Emerald Nursing & Rehab Brookside Llc
Inspection Findings
F-Tag F0880
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.18Based on observation, record reviews and interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP- an infection control strategy that focuses on the prevention of the spread of multi-drug resistant organisms [MDRO]) were followed when wound care was provided and failed to ensure hand hygiene was completed between glove changes for 1 (Resident 1) of 5 sampled residents. The facility's census was 106. A record review of an admission Record printed on 10/06/2025 revealed that Resident 1 was admitted to the facility on [DATE REDACTED] with a diagnosis of Diabetes Mellitus Type 2 (DMT2 a common form of diabetes mellitus that develops especially in adults that is characterized by high blood sugar levels, resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production). This condition can lead to poor blood flow to the feet resulting in a diabetic ulcer (a slow-healing, open wound).A record review of Resident 1's Order Summary dated 10/06/2025 reveals a wound care order for bilateral toe wounds. The order is to apply Medi Honey and Band-Aid daily, with a start date of 09/20/2025.An observation on 10/02/2025 at 8:30 AM revealed LPN (Licensed Practical Nurse) performing wound care on Resident 1. The LPN first gathered supplies including gauze, Medi Honey, and Band-Aids. The LPN placed gloves in scrubs (uniform) pocket, next performed hand hygiene with hand sanitizer and entered the resident's room. The LPN greeted the resident, applied gloves, removed old Band-Aids from the toes on the resident's right foot. The LPN then removed the dirty gloves and replaced them with new gloves. The LPN cleaned off the open wounds with
the gauze and applied the Medi-Honey to each of the open wounds. The LPN then covered each wound with a clean Band-Aid. The LPN disposed of soiled bandages and performed hand hygiene.At no time
during this wound care process did the LPN don (to put on) a gown as required for Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).A
record review of the facility's Infection Control MDRP PPE (Personal Protective Equipment) Enhanced Barrier Precautions policy dated 03/20/2024 revealed that EBP is to be used during routine cares of residents with chronic wounds including but not limited to those with diabetic foot ulcers. An interview with
the LPN on 10/02/2025 at 8:40 AM revealed that the LPN was under the impression that EBP was only used during catheter cares and tube feedings and not for wound cares. An interview with Director of Nursing on 10/02/2025 at 2:00 PM confirmed Resident 1 was in Enhanced Barrier Precautions and it is the facility's expectation for staff to use EBP, including applying a gown before performing wound cares and that hand hygiene should be performed before donning (applying) or after doffing (removing) gloves.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Emerald Nursing & Rehab Brookside LLC in Lincoln, NE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lincoln, NE, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Emerald Nursing & Rehab Brookside LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.