Cascades at Skyview: Infection Control Failures - NE
The inspection at Cascades at Skyview, triggered by a complaint and conducted on August 6, 2025, documented infection control failures that reached across the facility, from the wound care room to the medication cart in the hallway.
The wound care procedure involving Resident 18 unraveled in stages. The nurse, identified in inspection records as RN-A, started by cleansing the wound using gauze moistened with normal saline. The correct technique moves from the cleanest area outward, using a fresh section of gauze for each pass, to avoid dragging bacteria back into the wound. RN-A did the opposite, beginning at the surrounding skin and working toward the center, using the same gauze pad throughout.
Then she changed gloves. That part she did correctly. But after putting on the clean pair, she opened the alginate dressing packet with her gloved hands, then reached for the skin prep and the dressing packages that had been carried down the hallway exposed, touching surfaces that had not been sterile. The new gloves were now contaminated. She applied the skin prep, packed the alginate, and secured the dressing, all with the same compromised hands.
In her interview with inspectors at 10:10 that morning, RN-A said she had not known her gloves were contaminated when she applied them to the wound. She did not dispute what the inspector had observed. She simply had not seen it happening.
The inspection records note the violation affected many residents.
A separate observation, beginning at 8:27 a.m. on August 5, caught a medication aide identified as MA-B moving from one resident's room to the next without performing hand hygiene. MA-B had just finished administering medications to a previous resident. There was no handwashing, no alcohol-based hand rub, before beginning to prepare medications for Resident 3.
The cart's preparation surface had not been sanitized either.
MA-B picked up scissors to cut Resident 3's lidocaine patches in half, as ordered. Then used the same scissors, without sanitizing them, to cut open a packet of Arginaid, a nutritional supplement. The scissors that had just handled a medicated patch, a drug that absorbs through skin contact, were now touching something the resident would swallow.
MA-B dispensed Resident 3's Tums into one medication cup and the remaining medications into another. Then set the second cup on top of the first, letting the bottom of the cup press directly against the Tums inside.
After that, MA-B put on gloves and walked to Resident 3's room. Used the gloved hands to open the door. Then, with those same gloves, helped Resident 3 apply a medicated cream to their hip.
The facility's own hand hygiene policy, reviewed by inspectors, lists the moments when hand hygiene is required: before and after contact with residents, before donning gloves, before preparing or handling medications, after contact with objects near a resident. The policy was undated.
What the inspection captured was not a single lapse by one distracted worker on a hard morning. The nurse doing wound care did not know that carrying dressing packages down an open hallway and then opening them with clean gloves was a problem. The medication aide moved through an entire medication preparation and delivery sequence, touching scissors, supplement packets, door handles, and a resident's skin, without stopping once to clean their hands.
Resident 18's wound was dressed with contaminated gloves. Resident 3 swallowed medications that had shared a cup with Tums touched by the bottom of another cup, prepared by hands that hadn't been washed since the previous patient.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cascades At Skyview from 2025-08-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Cascades at Skyview in Bridgeport, NE was cited for violations during a health inspection on August 18, 2025.
The wound care procedure involving Resident 18 unraveled in stages.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.