Linden Court

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews and record review, the facility failed to ensure outdated food items were not available for use, opened items were dated, and failed to do to complete hand hygiene and change gloves while preparing food to prevent potential cross contamination and food-borne illness. The facility identified a census of 113. This had the potential to affect all residents who ate out of the kitchen.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(E&F), 12-006.18(B), and 1-005.06(D) Based on record review, interview, and observation, the facility failed to change their personal protective equipment when transitioning from infectious rooms to non-infectious rooms, failed to perform hand hygiene, and failed to ensure housekeeping services were provided to non-infectious rooms prior to infectious rooms. This had the potential to affect all residents residing within the facility. The facility census was 113. Findings Are: A. A record review of the Nebraska Infection Control Assessment and Promotion Program (ICAP) Nebraska Medicine 2026 website revealed a hyperlink in the COVID-19 Resources for Healthcare Settings section. The hyperlink was https://www.cdc.gov/covid/hcp/infection-control/. A record review of the CDC Infection Control Guidance: [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the ombudsman of 2 (Residents 116 and 118) of 3 sampled residents' discharge from the facility. The facility census was 113. Findings Are: A. A record review of Resident 116's admission Record dated 4/15/2026 revealed the resident was admitted to the facility on [DATE]. The document revealed the resident was discharged from the facility on 3/17/2026. A record review of a fax sent to the ombudsman by the Social Services Supervisor (SSS) on 4/1/2026 revealed no evidence of the ombudsman being notified of Resident 116's discharge from the facility. An interview on 04/14/2026 at 2:22 PM with the Administrator confirmed the ombudsman had not been notified of Resident 116's discharge from the facility. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the 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) was coded accurately for Resident 3's medication and Resident 5's Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability). The sample size was 23 and the facility census was 113. Findings Are: [...]

Inspectors wroteLicensure Reference Number 175 NAC 1-009.02(F)Based on observation, interview, and record review the facility failed to provide an environment free of accident hazards related to chemicals in the resident bathrooms for 3 residents (Resident 18, 92, 113) of 8 residents sampled. The facility census was 113.

Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(C)Based on record review and interviews, the facility failed to ensure a stop date for the use of antibiotics medication. This affected 1 (Residents 15) ) of 5 sampled residents. The facility census was 113.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record reviews and interviews, the facility failed to conduct and document a thorough investigation of misappropriation of resident property for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 104.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.09(I) Based on observations, interviews and record reviews, the facility failed to provide a safe environment when residents have been identified at risk for elopement. This affected 10 (Residents 1, 4, 5, 7, 8, 9, 10, 11, 12, and 13) of 12 sampled residents. The facility census was 105. The facility Administrator (ADM) was notified on 04/30/2025 at 6:00 PM of an Immediate Jeopardy (IJ) which began on 04/20/2025. The IJ was removed on 04/30/2025, as confirmed by surveyor onsite verification.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09(D) Based on record review, and interview, the facility failed to accurately code comprehensive assessments for 2 of 4 sampled residents (Resident #7 and Resident #14) and failed to accurately complete care area assessment summaries for 2 of 4 sampled residents (Resident #5 and Resident #14). The facility census was 105.

Inspectors wroteLicensure Reference Number: 175 NAC 12-006.09(F) Based on record review and interview, the facility failed to update resident care plans to reflect resident care needs for 1 resident (Resident #7). The facility census was 105.

Inspectors wroteLicensure Reference Number NAC 175 12-006.11E Based on observations, interviews, and record review, the facility failed to perform hand hygiene as required after handling uncooked meat and failed to wear hair restraints in the kitchen as required to prevent the potential for food-borne illness. This had the potential to affect all 104 residents who resided within the facility and were served out of the kitchen.

Inspectors wroteLicensure Reference Number 1-005.06(D) Based on observations and interviews, the facility failed to follow infection control practices during environmental cleaning, disinfection, and with the application of Personal Protection Equipment (PPE). This had the potential to affect all the residents. The facility identified a census of 104. Findings Are: A continuous observation on 1/28/25 from 10:20 AM to 10:45 AM of the 100 Hall revealed at 10:22 AM a housekeeping staff (HSK-H) coming out of a residents' room with gloves on both hands. HSK-H was then observed renewing supplies at the housekeeping cart and returning to a different room with the same gloves on. HSK-H was observed using this technique to clean three resident rooms. At 10:40 AM a Nurses Assistant (NA-I) was observed applying PPE to enter an Enhanced Barrier Precautions room (EBP). [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.09(E)(iii) Based on record reviews and interviews, the facility failed to develop comprehensive care plans (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) that reflected Resident 97's dialysis treatment and Resident 99's anticoagulant use. This affected 2 (Resident 97 and 99) of 21 sampled residents. The facility identified a census of 104.

Inspectors wroteLicensure Reference Number 12.006.04(F) Based on observation, interview, and record review; the facility failed to ensure that 1 (Resident 94) of 21 sampled residents care plan was reviewed and revised to reflect significant weight loss. The facility identified a census of 104.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(G)(i) Based on record reviews and interview, the facility failed to develop and provide a discharge summary (a detailed document with individualized care instructions to ensure continuity of care and a safe return home for the resident) that included a recapitulation of stay; information regarding the resident's physical functioning and assistance level needs, continence, and skin condition; and a reconciliation of the resident's medications as required for 1 (Resident 102) of 1 sampled resident. The facility identified a census of 104.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.12E8 Based on interview and record review, the facility failed to ensure 1 (Resident 76) of 5 sampled resident's Fentanyl Duragesic patch (a topical pain medication patch) destruction was witnessed by 2 credentialied individuals. The facility census was 98.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident 151) of 2 sampled resident's indwelling urinary catheter (a tube inserted in the bladder to drain urine) bag was kept off the floor and failed to ensure a clean barrier was used during tracheostomy (trach)(a breathing tube placed in the neck) care for 1 (Resident 58) of 1 sampled resident to prevent the potential for cross contamination, and failed to ensure handwashing was completed for at least 20 seconds during trach care for 1 (Resident 58) of 1 sampled resident. The facility census was 98.