Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Midlands Living Center L L C during CMS and state inspections, most recent first.
Incomplete MAR/TAR Medication Monitoring and Late Documentation: Multiple residents had missing MAR/TAR/Med Mon entries for antidepressant side effects, behavior monitoring, non-pharm interventions, dressing care, and weekly weights. Records also showed late back-dated assessments for a resident who had been sent to the ED and hospital, while staff interviews confirmed that documentation was expected before the end of each shift but practices were inconsistent.
An RN placed noon meds in front of multiple residents and left before confirming they were taken, allowing residents with cognitive or safety deficits to self-administer without orders to do so. Records showed the residents had diagnoses such as HF, HTN, DM, dementia or cognitive impairment, and care plans required staff to administer meds as ordered. Staff, including an LPN, RN, and DON, stated residents should not take meds unobserved unless they have a self-administration order.
Failure to obtain a physician order before applying compression hose to a resident with PAD and diabetes. A resident admitted after NSTEMI/CABG had significant foot edema, and staff documented use of compression stockings/TED hose without an order in the chart. Nursing notes later described purple toes, weak pedal pulses, and 3+ edema, and the NP ordered no TED hose after the resident’s toes became discolored. Staff interviews confirmed the hose had been applied despite the lack of an order.
Inconsistent Restorative Nursing Program: A resident with intact cognition, multiple chronic conditions, and dependence for transfers and toileting hygiene did not receive a consistent restorative nursing program to maintain strength and mobility. The care plan called for exercises several times per week, but progress notes showed only a few exercise sessions over a six-week period, with multiple no-restorative days and one refusal. Staff said the resident needed extra assistance for standing exercises, that restorative coverage was inconsistent, and that the resident was not offered exercises in her room.
A resident with normal cognition, heart failure, spinal stenosis, and right shoulder arthritis received a medication error when an RN applied Diclofenac gel to the shoulder without measuring the ordered 2 gm dose. Staff interviews stated the gel should be measured with the supplied applicator or measuring stick before administration, and the DON confirmed that staff should use the measuring stick to dispense the prescribed amount.
A CNA failed to follow infection control protocols during catheter care for a resident with a suprapubic catheter, including not performing hand hygiene before donning gloves, not changing gloves or sanitizing hands between clean and dirty tasks, and attempting to use a gauze package that had fallen on the floor. These actions did not comply with facility policy and infection prevention standards.
The facility failed to update care plans for two residents, one with edema and another receiving antidepressant and antianxiety medications. The care plans lacked necessary information and interventions related to their conditions, as acknowledged by the MDS nurse and confirmed by the DON.
A facility failed to ensure safe transfer techniques for a resident, as a CNA assisted the resident with ambulation without using a gait belt, contrary to the care plan. The resident, who had a history of cognitive decline and was at high risk for falls, was found ambulating without assistance during an unwitnessed fall. The facility lacked policies on gait belt use, contributing to the deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling suprapubic catheter. Despite being trained, a CNA forgot to don gowns while providing care. The Director of Nursing confirmed the expectation for staff to use EBP, as outlined in facility policy and CDC guidelines, for residents with indwelling medical devices.
The facility failed to include Enhanced Barrier Precautions (EBP) in the care plans of three residents who required them due to the use of catheters. Despite staff expectations for EBP to be part of care plans, these precautions were not documented for residents with cognitive impairments and catheter use, indicating a deficiency in infection control measures.
The facility failed to follow physician's orders for three residents, leading to medication administration errors. A resident with severe cognitive deficits received medications outside prescribed parameters due to staff confusion. Another resident with heart failure was given medications despite blood pressure readings outside set parameters, and weight records were missing. A third resident with asthma did not receive prescribed nebulizer treatments. The facility lacked policies on monitoring blood pressures and following physician's orders.
A resident with mild cognitive impairment was treated without dignity by a Nurse Aide in Training (NAT) who recorded a Snapchat video of their interaction. The NAT responded condescendingly to the resident's request for help, stating she couldn't assist because the resident hadn't listened. The Assistant Director of Nursing (ADON) intervened, educating the NAT on appropriate interaction with dementia residents. The Director of Nursing (DON) described the NAT's tone as borderline demeaning, highlighting a failure to uphold the facility's policy on Residents' Rights.
Incomplete MAR/TAR Medication Monitoring and Late Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for multiple residents in the MAR, TAR, and medication monitoring sections. Review of records showed missing or incomplete documentation for medication monitoring, side effect monitoring, behavior monitoring, non-pharmacological interventions, wound/dressing care, and weekly weights. The report identified deficiencies for Residents #11, #1, #13, #5, #67, and #71, and staff interviews confirmed that nurses and medication passers were responsible for completing the documentation before leaving their shifts. For Resident #11, the record showed a BIMS score of 7 and diagnoses including coronary artery disease, renal insufficiency, UTI, diabetes mellitus, and anxiety disorder. After the resident was sent to the ED for low blood sugar and later returned, social services notes were entered later and back-dated to reflect assessments during the time the resident was hospitalized. The Administrator stated these entries were created by a previous social services worker. The report also noted that the facility failed to accurately reflect the timeframe of assessments by late documentation entry. For Resident #1, the record showed diagnoses including heart failure, hypertension, non-Alzheimer’s dementia, and depression, with orders for alprazolam, duloxetine, and multiple monitoring requirements for antidepressant side effects and behavior monitoring. The MAR/TAR/Med Mon contained repeated missing documentation across November, December, and January for overnight, evening, and other shift entries. Similar missing documentation was identified for Resident #13, whose record included diagnoses such as CAD, HTN, diabetes, hyperlipidemia, non-Alzheimer’s dementia, and depression, with orders for alprazolam and duloxetine and required monitoring for antidepressant side effects, behaviors, and interventions; the same months showed repeated gaps in the medication monitoring record. Resident #5 had diagnoses including renal insufficiency, Parkinson’s disease, depression, adjustment disorder, and anticoagulant use, with orders for donepezil, escitalopram, Eliquis, and omeprazole, plus required monitoring for antidepressant side effects, physical and depressive behaviors, and side effects of an unidentified medication; the MAR/TAR/Med Mon showed missing entries for multiple shifts, including medication side effects, behavior monitoring, and dressing care. Resident #67 had severe cognitive impairment, diagnoses including dementia, anxiety, and depression, and orders for lorazepam, aripiprazole, risperidone, and venlafaxine, with required monitoring for side effects and behaviors; the record showed missing documentation for multiple shifts, including antidepressant side effects, behavior monitoring, depressive behaviors, and sacral dressing care. Resident #71 had moderate cognitive impairment, diagnoses including stroke, atrial fibrillation, HTN, renal insufficiency, dementia, hemiplegia/hemiparesis, and anxiety, with orders for levothyroxine, omeprazole, antidepressant monitoring, sadness monitoring, and weekly weights; the MAR/TAR/Med Mon showed missing documentation for antidepressant side effects and depressive behavior monitoring, and one weekly weight was missing. Staff interviews showed inconsistent understanding of when documentation had to be completed. One RN stated documentation should be finished before leaving the shift but believed late documentation up to 24 hours was allowed, while other staff stated documentation was required as soon as possible and before leaving the shift. Additional staff and the DON stated documentation should be completed by the end of each shift, and the Administrator stated all documentation was expected to be completed in its entirety prior to the end of the shift. The Administrator also stated the facility did not have a documentation policy and that staff were expected to complete charting during their assigned shift or before leaving for the day.
Medication left with residents without self-administration orders
Penalty
Summary
The facility failed to administer medications as prescribed when staff allowed residents to take their own noon medications without an order to self-administer and without staff observing the medications being taken. During direct observation in the dining hall, an RN placed medication in front of Resident #28, then moved to another resident and left the area to prepare more medication before confirming the dose had been taken. Resident #28 later took the medication on their own while unobserved. The resident’s record documented diagnoses including heart failure, hypertension, renal insufficiency, Non-Alzheimer’s dementia, and anxiety, and the care plan required staff to administer medications as ordered. A similar event was observed with Resident #34, whose record documented heart failure, hypertension, diabetes mellitus, and depression, along with a care plan noting impaired safety awareness and requiring staff to administer medications as ordered by a physician. The RN placed the resident’s medication in front of them and left before verifying ingestion, and the resident later took the medication without staff observation or assistance. Resident #61’s record documented atrial fibrillation or other dysrhythmias, hypertension, and mild cognitive impairment, and the care plan also required staff to administer medications as ordered. The same observation showed the RN placing medication in front of this resident and leaving before confirming the dose was taken, after which the resident took it independently. Staff interviews confirmed that residents should not take medications when staff are not watching unless there is an order to self-administer. An LPN stated it was never acceptable for a resident to take medication after the nurse had left the room and described the proper procedure as assisting the resident and observing the medication being taken before leaving. The RN acknowledged that she left medication next to the residents and returned later to see whether they had taken it, and she stated she had not seen orders for self-administration for the residents in question. The DON stated the residents did not have orders to self-administer medication and that staff should not place medication near a resident, walk away, and allow the resident to self-administer without such an order.
Failure to Obtain Order Before Applying Compression Hose
Penalty
Summary
The facility failed to obtain a physician’s order before applying edema wear/compression hose, including TED hose, to Resident #69’s bilateral lower extremities. Resident #69 was admitted after NSTEMI and CABG x4 and had diagnoses including peripheral vascular disease/peripheral arterial disease and diabetes mellitus. The care plan identified self-care deficits, need for assistance with transfers, and risk for skin breakdown related to impaired mobility and diabetic neuropathy. The clinical record did not contain a physician’s order for edema wear or TED hose, although nursing progress notes documented that the resident was wearing compression stockings/bandages and later TED hose. During the stay, staff observed significant swelling and discoloration of the resident’s feet and toes, with weak pedal pulses and 3+ edema. The NP ordered every-2-hour checks overnight, leg elevation, and no TED hose after the toes became purple and pulses were weak. Staff interviews showed that the LPN who completed admission paperwork said she had not applied the hose because there was no order, while another nurse later applied TED hose after the resident’s shower and before the NP directed that they not be used due to PAD. The DON stated nursing must have an order before using compression hose, and the Administrator said the facility did not have a policy on caring for residents with edema or on obtaining physician’s orders.
Inconsistent Restorative Nursing Program
Penalty
Summary
The facility failed to provide a consistent restorative nursing program to help Resident #21 maintain the highest practical physical well-being. The resident’s MDS showed a BIMS score of 14 and dependence on staff for toileting hygiene and chair-to-bed transfers. Her diagnoses included heart failure, renal insufficiency, diabetes mellitus, parkinsonism, low back pain, and neuralgia. The care plan called for a restorative nursing program to maintain strength and mobility for functional activities, with 3 sets of exercises to be offered 2-5 times per week and staff to encourage participation and report multiple refusals to the nurse. Restorative progress notes showed that over a six-week period the resident received exercises only on 4 occasions, with one documented refusal and multiple days marked as no restorative. The restorative aide stated that no restorative entries meant the aides were not on duty, and also said the standing exercises were challenging because the resident required a second person to assist. The resident said she was not offered exercises in her room and would participate if there were no added costs. The ADON stated there were not enough hours in the day or enough staff to provide consistent restorative activities, and the Administrator said the facility did not have a policy on restorative services.
Significant medication error with topical Diclofenac administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for one of eight residents reviewed, Resident #18. The resident’s MDS documented a BIMS score of 14/15, indicating normal cognition, and listed diagnoses including heart failure, spinal stenosis of the lower back, and primary arthritis to the right shoulder. The care plan identified a risk for altered comfort related to spinal stenosis, arthritis, and lower extremity pain, with an intervention to administer pain medication as ordered. The physician’s order in the EHR directed Voltaren gel 1% (Diclofenac 1%), 2 grams three times daily to the right shoulder for arthritis. During observation, Staff E, RN, removed Voltaren and Clotrimazole from the medication cart and administered Clotrimazole to the resident’s left foot. After hand hygiene and changing gloves, Staff E opened the Diclofenac 1% gel, squeezed an undetermined amount onto her hand, and applied it to the resident’s right shoulder without measuring the ordered 2 grams. Staff interviews later stated that Diclofenac gel was to be measured using a measuring stick or applicator, placed in a medication cup, and then applied to the resident. The DON also stated the medication came with a measuring stick and that staff should use it to dispense the prescribed amount, while the Administrator stated it was his expectation that medications be administered according to physician orders.
Failure to Maintain Infection Control During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nurse aide (CNA) failed to follow proper infection control practices during catheter care for a resident with a suprapubic catheter. The resident, who had intact cognition and diagnoses including paraplegia and neurogenic bladder, required daily catheter site care as documented in the care plan and treatment administration record. During the observed procedure, the CNA entered the resident's room, donned an isolation gown, and put on gloves without performing hand hygiene. The CNA proceeded to handle the resident's catheter and supplies without changing gloves or performing hand hygiene at appropriate intervals, as required by facility policy. The CNA removed and replaced the gauze dressing on the suprapubic catheter tubing, but when a new package of gauze was dropped on the floor, the CNA initially attempted to use it rather than discard it, only disposing of it after repeated instruction from the Assistant Director of Nursing (ADON). Throughout the procedure, the CNA continued to touch various surfaces and supplies, including opening drawers and cabinets, and handling a graduated cylinder for urine measurement, all while wearing the same pair of gloves. Hand hygiene was not performed between clean and dirty tasks, nor after glove removal until the end of the procedure. Facility policy and the catheter care audit tool both require hand hygiene before and after glove use, and after contact with potentially contaminated items. The observed actions did not align with these protocols, as the CNA failed to perform hand hygiene at critical points and did not change gloves when indicated, leading to a breach in infection prevention and control practices for the resident with an indwelling catheter.
Failure to Update Care Plans for Residents with Specific Medical Needs
Penalty
Summary
The facility failed to update care plans for two residents, leading to deficiencies in addressing their specific medical needs. Resident #22, who was admitted with a diagnosis of heart failure, conduct disorder, adjustment disorder, and edema, had a care plan that did not include information or goals related to his edema and subsequent skin issues. Despite having orders for daily treatments and the removal of TED hose due to edema, these were not reflected in the care plan. Observations showed that Resident #22 had tightly wrapped lower extremities with blue elastic bandages and edematous legs, indicating a need for updated care planning. Resident #12, who had severe cognitive deficits and was dependent on staff for daily activities, was receiving sertraline for depression and lorazepam for anxiety related to Alzheimer's Disease. However, her care plan lacked focus areas or interventions related to the use of these antidepressant and antianxiety medications. The MDS nurse acknowledged the oversight, and the Director of Nursing confirmed the absence of a policy for establishing or updating care plans, contributing to the deficiency.
Failure to Use Gait Belt During Resident Ambulation
Penalty
Summary
The facility failed to provide safe transfer techniques for a resident, leading to a deficiency in accident prevention. A Certified Nurse Aide (CNA) was observed assisting a resident with ambulation without using a gait belt, instead holding onto the elastic of the resident's pants. This occurred despite the resident's care plan indicating the need for substantial assistance with transfers and supervision during ambulation with a front wheel walker. The resident had a history of cognitive decline, as evidenced by a decrease in her Brief Interview for Mental Status (BIMS) score from 15 to 10, indicating a moderate cognitive deficit. Additionally, the resident was on anti-anxiety medication, which required monitoring for side effects such as drowsiness and clumsiness. The resident had a documented history of falls and was identified as high risk for falls due to conditions such as hypotension, vertigo, Parkinson's Disease, seizures, osteoporosis, and delirium. An incident report noted an unwitnessed fall in the resident's room, where she was found confused and ambulating without assistance. Despite these risks, the facility did not have policies on gait belt use or safe transferring techniques, as acknowledged by the Director of Nursing (DON). This lack of policy and the improper assistance provided by the CNA contributed to the deficiency in ensuring a safe environment for the resident.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care for Resident #29, who was diagnosed with benign prostatic hyperplasia, renal insufficiency, neurogenic bladder, and had a stroke. The resident relied on an indwelling suprapubic catheter, which was to be changed monthly. During an observation, two Certified Nurses Aides (CNAs) completed hand hygiene and repositioned the resident using a mechanical lift, performed peri care, and drained the resident's catheter without using the required EBP. Staff interviews revealed that one of the CNAs had been trained on the use of Personal Protective Equipment (PPE) for EBP but forgot to don gowns during the procedure. The Director of Nursing (DON) confirmed that the expectation was for staff to wear EBP while providing care for residents with catheters. The facility's policy and the Centers for Disease Control and Prevention guidelines indicated that EBP should be used for residents with indwelling medical devices, regardless of their infection or colonization status with multidrug-resistant organisms (MDROs).
Failure to Implement Enhanced Barrier Precautions in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for Enhanced Barrier Precautions (EBP) for three residents who required them. Resident #39, who entered the facility with moderate cognitive impairment and a diagnosis of urinary retention requiring a Foley catheter, did not have any focus, goals, or interventions related to EBP in their care plan. Similarly, Resident #29, diagnosed with benign prostatic hyperplasia, renal insufficiency, neurogenic bladder, and stroke, relied on a suprapubic catheter but lacked a comprehensive care plan addressing EBP. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed the expectation for EBP to be included in care plans, yet it was not implemented. Resident #40, admitted with a moderate cognitive deficit and an indwelling catheter, also lacked a care plan referencing EBP despite having a sign outside their room indicating the need for such precautions. The care plan for Resident #40, updated months prior, noted self-care deficits and the use of a Foley catheter but did not address EBP. The facility's failure to incorporate EBP into the care plans of these residents highlights a deficiency in meeting the residents' needs for infection control and prevention.
Medication Administration Errors and Lack of Policy
Penalty
Summary
The facility failed to adhere to physician's orders for three residents, leading to medication administration errors. Resident #160, who had severe cognitive deficits and multiple health issues including heart failure and orthostatic hypotension, received metoprolol and midodrine outside the prescribed blood pressure parameters on multiple occasions. The staff found the orders confusing, which contributed to the improper administration of these medications. Resident #55, with intact cognitive ability and diagnoses including heart failure and hypertension, was administered atenolol and furosemide despite blood pressure readings that were outside the parameters set by the physician. Additionally, there were missing weight records, which were crucial for monitoring the resident's condition as per the care plan. Staff interviews revealed confusion regarding the medication parameters, and the Director of Nursing acknowledged the lack of a policy on monitoring blood pressures. Resident #39, with moderate cognitive impairment and asthma, did not receive the prescribed nebulizer treatments as ordered. Staff H, an LPN, admitted to not administering the noon treatment because the resident allegedly refused it, and also failed to properly monitor and document the morning treatment. The Director of Nursing and the Administrator confirmed the absence of policies or procedures on following physician's orders or medication administration, which contributed to these deficiencies.
Resident Dignity Compromised by Inappropriate Staff Interaction
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity, as evidenced by an incident involving a Nurse Aide in Training (NAT), referred to as Staff A, and a resident with mild cognitive impairment. The resident, who had a Brief Interview of Mental Status Score of 5, indicating mild cognitive impairment, was heard asking for help in a Snapchat video recorded by Staff A. In the video, Staff A responded to the resident in a condescending manner, stating that she could not help the resident because the resident had not listened to her. This interaction was overheard by the Assistant Director of Nursing (ADON), who intervened and provided education to Staff A on appropriate interaction with residents. The incident occurred in a common area where the resident was sitting in a wheelchair, not attempting to leave or being disruptive. Staff A was recorded on Snapchat while interacting with the resident, and the video was shared with a small group of friends. Staff A admitted to not knowing how to handle residents with dementia and expressed feeling stressed and confused during the interaction. The ADON had previously educated Staff A on how to address the needs of dementia residents, emphasizing the importance of treating them with respect and dignity. The Director of Nursing (DON) and the facility's Administrator were made aware of the Snapchat video, which led to an investigation. The DON described Staff A's tone as borderline demeaning and acknowledged that Staff A might not have understood how to interact with residents with dementia, despite having received training. The facility's policy on Residents' Rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Council Bluffs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Crest Living Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Bethany Lutheran Home | 1.6 mi | ★★★★★ | 13 | 1 |
| Prairie Gate | 2.2 mi | — | 0 | 0 |
| Prairie Gate | 2.2 mi | — | 0 | 0 |
| Prairie Gate | 2.3 mi | ★★★★★ | 3 | 0 |
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