Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Red Oak Rehab And Care Center during CMS and state inspections, most recent first.
A resident with dementia, wandering, agitation, and behavioral disturbances repeatedly tried to leave, entered other residents’ rooms, and became physically aggressive toward staff. The facility discharged the resident AMA after escalating behaviors, but did not obtain a physician order for the transfer, did not timely notify the PCP or DON, and did not document proper discharge planning before sending the resident to the hospital.
Failure to complete bed-hold documentation and LTCO notification for two residents transferred to the hospital. One resident had an unplanned discharge AMA to a short-term hospital, and another had an unplanned hospital transfer with no bed hold completed and no LTCO notification reports available. Facility leadership stated the required bed-hold and ombudsman notices could not be produced, despite policy requiring timely LTCO notice and bed-hold notice during emergency transfers.
Inaccurate MDS Coding for Resident Mobility: A resident’s MDS coded partial/moderate assistance for transfers and ambulation despite the care plan, Kardex, observations, and multiple CNA/CMA interviews showing the resident was independent with transfers and walking using a 4WW. The MDS also recorded severe cognitive impairment with a BIMS score of 3/15, and facility leadership stated MDS coding was expected to accurately reflect residents’ levels of care and assistance.
Care plans were not revised for two residents to reflect current status and fall interventions. One resident’s record showed improved independence, a walker order, and discontinuation of some alarms, yet the care plan still listed older assistance levels and fall precautions after multiple unwitnessed falls. Another resident with dementia had fall interventions listed, but observations and staff interviews showed the call light was not within reach, skid strips were absent, and staff described the resident as independent with mobility despite cognitive impairment.
Failure to re-evaluate a resident’s motorized wheelchair use quarterly. A resident with hemiplegia, DM, HF, AFib, anemia, respiratory failure, and episodes of confusion used a power chair for mobility and outside appointments, but the record showed no completed in-person safety assessment or quarterly interdisciplinary re-evaluation after the chair was delivered. The resident was observed leaning heavily to one side in the chair, had documented altered cognition and unsafe chair use, and sustained bruising after getting an arm caught in the wheelchair.
Incomplete MAR-TAR documentation was found for two residents. One resident with dementia, COPD, and behavior-related orders had blank entries for ordered ear and skin treatments and shift behavior documentation, while another resident with dementia, epilepsy, and behavioral diagnoses had missing entries for fluid pushes, behavior monitoring, and wander guard checks. Staff stated refusals or missed documentation should not be left blank, and the DON said staff were expected to complete the record.
The facility did not ensure RN coverage for eight consecutive hours on 11 days between April and June 2024, as required by federal law. The PBJ staffing data revealed missing RN hours, and the Administrator confirmed the absence of coverage, noting only one RN was available during this period. The facility's assessment document highlighted the federal requirement for sufficient staffing, including RN presence for 8 hours daily.
The facility failed to maintain sanitary practices in food service, with staff using the same gloves for handling food and non-food items without changing them or performing hand hygiene. Additionally, sanitizer test strips were not available to ensure proper sanitizing solution concentration, leading to improper cleaning practices.
A facility failed to include anticoagulant medication in a resident's care plan, despite the resident being prescribed Apixaban 5mg twice daily. The MDS indicated anticoagulant use for the entire 7-day period, but the care plan lacked documentation of this medication. Interviews with the MDS coordinator and DON confirmed the expectation for anticoagulants to be included in care plans, as per facility policy.
A resident suffered a compression fracture after a sit-to-stand lift broke during a transfer due to inadequate maintenance checks. The facility failed to inspect the actuator assembly as recommended by the manufacturer, leading to the equipment's failure. Staff confirmed the lift was used correctly, but the maintenance director admitted to not inspecting critical components, resulting in the accident.
A resident with severe cognitive impairment fell and fractured her shoulder after staff failed to use a gait belt during a transfer. The resident, who required assistance for transfers, was being helped from the toilet to the sink when she lost balance and fell. The facility's policy mandated the use of gait belts for such transfers, but the staff member did not have one available, leading to the incident.
Two residents in an LTC facility were subjected to inappropriate comments by staff, violating their right to dignity and respect. One resident was jokingly told by a CNA that whipped cream should be shoved in her face, while another was repeatedly called "brat" by a different CNA. Both incidents were deemed unprofessional by facility leadership, highlighting a failure to uphold resident rights.
Two residents in an LTC facility were affected by medication misappropriation and exploitation. An LPN signed out Tramadol for a resident after clocking out, raising doubts about administration. Another resident's PRN Hydrocodone was signed out by the same LPN, despite the resident not requesting it. Erratic behavior from the LPN prompted a review, revealing a pattern of medication discrepancies.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in a fractured humerus. The facility failed to update her care plan to include this new fracture and necessary interventions, despite having a policy in place for care plan revisions upon status change. The Director of Nursing acknowledged the oversight.
Failure to document and manage an unplanned AMA discharge
Penalty
Summary
The facility failed to provide sufficient notice of discharge for one resident and failed to ensure proper discharge planning was documented prior to discharge. Resident #2 was admitted from a short-term general hospital with diagnoses including unspecified dementia with behavioral disturbances, restlessness, and agitation. The resident’s MDS documented memory problems, severe impairment for daily decision making, fluctuating inattention and disorganized thinking, delusions, wandering, rejection of care, and verbal and physical behavioral symptoms toward others. The resident also required assistance with several activities of daily living and was receiving antipsychotic and antianxiety medications. During the brief stay, staff documented repeated exit-seeking, agitation, and attempts to leave the facility. Progress notes and hospital updates described the resident stating she wanted to go home, packing belongings, trying multiple doors, entering other residents’ rooms, and becoming increasingly anxious and agitated. The resident was also physically aggressive, including striking staff. An elopement evaluation identified a history of elopement or attempted elopement, verbalized desire to go home, wandering, and recent admission with non-acceptance of the situation. The physician was notified of the elopement risk and a WanderGuard and psychiatric evaluation were ordered, but the record showed the order was noted by nursing later. The resident was discharged against medical advice and transported to the hospital after escalating behaviors and aggression. The record showed the resident signed an AMA release form along with staff signatures, despite the resident’s competency being in doubt. The facility failed to obtain a written physician order for the transfer and unplanned discharge, failed to timely notify the PCP and Medical Director of the escalating verbal, physical, and exit-seeking behaviors, and failed to document discharge planning prior to discharge. Staff interviews confirmed the resident had a history of wandering and police involvement, that the resident’s behaviors escalated during the stay, and that the facility allowed the resident to sign the AMA document because she did not have a medical POA.
Failure to Complete Bed Hold and LTCO Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold and failed to notify the Long-Term Care Ombudsman (LTCO) of hospital transfers for 2 of 3 residents reviewed, Residents #2 and #5. Resident #2’s discharge return not anticipated MDS assessment showed the discharge was unplanned and occurred on 4/29/26 to a short term general hospital, and the clinical record census showed the resident discharged against medical advice (AMA) on 4/29/26 at 4:02 PM. Resident #5’s discharge return anticipated MDS assessment showed an unplanned discharge, and the clinical record census showed the resident transferred to the hospital on 3/6/26 at 7:51 AM and discharged on 3/25/26. On 6/17/26, the Administrator stated a bed hold had not been completed for Resident #5 and that the LTCO notification reports for 3/26 and 4/26 could not be located. The President of Operations for Nebraska and Iowa also stated the facility could not produce a bed hold for Resident #5 or LTCO reports for notification of discharges for 3/26 and 4/26. The facility’s policy stated notice to the ombudsman must occur at the same time as discharge notice or as soon as practicable, and that during emergency transfers a copy of the bed-hold notice must be provided to the resident and representative.
Inaccurate MDS Coding for Resident Mobility
Penalty
Summary
The facility failed to represent an accurate assessment of Resident #3’s status during the observation period of the MDS assessment. The MDS dated [DATE] coded the resident with a BIMS score of 3/15, indicating severe cognitive impairment, and also indicated the resident required partial/moderate assistance for sitting to/from stand, transfers to/from a chair, and ambulation up to 150 feet. However, the resident’s care plan and Kardex identified the resident as independent with transfers and ambulation using a wheeled walker, and the Kardex stated the resident could get into bed and make position changes independently. Observations on 6/15/26 and 6/16/26 showed the resident seated in a recliner, ambulating in the room with a 4WW, participating in group activity, and walking to the dining room independently with a 4WW. Multiple CNAs/CMA staff stated the resident was independent with walking, transfers, and use of the walker, with only occasional cues needed to use the walker. The Administrator and the President of Operations stated the MDS coding was expected to accurately reflect the residents’ levels of care and assistance.
Care plans not updated to match residents’ current mobility and fall needs
Penalty
Summary
The facility failed to revise care plans for 2 of 3 residents reviewed, including one resident with normal cognition and another resident with dementia and severe cognitive impairment. The deficiency involved care plans that were not updated to reflect changes in status and fall interventions, even though the residents’ records, observations, and staff interviews showed that their needs and mobility levels had changed over time. For one resident, the MDS showed a BIMS score of 15/15 and independence with toileting, dressing, grooming/hygiene, ambulation, transfers, and bed mobility, while also noting a bed alarm in use. The care plan still contained multiple older interventions, including assistance levels for dressing, toileting, and walking, as well as fall-related interventions tied to prior unwitnessed falls. The record showed unwitnessed falls in the bedroom and leaving the bathroom, and later physician communication and orthopedic follow-up documented that the resident could be up as tolerated with a walker, did not need assistance, and that the chair alarm could be discontinued while the bed alarm could remain at HS. Staff interviews described the resident as very independent with self-care and mobility, and observations showed the resident ambulating independently in her room and being up in her room when breakfast was delivered. For the other resident, the MDS documented memory problems, severe impairment in daily decision making, total assistance for self-care, and supervision/touching assistance for transfers and ambulation. The care plan listed fall interventions such as a low bed, a disc call light by the hip, and skid strips next to the bed, along with other fall precautions. However, observations showed the resident in a low bed with the call light on the nightstand or at the head of the bed rather than within reach, and no skid strips were present at the bedside. Staff interviews stated the resident was independent with mobility and could get in and out of bed by herself, while also stating the resident did not know how to use the call light and did not understand cause and effect. The facility’s care planning policy stated care plans should be updated between care conferences to reflect current care needs as changes occur, but the care plans reviewed were not consistent with the residents’ current levels of care.
Failure to Re-evaluate Motorized Wheelchair Use
Penalty
Summary
The facility failed to re-evaluate the use of a motorized wheelchair quarterly for a resident who used the chair for mobility and outside appointments. The resident had a history of hemiplegia following cerebral infarction affecting the left non-domical side, heart failure, atrial fibrillation, anemia, diabetes mellitus, respiratory failure, visual hallucinations, and nausea without vomiting. The MDS documented a BIMS score of 15, indicating intact cognition, and also showed that the resident required total dependence on staff for transfers and used a wheelchair for mobility. The resident was observed using the motorized wheelchair while leaving the room for an outdoor activity and was leaning heavily to the left. The back of the chair did not extend high enough to support his back, and a staff member stopped him in the hallway and offered to reposition him, but he declined. The resident stated that he tended to lean to the left because of his stroke and that staff were concerned about it, though he was not concerned. He also stated that he used the motorized wheelchair in the facility and outside the facility for doctor appointments, and that maintenance staff helped with minor adjustments when needed. The record showed multiple entries of altered cognition and unsafe or unusual behavior while using the power chair, including confusion, visual misperceptions, and driving the chair under a sink after waking up. The record also documented bruising and injuries associated with the wheelchair, including bruising to the right arm after the resident reported getting his arm caught under the arm of the wheelchair and another bruise to the right posterior forearm. Facility interviews confirmed there was an expectation for a safety assessment before use of an electric wheelchair and that the interdisciplinary team was to re-evaluate physical and cognitive ability quarterly, but the OT supervisor stated no in-person assessment was completed when the chair arrived and the DON stated she did not verify that the care plan reflected the resident's electric wheelchair use.
Incomplete MAR-TAR Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented MAR-TAR records for 2 residents. For one resident with diagnoses including non-Alzheimer’s dementia, anxiety, depression, and COPD who required oxygen, the record showed orders for Vaseline to both ears for oxygen tubing-related ear breakdown, Remedy Specialized Protect to the buttocks for skin integrity, and documentation of suicidal ideation, anger outbursts, and behavior each shift. The resident’s care plan addressed shortness of breath and behavior-related interventions, but it did not identify the ear skin integrity concern related to the nasal cannula. The resident’s MAR-TAR contained multiple blank entries for the ordered ear treatment, the buttocks treatment, and the behavior documentation on several shifts. Staff told surveyors the resident was likely refusing the early morning treatment because she did not like to get up or be bothered, and acknowledged that refusals should have been documented rather than left blank. The DON also stated she was unsure what happened on the evening shift reviewed, but expected staff to complete the documentation. For a second resident with non-Alzheimer’s dementia, epilepsy, autistic disorder, and intermittent explosive disorder, the record showed orders for pushing fluids every shift, monitoring behaviors during shift, and checking the wander guard every shift. The resident’s MAR-TAR lacked documentation for behaviors, wander guard checks, and fluid push on the reviewed shift. Staff interviews reflected that blanks should not be left on the MAR-TAR and that if something could not be documented, staff should seek assistance rather than leave the record incomplete. The facility’s documentation policy stated that all services provided must be documented in the resident’s medical record and that the record should be up to date at all times.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for eight consecutive hours each day for 11 out of 90 days during the period from April 1st to June 30th, 2024. This deficiency was identified through a review of the Payroll Based Journal (PBJ) staffing data, which showed no RN hours recorded on specific dates. The facility had a census of 25 residents during this time. An interview with the Administrator confirmed the absence of RN coverage on these dates and acknowledged that the facility only had one RN available. The Administrator also confirmed that the expectation was to have RN coverage for 8 hours each day. The facility's own assessment document, completed on July 15, 2024, reiterated the federal requirement for nursing homes to have sufficient staff, including the use of an RN for at least 8 consecutive hours a day, 7 days a week.
Sanitary Practices Deficiency in Food Service
Penalty
Summary
The facility failed to maintain sanitary practices in food service, as observed during a survey. Staff A, a cook, was seen using the same pair of gloves to handle both food and non-food items without changing them or performing hand hygiene. This included grabbing potato chips, handling a mashed potato scoop, and preparing a sandwich, all with the same gloves that had previously touched non-food items. Additionally, Staff C, the Dietary Manager, was observed using gloved hands to move non-food items and then touching a plate's food contact surface without changing gloves. Furthermore, the facility did not ensure the proper concentration of sanitizing solutions, as Staff A and Staff B, a Dietary Aide, were unable to locate sanitizer test strips to check the concentration. Staff B admitted to using detergent instead of a sanitizing solution to clean dining room tables. The Dietary Manager later confirmed that staff should perform appropriate hand hygiene and that sanitizing solution strips should be accessible and used correctly. The facility's policy on handwashing for dietary employees, dated 2023, directed staff to clean their hands as often as necessary to prevent cross-contamination, which was not adhered to in these instances.
Incomplete Care Plan for Anticoagulant Medication
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident who was prescribed anticoagulant medication, specifically Apixaban 5mg to be taken orally twice daily. The resident's Minimum Data Set indicated anticoagulant usage for the entire 7-day look-back period. However, a review of the resident's care plan, dated August 23, 2024, showed no documentation regarding the anticoagulant medication. Interviews with the MDS coordinator and the Director of Nursing confirmed that anticoagulants should be included in care plans, and the facility's policy requires physician's orders to be referenced in the resident's care plan.
Failure to Maintain Safe Equipment Leads to Resident Injury
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating conditions, leading to an accident involving a resident. The incident involved a sit-to-stand mechanical lift that broke during a transfer, causing the resident to fall and sustain a compression fracture. The resident, who had no cognitive impairment, was being transferred using the lift when the actuator mount failed, resulting in the fall. The resident initially refused an x-ray but later experienced significant pain and was diagnosed with compression fractures. The facility's maintenance procedures were inadequate, as the maintenance director admitted to not inspecting the actuator or actuator arm bolt connection, despite the manufacturer's service manual recommending such checks every six months. The maintenance records indicated that inspections were signed off as completed, but the specific inspection of the actuator assembly for wear and damage was not performed. Staff involved in the incident confirmed that the lift was used appropriately, and the failure was attributed to the mechanical breakdown of the equipment. Interviews with staff revealed that the maintenance checks did not include a thorough inspection of the lift's critical components, which could have prevented the accident. The facility's protocol required inspection of the lift actuator assembly, but this was not adhered to, leading to the equipment's failure. The administrator acknowledged that the facility's expectation was for the actuator arm to be checked for wear or damage during monthly maintenance, which was not done, resulting in the resident's injury.
Failure to Use Gait Belt Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, leading to a fall and injury. The incident involved a resident with severe cognitive impairment, who required assistance with transfers and ambulation, as documented in her care plan. On the day of the incident, staff attempted to assist the resident from the toilet to the sink without using a gait belt, instead holding onto the resident's pants. As the resident turned away from the sink, she lost her balance, and the staff member lost grip, resulting in the resident falling and sustaining a right proximal humerus fracture. The resident's medical history included previous falls and fractures, and she was dependent on staff for toilet transfers. The facility's policy required the use of a gait belt for transfers and ambulation to prevent accidents. However, on the day of the incident, the staff member did not have a gait belt available and did not follow the procedure to ensure the resident's safety by obtaining one before assisting her. This oversight directly contributed to the resident's fall and subsequent injury. Interviews with staff and the Director of Nursing revealed that gait belts were sometimes not readily available in residents' rooms, and staff were expected to find one before assisting residents. The facility's policy emphasized the importance of using a gait belt to provide a secure grip and prevent falls, but this protocol was not followed in this instance, leading to the deficiency.
Inappropriate Staff Comments Violate Resident Dignity
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect, as evidenced by inappropriate comments made by staff members. Resident #3, who had no cognitive impairment, was subjected to a comment by Staff B, a CNA, suggesting that whipped cream be shoved in her face. This comment was made in a joking manner, but was deemed inappropriate by other staff members, including the Corporate Nurse Consultant and the Director of Nursing (DON). Staff B was known for making sarcastic comments, which were not always well-received, and this behavior was reported to the Administrator. Resident #10, also without cognitive impairment, expressed discomfort with being called "brat" by Staff A, a CNA. Although Staff A claimed the term was used jokingly and had asked the resident if she liked it, the resident found it unprofessional. Staff A later changed the nickname to "lovebug" after realizing the inappropriateness of the term "brat." The DON and Administrator both agreed that such nicknames were not appropriate, emphasizing the need for staff to use residents' names instead. The facility's Resident Rights Policy, revised in 2019, states that residents have the right to a dignified existence and to be treated with respect and dignity. The incidents involving Residents #3 and #10 highlight a failure to uphold these rights, as staff members used language and behavior that did not align with the facility's standards for resident treatment.
Medication Misappropriation and Exploitation in LTC Facility
Penalty
Summary
The facility failed to protect two residents from exploitation, as evidenced by discrepancies in medication administration records and staff behavior. Resident #4, who had severely impaired cognitive skills and required scheduled pain medication, was affected when Staff C, an LPN, signed out Tramadol at 12:00 AM, despite clocking out at 11:09 PM. Staff C claimed to have administered the medication before leaving, but the medication was not signed out on the MAR, and there was uncertainty about whether the medication was actually given. Staff D, another LPN, confirmed that the medication was signed out but not administered, raising concerns about potential misappropriation. Resident #5, who had no cognitive impairment and a history of chronic pain, was also affected. Staff C consistently signed out PRN Hydrocodone for Resident #5, despite the resident stating he had not requested or received the medication for several weeks. Other staff members, including Staff G and Staff D, corroborated that Resident #5 did not ask for pain medication, and the narcotic counts were never off. The DON and Administrator noted erratic behavior from Staff C, including an incident where she appeared unfit for work, which prompted a review of narcotic logs and revealed a pattern of medication being signed out only by Staff C. The facility's policy on abuse prevention emphasizes protecting residents from exploitation and misappropriation of property. However, the actions of Staff C, including signing out medications without proper administration and exhibiting unprofessional behavior, suggest a failure to adhere to these policies. The investigation into Staff C's conduct revealed inconsistencies in medication administration and raised concerns about the potential exploitation of residents' medications for personal gain.
Failure to Update Care Plan After Resident's Fracture
Penalty
Summary
The facility failed to update the care plan for one resident after she sustained a fractured humerus. The resident, who had a severe cognitive impairment with a Brief Interview of Mental Score of 3, was dependent on staff for toilet transfers and used a walker and wheelchair. Her medical history included fractures, coronary artery disease, thyroid disorder, hip fracture, anxiety, and depression. After a fall in her room, she was sent to the emergency room where an x-ray confirmed a mildly displaced humeral neck fracture. Despite this significant change in her condition, the care plan was not updated to include the new fracture and necessary interventions for her care. The Director of Nursing acknowledged that the fracture should have been included in the resident's care plan. The facility's policy on care plan revisions upon status change outlines a procedure for updating care plans when a resident experiences a change in status. This includes notifying the MDS Coordinator, discussing intervention options with the interdisciplinary team, documenting the discussion, updating the care plan, and communicating the interventions to all staff involved in the resident's care. However, these steps were not followed in this case, resulting in a deficiency in the resident's care plan management.
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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 Red Oak
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Red Oak | 0.9 mi | ★★★★★ | 22 | 0 |
| Accura Healthcare Of Stanton | 6.5 mi | ★★★★★ | 1 | 0 |
| Good Samaritan - Villisca | 13.4 mi | ★★★★★ | 10 | 0 |
| Griswold Rehabilitation & Health Care Center | 15.8 mi | — | 0 | 0 |
| Accura Healthcare Of Shenandoah | 19.9 mi | ★★★★★ | 0 | 0 |
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