Gordon Countryside Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure accuracy of 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) related to an active diagnosis for Resident 14 and weight loss for Resident 1. The sample size was 12 and the facility census was 33.Findings Are: A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2024 revealed in Chapter 3 coding instructions for Active Diagnoses that diseases should be coded that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(H)(iv) Based on record review and interview, the facility failed to follow their bowel protocol to prevent constipation for 1 (Resident 4) of 5 sampled residents. The facility census was 33.Findings Are: A record review of facility policy Bowel Management Policy dated 8/1/2024 revealed all residents will have a bowel management plan tailored to their individual needs, preferences, and medical conditions. In the Documentation section the policy states staff are to document absence of bowel movements for 3 days or more and initiate appropriate action. In the Intervention Protocol for Constipation section the policy states that on Day 1 staff are to monitor and encourage natural bowel movement and offer fluids and dietary fiber. On Day 2, staff are to administer prescribed stool softener or laxative. On Day 3, staff are to reassess and consider use of a suppository if no bowel movement, and on Day 4+ staff are to notify the physician and consider enema or other medical interventions. A record review of Resident 4's quarterly Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-006.09(I) Based on record review, observation, and interview, the facility failed to ensure developed interventions were implemented to prevent falls for 1 (Resident 19) of 3 sampled residents. The facility identified a census of 33.Findings are: A record review of the facility's policy, Falls - Clinical Protocol (dated March 2018) revealed the facility would monitor and document a resident's response to interventions intended to reduce falls or their consequences. A record review of Resident 19's undated Care Plan Report revealed Resident 19 was at risk for falls due to deconditioning, knee pain, and occasional incontinence. Additionally, it revealed on 8/29/2025, the resident had fallen when attempting to get up from their bed unassisted and on 9/16/2025 had fall from their bed and received a bruise to the center of their forehead. On 9/16/2025, an intervention was added to place a fall mat beside the bed when the resident was in bed. An observation on 9/18/2025 at 11:00 AM revealed Resident 19 had been resting in bed. Resident 19's floor mat had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.11(D) Based on record reviews, observations, and interviews, the facility failed to ensure staff followed proper glove use of hand hygiene practices prior to food preparation or between tasks in accordance with the food code and Center for Disease Control (CDC) guidelines during meal service to prevent the potential for cross-contamination. This had the potential to affect 1 resident who resided within the facility. The facility identified with a census of 33. Findings are: A review of the Nebraska food code (last revised 2017, 3.301.11, Section ( A3 ) and (F)) revealed staff are required to perform hand hygiene during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Before donning (put on) gloves to initiate a task that involves working with food. A CDC guideline titled Clinical Safety: Hand Hygiene for Healthcare Workers (dated 2/27/2024) revealed gloves are to be changed between tasks and after contact with potentially contaminated surfaces or residents. - An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on record review and interviews; the facility failed to notify the family or responsible party of a change in condition for 2 (Resident 1 and Resident 2) of 3 sampled residents. The facility identified a census of 30. The findings are: A record review of an undated policy titled Notification of Changes stated the facility will notify resident representative or responsible party regardless of competency level since the resident may not be able to notify them themselves. A. A record review of an admission Record indicated the facility admitted Resident 1 on 3/21/24. Under the Contacts section, the Emergency Contact section listed 2 people with their phone numbers. A record review of Resident 1's Progress Notes with a date of 10/16/24, written by Registered Nurse (RN-A) indicated that Resident 1 had no improvement to to their right lower extremity with a marked increase in redness and swelling. The physician was notified and provided an order to transfer Resident 1 to the hospital as a direct admit for intravenous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12- 006.11(E) Based on observations, interviews, and record reviews; the facility failed to ensure foods were disposed or consumed prior to best-by and use by dates, store foods at least six inches off the floor as required, and to implement hand hygiene practices as required to prevent the potential for cross contamination and foodborne illness. This had the potential to affect all 26 residents who resided within the facility. Findings are: A. A record review of a facility policy Food Storage with a last reviewed date of January 2021, indicated date marking should be visible on foods to indicate the date by which ready to eat foods should be consumed or discarded and that all foods will be consumed by their safe use by dates or discarded. An initial kitchen tour observation on 7/29/2024 at 9:50 AM revealed the following: -In the dry food storage area: -An opened bag of French-Fried Onions that had been opened, but no open date or use by date. -Five cans of Whole Oysters with best if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12- 006.18(B) Based on observations, interview, and record review; the facility failed to disinfect multi-use equipment during medication administration for 3 (Residents 1, 16, and 23) of 3 sampled residents and implement infection control practices during wound to prevent the potential for cross-contamination for 1 (Resident 23) of 1 sampled resident. Findings are: A. A record review of a facility policy Cleaning of Patient Care Equipment with a last reviewed date of 7/20/2021 indicated patient care equipment should be cleaned after each use. A continuous observation on 7/30/2024 from 7:37 AM to 8:04 AM revealed Medication Aide (MA)-B had taken a pair of tweezers from the side of the medication cart from a graduated cylinder to pull a piece of plastic from Resident 23's medication cup, touching Resident 23's medication in the cup with the tweezers. MA-B did not disinfect the tweezer prior to use or after use. At 7:39 AM, MA-B had taken the pair of tweezers back out of the side of the medication cart to pull a piece of plastic from Resident 16's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.09(I) Based on observations, record review, and interviews; the facility failed to ensure 1 (Resident 18) of 2 sampled residents' oxygen concentrator was turned off when not in use and unattended. The facility census was 26. The Findings Are: A record review of facility policy Oxygen Administration with revision date of October 2010 revealed that the facility would instruct the resident, their family, visitors, and roommate (if any) of the oxygen safety precautions. The policy also stated that the facility would provide the resident with a written copy of the Oxygen Safety Handout. A record review of undated facility provided document Using Oxygen Safely, revealed instruction to Turn off your oxygen when you're not using it. A record review of Resident 18's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 7/2/2024, revealed that the resident had diagnoses of non-Alzheimer's dementia, pulmonary hypertension due to lung diseases and hypoxia (An absence of enough oxygen in the tissues to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure 1 (Resident 8) of 2 sampled residents was free from unnecessary medications related to a) the long-term use of an antibiotic medication which did not specify a duration and b) the use of an antibiotic which had no supporting documentation for clinical use based on laboratory results. The facility census was 26. The Findings Are: A record review of facility policy Antibiotic Stewardship Program with revision date of 3/4/24 revealed that all prescriptions for antibiotics would specify the dose, duration, and indication for use. The policy also stated that the facility would monitor resident response to antibiotics, and laboratory results when available, to determine if the antibiotic was still indicated or adjustments should be made. A. A record review of Resident 8's facility admission orders dated 10/25/23, revealed Resident 8 was admitted to the facility with an order for nitrofurantoin (an antibiotic used to treat urinary tract infections (UTI)) 100 milligrams (MG) at bedtime for UTI prevention. A record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference 175 NAC 12-002.10 Based on observations, interviews, and record reviews; the facility failed to ensure medications were administered at the right time for 2 (Residents 1 and 15) of 6 sampled residents and to ensure the medication error rate was less than 5%. The medication error rate was 5.4% (37 medications administered with 2 medication errors.) The facility census was 26. Findings are: A record review of a facility policy Administering Medications with a revision date of April 2019 indicated medications are to be administered within one hour of their prescribed time unless otherwise specified and the individual administering the medication is to check the label to verify the right time before administering the medication. A record review of Resident 15's Medication Administration Record with a date of July 2024 indicated an order for Basaglar insulin (a medication used to treat hyperglycemia) to be administered at 9:00 AM with no special instructions related to the administration time. An observation on 7/30/2024 at 7:29 AM revealed Registered Nurse (RN)-A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, interviews, and record reviews, the facility staff failed to ensure cleaning agents were not next to food, failed to ensure high risk food preparation splashing did not contaminate clean dishes and equipment to prevent the potential food contamination. This had the potential to affect all 25 residents who resided at the facility. The facility identified a census of 25 residents at the time of the survey. Findings are: An initial tour of the kitchen on 7/19/2023 at 1:25 PM revealed the handwashing sink was on the middle island countertop where the dietary staff prep the food and there were three trays filled with clean cups that were on the counter, directly behind the faucet of the handwashing sink. There were clean dishes pitchers, cups and pan sitting on the counter directly to the left of the handwashing sink as well. There was no guard in-between the clean dishes and the handwashing sink. An observation of lunch meal preparation on 7/25/2023 at 9:26 AM revealed Cook-B preparing BBQ chicken, au gratin potatoes,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.14 Based on record review, observations, and interviews, the facility staff failed to ensure 1(Resident 2) of 3 sampled residents received routine dental services. The facility staff identified a census of 25 residents at the time of the survey. Findings are: An interview with Resident 2 on 7/19/2023 at 2:42 PM revealed Resident 2 was concerned about their teeth. Resident 2 explained the facility staff had transported them to a dentist who Just broke my teeth instead of pulling them. Resident 2's teeth were sore, and they were concerned about an infection. Resident 2 said they can barely eat as they cannot chew. Resident 2 had reported their concerns to Social Services Coordinator (SSC)-A who arranges appointments, however, Resident 2 did not have a scheduled dental appointment. Resident 2 indicated Resident 2 was told there was nothing they (the facility) could do. An observation of Resident 2's mouth on 7/19/2023 at 2:42 PM revealed the bottom front to the bottom right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.