Mid-Nebraska Lutheran Home

In the surveyor’s words

From the most serious findings on record at Mid-Nebraska Lutheran Home, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 12, 2024

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(I)(i). Based on record review and interview; the facility failed to identify causal factors and to revise and/or develop additional interventions for the prevention of ongoing falls for Resident 29 and falls with injury for Resident 135. The sample size was 5 and the facility census was 34. Findings are: A. Review of the facility Falls-Clinical Protocol with a revision date of 3/2018 revealed the facility was to review each resident's risk factors for falling and document in the resident's medical record. If the resident had a fall, staff were to identify possible causes within 24 hours of the fall. […]

• Actual harm, isolatedF580Aug 24, 2023

  Licensure Reference Number 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to notify the physician of a significant change for Resident's 8 and 29. The sample size was 18 and the facility census was 33. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with a revision date of 2/2021 revealed the following; -the facility promptly notified the resident, the attending physician, and the resident representative of changes in resident's condition/status. […]

• No harm, potential for more than minimal, widespreadF882Aug 24, 2023

  Licensure Reference Number 175 NAC 12-006.17 Based on interview and record review; the facility failed to ensure the designated Infection Preventionist (IP-staff who looks for patterns, observes and educates staff on infection control and compiles infection data) met the required qualifications for the position and was not the Director of Nursing (DON) . This had the potential to affect all residents. The total sample size was 18 and the census was 33. A. Review of the facility policy Infection Preventionist with a revision date of 9/22 revealed the following responsibilities were identified for the role: -coordinates the development and monitoring of infection prevention and control program; -reports information related to compliance with the infection prevention and control program to… […]

• No harm, potential for more than minimal, patternF552Nov 17, 2025

  Number of residents sampled: 5Number of residents cited:4 Licensure Reference Number 175 NAC 12-006.12Based on record review and interview; the facility failed to have signed informed consent in advance for the use of psychotropic medications (medications which alter consciousness, mood and thoughts) for Residents 1, 2, 11, and 21. The sample size was 5 and the facility census was 30. Findings are:A. Review of the facility policy Psychotropic Medication Use dated 7/2022 revealed the following: -residents wound not receive medications that were not clinically indicated to treat a specific condition, -psychotic medications were subject to prescribing, monitoring, and review requirements that were specific to psychotropic medications, -residents would not be given these medications unless… […]

• No harm, potential for more than minimal, patternF883Nov 17, 2025

  License Reference Number: 175 NAC 12-006.18(A)Based on record review and interviews; the facility failed to offer and/or provide the influenza vaccine to Resident 14 and to ensure Residents 11 and 22 were offered and/or provided the pneumococcal vaccine and the residents were educated about the risks and benefits associated with the vaccines. The sample size was 5 and the facility census was 30. Findings are:A. Review of the undated facility policy Pneumococcal Vaccine revealed the receipt of vaccinations was essential for the prevention of pneumonia/pneumococcal infections. […]