Good Shepherd Lutheran Home

actions that can be measured.

Reference Number 175 NAC 12-006.09(E) Based on interview and record review, the facility failed to

detailed roadmap outlining a resident's medical, physical, and daily living needs).

The facility census was 62.

Findings are:A record review of the facility's undated Comprehensive Care Plans policy revealed that the care plan would include the services to be furnished to the resident. A record review of Resident 22's Clinical Census dated 05/26/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 22's Medical Diagnosis dated 05/26/2026 reveled the resident had diagnoses of Cerebral Infarction (stroke) and Morbid (Severe) Obesity. A record review of Resident 22's Minimum Data Set (MDS, a comprehensive assessment used to develop a resident's care plan) dated 05/15/2026 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a resident's cognitive abilities) of 14 which indicated the resident was cognitively aware (able to understand).

The resident required setup or clean-up assistance with eating and oral hygiene (cleaning), partial/moderate assistance with upper body dressing and personal hygiene, and required substantial/maximal assistance with lower body dressing, toileting hygiene, bathing, and footwear.

The resident required partial/moderate assistance with bed mobility and transfers.

The resident was on oxygen. A record review of Resident 22's Clinical Physician Orders dated 05/26/2026 revealed the resident had an order for oxygen at 1-2 liters per minute (l/m) via nasal cannula (a tubing inserted in a resident's nose to deliver oxygen).

Notify primary care provider (PCP) if saturations less than 90 percent (%). A record review of Resident 22's Care Plan Report with an admission date of 11/10/2025 did not reveal a focus area or interventions for the resident's oxygen. An observation on 05/18/2026 at 10:12 AM revealed Resident 22 was not in the resident's room, the oxygen concentrator (machine used to purify oxygen) was on, and the nasal cannula was lying on the bed sheet. An observation on 05/20/2026 at 7:01 AM revealed Resident 22 was not in the resident's room, the oxygen concentrator was on, and the nasal cannula was lying on the bed sheet. An observation on 05/20/2026 at 10:45 AM with the Director of Nursing (DON) revealed Resident 22 was not in the resident's room, the oxygen concentrator was on, and the nasal cannula was lying on the bed sheet. In an interview on 05/20/2026 at 7:04 AM, Resident 22 confirmed the resident wore oxygen, but only at night. In an interview on 05/20/2026 at 10:45 AM, the DON confirmed Resident 22 was on oxygen at night. In an interview on 05/26/2026 at 8:52 AM, the DON confirmed Resident 22's oxygen was not on the care plan and should have been.

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

Document:

Reason order was not completed Notifications made Practitioner response Resident outcome Corrective actions taken Follow alternative interventions ordered by practitioner.

Record Review of Resident 7's Order Report Summary dated 5/20/2026 revealed Resident 7's practitioner had ordered daily weights be obtained and notify Primary Care Practitioner (PCP) if weight gain is greater than 5 pounds.

Record Review of Resident 7's April 2026 and May 2026 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed the following: Weights were not obtained on 4/9/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/25/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/6/2026 and 5/14/2026.

Record Review of Resident 7's Electronic Health Record (EHR) revealed there was no provider notification regarding weight increase on 4/7/2026 with a weight gain of 7 pounds, 4/24/2026 with a weight gain of 7.2 pounds, 4/28/2026 with a weight gain of 5.4 pounds and on 5/10/2026 with a weight gain 8.2 pounds.

In an interview on 5/26/2026 at 7:04 AM Infection Preventionist (IP) confirmed that weights were not obtained on 4/9/2026, 4/15/2026, 4/16/2026, 4/22/2026, 4/23/2026, 4/25/2026, 4/29/2026, 4/30/2026, 5/1/2026, 5/6/2026 and 5/14/2026 and should have been.

The IP confirmed that there was no notification to the provider seen in the residents EHR regarding the 5 pound or greater weight gain.

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

Observation of Resident 55 on 5/20/26 at 6:35 AM revealed Resident 55 alone in room, sitting up on the left side of the bed with the fall matt folded up against the wall between the dresser and the heating/air conditioner unit.

Observation of Resident 55 on 5/21/26 at 7:13 AM revealed the resident sitting on the left side of the bed with the fall matt folded up against the wall between the dresser and the heating/air conditioner unit.

In an interview with the Director of Nursing (DON) on 5/20/26 at 6:37 AM confirmed the fall matt was not on the floor next to the bed as is care planned when resident is in bed and should be.

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

Observation on 05/19/26 at 3:20 PM and 5/20/26 at 3:25 PM revealed the posted nursing staffing information for 05/18/26, 5/19/26 and 5/20/26 did not contain the facility census, a calculation of the number of hours worked per discipline per shift or the total number of hours worked per shift and daily.

Record review of 30 days past posted nurse staffing documentation between 4/18/26 and 5/20/26 revealed the daily posted nurse staffing did not contain the facility census, a calculation of the total number of hours worked per discipline per shift and the total number of hours worked for each shift.

Interview on 05/21/2026 at 8:34 AM with the facility Director of Nursing [DON] confirmed that the facility census was not included on the past 30 days of the posted nurse staffing information and no calculation of hours worked per discipline and no calculation of the total number of hours worked had been completed or documented on the posted nurse staffing information.

The DON confirmed that those items should have been included in the posted nurse staffing information.

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

increased on 4/28/2026 to 137mcg but not administered as scheduled on 5/3/2026, 5/4/2026, 5/9/2026, 5/14/2026. No documentation of administration on 4/12/2026. -Lantus Solos injection was not administered on 4/16/2026, 4/18/2026, 4/22/2026, 4/23/2026, 5/3/2026, 5/13/2026.

Refused on 4/21/2026, 4/30/2026 and 5/2/2026. -Mirtazapine tablet 15MG was not administered on 4/16/2026, 4/18/2026, 4/22/2026, 4/23/2026, 5/3/2026, 5/13/2026. -Olanzapine tablet 5MG was not administered on 4/16/2026, 4/18/2026, 4/22/2026, 4/23/2026, 5/3/2026 and 5/13/2026.

In an Interview on 5/19/2026 at 1:31 PM, Director of Nursing (DON) confirmed nurses should be attempting to administer the medication three times before charting an omission (not given) and should be documenting that an attempt was made three times in the progress notes.

In an Interview on 5/19/2026 at 1:31 PM, Infection Preventionist (IP) confirmed the medications listed were not administered on the dates listed. .

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

serve food in accordance with professional standards.

Reference Number 175 NAC 12-006.11 Based on observation, interview, and record review the facility

during dining service and failed to perform hand hygiene when indicated during food prep.

This had the potential to affect all residents but 1 resident in the facility.

The facility census was 62.

Findings are: A.

RR of the facility's undated Handwashing Guidelines for Dietary Employees policy revealed the following:

• Frequency of Handwashing:

Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and [NAME] use articles and also in the following situations: a.

Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. b.

After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. c.

After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.). g. when switching between working with raw food and working with ready to eat food. h.

Before donning gloves for working with food.

An observation during meal preparation on 5/20/2026 between 8:44 AM and 10:25 AM revealed the Dietary Manager (DM) completed hand hygiene (HH) for 20 seconds (sec), applied gloves, grabbed a box of pork chops, cut open each individual wrapped pork chop and placed them on the baking sheet.

The DM removed the soiled gloves and did not complete HH touching clean baking sheets.

The DM lined the baking sheets with parchment paper without completing HH and applied gloves.

The DM open each individually wrapped pork chop with a knife and place them on the baking sheet.

The DM discarded the trash from the porkchops, removed the soiled gloves, and did not complete HH.

The DM washed the counter with a sanitizer washcloth towel, took the washcloth to the dish area, did not complete HH, went to walk-in to grab potato salad and brought potato salad back to prep area and opened the containers of potato salad.

The DM removed trash, removed the soiled gloves and did not complete HH.

In an interview on 5/20/2026 at 9:43 AM DM confirmed that hand hygiene was not completed between glove changes and should have been.

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

F 0812 B.

and after touching a resident.

An observation on 05/20/2026 at 8:06 AM revealed Nursing Assistant (NA)-M entered the dining room and assisted Resident 58 with setting up the resident's meal tray and applying a clothing protector while touching the resident's neck and clothing without performing hand hygiene. NA-M then approached Resident 62 and applied a clothing protector while touching the resident's neck and clothing before NA-M sat down beside Resident 62 to assist Resident 62 with eating. No hand hygiene was performed before or after contact with Resident 58, or before resident contact with Resident 62.

In an interview on 05/21/2026 at 7:54 AM, the DON confirmed NA-M should have completed hand hygiene before and after resident contact in the dining room.

285148 05/26/2026

Good Shepherd Lutheran Home 2242 Wright Street Blair, NE 68008

for residents competently during both day-to-day operations (including nights and weekends) and

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on

information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff and a contingency plan for events that do not require the activation of the facility emergency plan but have the potential to impact resident care.

This had the potential to affect all residents that resided in the facility.

The facility census was 62.

Findings are:A record review of the facility's undated Facility Assessment policy revealed The facility would conduct and document a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations (including nights and weekends) and emergencies.

The assessment would address or include the resident population including, but not limited to number of residents and the facility's capacity, staff competencies and skill sets, physical environment, equipment and services, and cultural, ethnic, and religious factors and the facility resources, The care required by the resident and the facility resources.

The facility would be used to Inform staffing decisions to ensure sufficient number of staff with appropriate competencies and skill sets, consider specific staffing needs per unit and each shift, develop and maintain plan to maximize recruitment and retention of staff, and a contingency plan for events that do not require activation of the facility's emergency plan.

Record review of the Facility assessment dated [DATE] revealed no information related to specific staffing needs per unit and each shift, no total calculation of the hours worked per each shift, no plan for the development or retention of staff and no contingency plan related to events that could happen which don't active the emergency plan but still had the potential to affect residents.

Interview on 05/21/2026 at 7:20 AM with the facility Administrator confirmed that the Facility Assessment did not contain specific information related to staffing needs per unit pershift and did not include a list of specific personnel in house to meet the resident needs.

The Administrator confirmed that the plan did not cover specific staffing levels withnumbers of staff needed for each shift.

The Administrator confirmed that the Facility Assessment did not include information about retention and recruitment of staff and did notinclude a contingency plan for events that did not require the activation of the facility emergency plan but could have the potential to impact resident care.