Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Beatrice Health And Rehabilitaion during CMS and state inspections, most recent first.
A deficiency was found when a cook failed to perform hand hygiene for the required 20 seconds and did not wash hands before donning gloves while preparing and serving food. The Certified Dietary Manager confirmed these actions were not in line with facility policy, potentially affecting all residents.
Staff failed to follow proper hand hygiene and infection control procedures during catheter and perineal care for two residents, including not performing hand hygiene before and after glove use, using contaminated gloves to remove wipes from containers, and placing a catheter drainage bag above bladder level during a transfer. These actions were confirmed by staff interviews and were not in accordance with facility policies.
The facility failed to maintain the cleanliness of vents in multiple resident rooms, with a thick brown buildup of debris observed. The Maintenance Director confirmed the lack of a policy or procedure for vent checks or cleaning, and the Housekeeping Supervisor confirmed that vents were not on the cleaning list.
The facility failed to maintain the indwelling catheter drainage bag below bladder level during toileting and catheter care for a resident with neuromuscular dysfunction of the bladder and overactive bladder. The catheter drainage bag was observed above bladder level for 20 minutes, confirmed by nursing assistants and the Director of Nursing.
A resident's medications were administered late due to the resident visiting with their spouse. The Medication Aide did not inform the charge nurse about the delay, contrary to facility policy. The Director of Nursing confirmed the need for timely administration and communication with the charge nurse.
The facility failed to maintain mechanical ventilation in resident bathrooms in rooms 38, 39, 40, 47, and 48. Observations and interviews confirmed non-functioning vents and a lack of policy, procedure, and documentation for vent function checks.
The facility failed to obtain a physician's order for a CPAP for a resident with Obstructive Sleep Apnea. The resident had been using the CPAP nightly since admission, but no order was documented in the records, and it was not listed on the eMAR. The Director of Nursing confirmed the oversight.
The facility failed to ensure a resident was free from unnecessary medications by not attempting a gradual dose reduction (GDR) for psychotropic medications, despite the resident showing no documented behaviors, hallucinations, delusions, or signs of depression for several months. Interviews with the DON confirmed no GDRs were completed in the last year, and the facility's policy requiring GDR and behavioral intervention was not followed.
The facility failed to perform proper hand hygiene during wound care for one resident and catheter care for another. Staff did not change gloves or perform hand hygiene between tasks, and hand washing was insufficient. These lapses were confirmed during interviews with the staff involved and the Director of Nursing.
Failure to Ensure Proper Hand Hygiene in Kitchen
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure proper hand hygiene practices in the kitchen, as required to prevent the spread of foodborne illness. During meal preparation, the cook was observed performing hand hygiene with soap and water for less than the facility's required 20 seconds on multiple occasions. Additionally, the cook was seen donning gloves without performing hand hygiene beforehand, specifically before serving breakfast plates to staff for resident service. These actions were not in accordance with the facility's Infection Control Prevention and Control Program-Hand Hygiene Policy, which mandates hand hygiene before handling food and before donning gloves. The Certified Dietary Manager confirmed that the cook should have performed hand hygiene for at least 20 seconds and before putting on gloves. The facility's policy also specifies the use of alcohol-based hand rub or soap and water before and after handling food. The failure to follow these procedures had the potential to affect all 55 residents in the facility, as proper hand hygiene is considered the primary means to prevent the spread of infection.
Failure to Follow Hand Hygiene and Infection Control During Catheter and Perineal Care
Penalty
Summary
Staff failed to perform proper hand hygiene and infection control practices during catheter and perineal care for two residents. In one instance, two nurse aides provided catheter care to a resident with multiple diagnoses, including neuromuscular dysfunction of the bladder and multiple sclerosis, without performing hand hygiene before donning gowns and gloves. During the procedure, contaminated gloves were repeatedly used to remove cleansing wipes from the container, and hand hygiene was not performed after glove removal. The catheter drainage bag was also placed at or above the level of the bladder during a transfer, contrary to facility policy and physician orders. Both nurse aides confirmed in interviews that these actions were not in accordance with proper infection control procedures. In another case, two nurse aides performed catheter and perineal care for a resident with an indwelling catheter and multiple medical conditions, including fractures and chronic respiratory failure. Although hand hygiene was performed before donning gowns and gloves, one aide repeatedly reached into the wipes package with soiled gloves and failed to change gloves or perform hand hygiene between cleaning different body areas. The same soiled gloves were used to apply barrier cream to both the buttocks and the labia/groin folds without changing gloves or performing hand hygiene in between. The aide confirmed in an interview that these actions were not appropriate and did not follow infection control protocols. Facility policy reviews revealed that hand hygiene is required before and after handling invasive devices, after removing gloves, and after contact with blood or bodily fluids. Policies also specify that gloves do not replace hand hygiene and that the drainage bag should be kept below the level of the bladder. The Director of Nursing confirmed in interviews that the observed practices did not align with facility policies and expectations for infection prevention and control.
Failure to Maintain Cleanliness of Vents
Penalty
Summary
The facility failed to maintain the cleanliness and condition of vents in multiple resident rooms, specifically rooms 7, 16, 17, 29, 33, 38, 39, 40, 47, and 48. During an environmental tour, a thick brown buildup of debris was observed on the outside of vents in these rooms. The Maintenance Director confirmed the presence of the debris and revealed that there was no policy or procedure for vent checks or cleaning. Additionally, there was no monthly tracking or documentation of vent checks or cleaning. The Housekeeping Supervisor confirmed that vents in resident bathrooms were not included in the cleaning or checking list.
Improper Positioning of Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain the indwelling catheter drainage bag below bladder level during toileting and catheter care for a resident diagnosed with neuromuscular dysfunction of the bladder and overactive bladder. During an observation, nursing assistants were seen completing catheter care while the resident was seated on the toilet with the catheter drainage bag positioned on a transfer device above the bladder level for a total of 20 minutes. Interviews with the nursing assistants and the Director of Nursing confirmed that the catheter bag was improperly positioned above the bladder level during this time.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to administer the correct medication within the prescribed time frame for one resident. During an observation, a Medication Aide (MA) administered multiple medications to a resident at 12:30 PM, which were due no later than 11:00 AM. The MA acknowledged that the medications were late and attributed the delay to the resident visiting with their spouse. The MA also mentioned that medications are given in block times and should be administered within a specific time frame to ensure proper separation between doses. However, the MA did not inform the charge nurse about the delay as required by the facility's policy. The Director of Nursing (DON) confirmed that the MA should have informed the charge nurse about the late medications and sought assistance if needed. The facility's policy states that medications must be administered within one hour before or after their prescribed time. The DON also mentioned that the facility would need to contact the physician to adjust the medication times. The physician was later informed about the late administration of Carbidopa-Levodopa, and an order was obtained to hold the afternoon dose and give the evening dose as scheduled.
Failure to Maintain Mechanical Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to maintain mechanical ventilation in residents' bathrooms located in rooms 38, 39, 40, 47, and 48. During an environmental tour, it was observed that the vents in these rooms were not functioning. Interviews with the Maintenance Director confirmed the non-functioning vents and revealed that there was no policy or procedure for vent function checks, nor was there any tracking or documentation of such checks. Additionally, the Housekeeping Supervisor confirmed that vents in the resident bathrooms were not on the list to be cleaned or checked.
Failure to Obtain Physician's Order for CPAP
Penalty
Summary
The facility failed to obtain a physician's order for a CPAP for Resident 70, who had a diagnosis of Obstructive Sleep Apnea. Observations on 4/17/24 revealed a CPAP machine assembled and sitting on the bedside table in Resident 70's room. The resident confirmed during an interview that they had been using the CPAP every night since admission. However, a review of the resident's records, including the Hospital Admission Physician orders and the Minimum Data Set (MDS), showed no documented physician order for the CPAP or its settings, and it was not listed on the eMAR. The Director of Nursing confirmed in an interview on 4/23/24 that the admission physician orders did not include a CPAP order and acknowledged that one should have been obtained. The facility's Physician Orders Policy, revised in January 2018, mandates that medications, treatments, or related orders must be transcribed accurately and verified via a double-check system process. This policy was not followed in the case of Resident 70, leading to the deficiency.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications by not attempting a gradual dose reduction (GDR) for psychotropic medications. The resident, who was admitted on 05/09/2020, had multiple diagnoses including Major Depressive Disorder, Delusional Disorders, Vascular Dementia with Behavioral Disturbance, Anxiety Disorder, Schizoaffective Disorder, Depression, and Unspecified Psychosis. Despite the resident showing no documented behaviors, hallucinations, delusions, or signs of depression for the months of February, March, and April of 2024, no GDRs were attempted between 05/31/2023 and 03/31/2024. Additionally, there were no notes from the in-house psychiatric physician since 01/18/2023, and the facility's policy required GDR and behavioral intervention unless clinically contraindicated. Interviews with the Director of Nursing (DON) confirmed that no behaviors were documented for the resident during the specified months and that no GDRs had been completed in the last year. The facility's failure to document and attempt GDRs, despite the resident's stable condition and lack of target behaviors, led to the deficiency. The facility's psychotropic medication policy, dated 12/2023, was not followed, resulting in the resident continuing on psychotropic medications without necessary evaluations and reductions.
Failure to Perform Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to perform proper hand hygiene during wound care for one resident and catheter care for another resident. During wound care, a registered nurse (RN) gathered supplies without performing hand hygiene, sanitized hands, applied gloves, and then touched various surfaces before and after cleansing the resident's wound. The RN did not change gloves or perform hand hygiene after cleansing the wound and before applying a moisture barrier. Additionally, the RN performed hand washing for only 12 seconds instead of the required 30 seconds. The RN confirmed these lapses in hand hygiene during an interview. During catheter care, two nursing assistants (NAs) sanitized their hands, donned gowns and gloves, and then entered the resident's bathroom. One NA wiped the resident's groin and catheter insertion site without changing gloves or performing hand hygiene between tasks. The other NA applied barrier cream to the resident's buttocks without removing gloves or performing hand hygiene. Both NAs confirmed these lapses in hand hygiene during interviews. The Director of Nursing stated that the expectation for catheter care is to perform hand hygiene after cleansing the groin and before performing catheter care.
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Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Beatrice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Beatrice | 1.2 mi | ★★★★★ | 12 | 0 |
| Gold Crest Retirement Center | 16.3 mi | ★★★★★ | 0 | 0 |
| Wilber Care Center | 18.8 mi | ★★★★★ | 2 | 0 |
| Jefferson Community Health & Life Gardenside | 25 mi | ★★★★★ | 11 | 0 |
| Heritage Care Center | 25 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.