on purred diets should have received augratin potato's and peach cobbler.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
D. On 11/15/2022 at 07:10 AM the ADON(Assistant Director of Nursing)was observed providing care to Resident 40. The ADON put on gloves after sanitizing their hands. The ADON assisted Resident 40 to st...
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D. On 11/15/2022 at 07:10 AM the ADON(Assistant Director of Nursing)was observed providing care to Resident 40. The ADON put on gloves after sanitizing their hands. The ADON assisted Resident 40 to stand beside the bed and lowered the resident's trousers and brief. The ADON was observed cleaning Resident 40's peri rectal/scrotal area with cleansing wipes while Resident 40 stood beside bed. The ADON removed the glove from their right hand and replaced it with a clean glove. The ADON applied Medihoney (tradename of a wound gel dressing) to Resident 40's gluteal cleft area. The ADON removed the soiled glove from their right hand, replaced it with a clean glove and then applied combination ointment(Nystatin/Triamancinolone/A&D)to Resident 40's peri area, scrotum and groin. The ADON discarded the gloves and used hand sanitizer. The ADON recorded the administration of the combination ointment and the Medihoney The ADON did not use hand sanitizer in between glove changes.
An interview on 11/16/22 at 03:25 PM with ADON confirmed that the ADON did not hand sanitize between glove changes when applying medication to Resident 40's peri rectal/scrotal area. The ADON confirmed hand sanitization should have been performed between glove changes.
Medications are as follows:
-Medi honey - Apply to Dorsal Sagital area three times daily.
-Nystatin/Triamancinolone/A&D ointment apply to peri area, scrotum and groin twice daily.
LICENSURE REFERENCE NUMBER 175 NAC 12-006.17
Based on observations, record review and interview; the facility staff failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination during the provision of care and medication administration for 4 (Resident 3, 50, 64 and 40) of 8 residents. The facility staff identified a census of 64.
Findings are:
A. Record review of Resident 3's Comprehensive Care Plan (CCP) dated 9-24-2021 revealed Resident 3 was incontinent of bladder.
Observation on 11-15-2022 at 2:42 PM of personal care for Resident 3 revealed Nursing Assistant (NA) H had donned gloves. NA H unfastened Resident 3's adult brief and placed the brief between Resident 3's legs. NA H using a disposable cloth, wiped Resident 3's left groin and obtained a new wipe and cleansed the right groin area and without changing the gloves wiped the labia area. NA H with the soiled gloves assisted Resident 3 into a right laying position touching Resident 3's hips and blanket. NA H cleansed Resident 3's buttock, removed the soiled gloves and completed the care.
On 11-15-2022 at 2:55 PM a interview was conducted with NA H. During the interview NA H reported gloves are to be changed when soiled. NA H reported being taught to clean the groin area and then the labia.
B. Record review of Resident 50's CCP dated 10-31-2022 revealed Resident 50 was incontinent of bladder.
Observation on 11-16-2022 at 8:50 AM revealed NA A and NA B donned gloves uncovered Resident 50 and unfastened an adult brief between Resident 50's legs. NA A using a disposable wipe, cleansed the abdominal folds. NA A without changing the soiled gloves obtained a disposable wipe and clean the groin left groin then obtained another disposable wipe and cleaned the right groin area. NA A without changing the soiled gloves obtained a disposable wipe and cleaned Resident 50's labia area.
On 11-16-2022 at 9:10 AM an interview was completed with NA A. During the interview NA A reported gloves are to be changed when soiled. NA A reported being taught to clean the groin before cleaning the labia area.
C. Record review of Resident 67 admission Care Plan (ACP) dated 11-12-2022 revealed Resident 67 had an indwelling catheter (tubing placed into the bladder to drain urine).
Observation on 11-15-2022 at 2:20 PM of personal/catheter care revealed NA M had donned gloves. NA M obtained a disposable wipe and uncovered Resident 67. NA M using the disposable wiped wiped the top portion of Resident 67's penis. NA M obtained another disposable wipe cleansed the tubing of the catheter. Without changing the soiled gloves obtained a disposable wipe the top of the penis using several wiping motions.
On 11-15-2022 at 2:30 PM an interview was conducted with NA M. During the interview NA M reported gloves are to be changed when soiled.
Record review of an undated process for Pericare Procedure-Male/Female revealed the following information:
-#8. Staff member to wash resident from front to back and change side of wash cloth with each swipe.
-#9. Female front, Wash middle first then sides. Male, wash tip first, the shaft ad then the scrotal sac.
Record review of the facility Handwashing/Hand Hygiene policy dated 6-2010 revealed the following information:
-Policy statement:
-The facility considers hand hygiene the primary means to prevent the spread of infections.
-#5. Employees must wash their hands for at least 15 seconds using soap and water under the following conditions:
-Before and after assisting a resident with personal care.
-Before and after assisting a resident with toileting.
-Before and after direct resident contact ( for which hand hygiene is indicated by acceptable professional practice.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E
Based on observations, record review and interview, the facility staff failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E
Based on observations, record review and interview, the facility staff failed to ensure the dishes were sanitized, floors in the dry storage area, [NAME] cooler and freezer were clean and failed to ensure food temperatures were maintained in a manner to prevent the potential for food borne illness. This had the potential to affect 63 of 64 residents who ate from the kitchen. The facility staff identified a census of 64.
Findings are;
A. Observation of the kitchen on 11-14-2022 at 6:55 AM revealed [NAME] L was preparing breakfast. Further observations revealed the facility dishwasher was connected to a container of sanitizer. During the observation [NAME] J reported the dishwasher was a hot water sanitizing machine and started the dishwasher. Observations at this time revealed the chemicals in the container moved during the rinse cycle.
Record review of a Dish Machine-Parts Per Million (PPM) Sanitizer record log for November 2022 revealed the following information:
-11-01-2022 AM, PPM was identified as 124 and the PM PPM was 124.
-11-02-2022 AM, PPM was 123 and the PM PPM was 124.
-11-03-2022 AM, PPM was 124 and the PM PPM was 122.
-11-04-2022 AM PPM was 127 and the PM PPM was 124.
-11-05-2022 AM PPM was 121 and the PM PPM was 126.
-11-06-2022 AM PPM was 120 and the PM PPM was 122.
There were no PPM identified for 11-12-2022 and 11-13-2022.
On 11-14-2022 at 9:30 AM an interview was completed with the Dietary Services Manager (DSM). During the interview the DSM reported the facility dishwasher is a hot water temperature machine and provided the Dish Machine-PPM Sanitizer record log for November 2022 and reported the record PPM were actually the water temperature of the dishwasher. The DSM reported that water temperatures recorded were on the wash cycle and not the rinse. The DSM was not able to state what the rinse cycle was and what the requirements were to ensure dishes were sanitized.
On 11-14-2022 at 9:40 AM an interview was conducted with the Maintenance Director (MD). During the interview the MD reported the facility dishwasher is a chemical sanitation machine
On 11-14-2022 at 9:40 AM a follow up interview was conducted with the DSM. During the interview the DSM reported not being aware the dishwasher was a chemical sanitizer and was not monitoring the chemicals to ensure the dishwasher was sanitizing the dishes and did not have the test strips for the dishwasher.
On 11-14-2022 at 10:30 AM the DSM reported the kitchen staff will run the dishes through the dishwasher and then in the 3 compartment sink, they would sanitize the dishes as there were test strips for that sanitizing chemicals until the test strips for the dishwasher were obtained.
B. Obsetvation on 11-14-2022 at 6:55 AM revealed the floor in the dry goods area, walk in cooler and freezer had black grime build up around the base and was sticky when walked on.
C. Observation on 11-16-22 from 12:00 PM through 12:58 PM with the Registered Dietician (RD) J revealed the food temperatures were obtained after the completion of meal service in the west dining room. The food temperature of the pureed meat was 118.4 degrees and the pureed brussel sprouts was 119.0 degrees.
On 11-14-2022 at 9:30 AM an interview was conducted with the DSM. During the interview the DSM confirmed the floors in the dry goods area, [NAME] cooler and freezer were sticky and [NAME] had blackish grime build up around the base.
On 11-16-2022 at 12:58 PM an interview was conducted with RD J. During the interview RD J reported the pureed meat and the pureed brussel sprouts was to cold and the holding temperature should be be around 135 degrees to 140 degrees.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 42% turnover. Below Nebraska's 48% average. Good staff retention means consistent care.
Concerns
- • 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • $60,671 in fines. Extremely high, among the most fined facilities in Nebraska. Major compliance failures.
- • Grade F (30/100). Below average facility with significant concerns.
Bottom line: Trust Score of 30/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Emerald Nursing & Rehab Legacy Pointe Llc's CMS Rating?
CMS assigns Emerald Nursing & Rehab Legacy Pointe llc an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Nebraska, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Emerald Nursing & Rehab Legacy Pointe Llc Staffed?
CMS rates Emerald Nursing & Rehab Legacy Pointe llc's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 42%, compared to the Nebraska average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Emerald Nursing & Rehab Legacy Pointe Llc?
State health inspectors documented 33 deficiencies at Emerald Nursing & Rehab Legacy Pointe llc during 2022 to 2025. These included: 33 with potential for harm.
Who Owns and Operates Emerald Nursing & Rehab Legacy Pointe Llc?
Emerald Nursing & Rehab Legacy Pointe llc is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EMERALD HEALTHCARE, a chain that manages multiple nursing homes. With 108 certified beds and approximately 63 residents (about 58% occupancy), it is a mid-sized facility located in Omaha, Nebraska.
How Does Emerald Nursing & Rehab Legacy Pointe Llc Compare to Other Nebraska Nursing Homes?
Compared to the 100 nursing homes in Nebraska, Emerald Nursing & Rehab Legacy Pointe llc's overall rating (1 stars) is below the state average of 2.9, staff turnover (42%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Emerald Nursing & Rehab Legacy Pointe Llc?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Emerald Nursing & Rehab Legacy Pointe Llc Safe?
Based on CMS inspection data, Emerald Nursing & Rehab Legacy Pointe llc has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Nebraska. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Emerald Nursing & Rehab Legacy Pointe Llc Stick Around?
Emerald Nursing & Rehab Legacy Pointe llc has a staff turnover rate of 42%, which is about average for Nebraska nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Emerald Nursing & Rehab Legacy Pointe Llc Ever Fined?
Emerald Nursing & Rehab Legacy Pointe llc has been fined $60,671 across 9 penalty actions. This is above the Nebraska average of $33,686. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Emerald Nursing & Rehab Legacy Pointe Llc on Any Federal Watch List?
Emerald Nursing & Rehab Legacy Pointe llc is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.