Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Callaway Good Life Center, Inc during CMS and state inspections, most recent first.
The facility failed to document the required 12 hours of annual continuing education for three medication aides. The DON confirmed that the aides were supposed to receive 12 hours each year based on their hire-date anniversaries, but the employee files did not show the full amount. Record review showed each of the three medication aides had fewer than 12 documented training hours, and the DON stated that 2024 education hours were missing and unaccounted for.
Improper Medication Refrigerator Storage: The facility failed to keep items in the medication room refrigerator separated by route of administration and failed to keep food stuff items separate from medication items. An observation found insulin pens, suppository medication bottles, and liquid nutritional supplement drinks stored together on the same shelf in the medication room refrigerator. The DON confirmed the items should have been stored separately.
The facility failed to ensure PBJ staffing data was submitted to CMS by the required deadline. Record review showed the PBJ report for the quarter ending 12/31/2025 was not received by CMS on time, and the BOM confirmed it had not been submitted. The FA stated the information should have been submitted and received before it was due.
Unsanitary meal delivery and hand hygiene failures were observed during meal service. A dietary aide repeatedly delivered plated meals and beverages to multiple residents without sanitizing hands between resident contacts, handled plates with thumbs on the food-contact surface, touched resident wheelchairs and tables, and used a resident’s utensils to serve condiments and cut food. An NA was also observed carrying a plate with a thumb on the top surface before placing it in front of a resident. The DM confirmed that hand sanitization is required between resident contacts and that plates should be carried without touching the food surface.
Psychotropic Medication Lacked Approved Indication: A resident with dementia, psychotic disturbance of mood, anxiety, and depression received Seroquel 25 mg daily for mild dementia with agitation and Quetiapine 25 mg at bedtime for depression. The MAR showed both medications were administered daily, and the DON confirmed the listed indications were not manufacturer-recommended uses under the facility policy.
A resident was discharged home with the spouse, and the record showed belongings, discharge instructions, and a medication list were provided. However, there was no documentation of the required summary or recapitulation of stay in the EMHR, and the DON confirmed the discharge summary was not completed.
The facility failed to accurately code MDS assessments for two residents, including one resident who used CPAP nightly and another resident who received a regular diet but was coded for a mechanically altered diet. The facility also failed to fully complete a CAA for one resident, with multiple sections lacking required narrative and analysis, and failed to complete a PPS Discharge assessment when another resident’s payor source changed from Medicare to Medicaid.
Baseline Care Plan Not Completed or Shared as Required: The facility failed to complete a baseline care plan within the required timeframe for one resident, and failed to provide a written summary of the baseline care plan to another resident or the resident representative. The DON confirmed the baseline care plan should identify the resident’s immediate care needs and that the written summary should be reviewed with and provided to the resident and/or representative before the comprehensive care plan was completed.
Incomplete Comprehensive Care Plans: The facility failed to include all care needs identified in the MDS in the comprehensive care plans for two residents. One resident had a history of UTI, confusion, saturated briefs, and antibiotic treatment, but the care plan did not address toileting needs, UTI risk, or monitoring/prevention interventions. Another resident had diabetes and edema, with insulin orders and ongoing swelling, but the care plan did not include diabetes or edema as focus areas.
A resident with a history of falls had a provider order for a bed alarm and chair alarm, and the MAR documented the alarms were maintained twice daily. During observation, the resident was found with legs over the edge of the bed while an alarm sounded, and staff assisted with care needs. The CCP addressed fall risk but did not include the bed and chair alarm intervention, which the DON confirmed should have been listed.
Unmeasured topical Diclofenac gel was applied to a resident’s hip, shoulder, and elbow instead of the ordered 2 grams per joint. During observation, an MA squeezed out unmeasured amounts and rubbed the gel on each joint without using the marked measuring device. The MA and DON both confirmed the ordered dose was not followed.
The facility did not consistently record refrigerator, freezer, or food temperatures, and failed to label or date food items as required. Staff were observed not following proper hand hygiene or food safety practices, and some foods were served below recommended temperatures. Residents reported that hot foods were often not warm enough, and the dietary manager confirmed incomplete temperature logs and lack of Serve Safe training among staff.
A resident reported that personal items, including a candle warmer and a welcome sign, were taken from their room without notification, and mail was opened by staff. The DON and ADM confirmed that these incidents were not reported to the state as required by facility policy, and staff avoided cleaning the resident's side of the room due to fear of accusations. The facility failed to follow its own procedures for reporting allegations of abuse and misappropriation of property.
The facility failed to ensure safe food handling and preparation practices, as observed during meal services. Dietary Aides did not change gloves between tasks, leading to potential cross-contamination. A Dietary Aide improperly prepared meatballs without following a recipe, resulting in incorrect ingredient measurements and cooking methods. Interviews revealed staff were unaware of proper food handling procedures, contrary to the facility's policy to minimize foodborne illness risk.
The facility failed to ensure that three nurse aides completed the required 12 hours of continuing education. Nurse Aide M completed 2.37 hours, Nurse Aide N completed 1.63 hours, and Nurse Aide O completed 4 hours from January 2024 to February 2025. The DON confirmed the deficiency.
The facility failed to maintain operational ventilation systems in bathrooms of rooms 7, 8, 9, 10, 11, 14, 15, and 19, affecting 13 residents. Observations showed that the ventilation systems were not functional, as evidenced by a lack of air draw when tested with toilet paper. The Administrator confirmed the issue, acknowledging that the ventilation should be working.
The facility failed to complete a comprehensive annual assessment for a resident within the required 366-day period and did not conduct a quarterly assessment for another resident every 92 days as mandated. These lapses were confirmed by the MDS coordinator and the Administrator.
The facility failed to ensure accurate MDS assessments for two residents. One resident was incorrectly documented as receiving insulin injections, while another was inaccurately coded as taking an anticoagulant. These errors were confirmed by the MDS coordinator and attributed to an LPN who is no longer completing MDS assessments.
A resident was found to be using two antifungal medications, Ketoconazole Cream and Nystatin Powder, on the same area of the body, contrary to recommendations. The resident self-applied Nystatin Powder, while nursing staff applied Ketoconazole Cream at night. Interviews confirmed the concurrent use, and the DON acknowledged that both medications should not be used on the same area, indicating a failure to ensure the resident's drug regimen was free from unnecessary medications.
A resident was prescribed Seroquel for depression, despite not having a diagnosis of schizophrenia or bipolar disorder, which are the indicated uses for the medication. The facility's policy requires compliance with regulatory requirements for medication use, but the prescribed use did not align with these indications. This was confirmed by the DON during an interview.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 7%. An RN did not follow the facility's policy of priming insulin pens with 2 units before each use, affecting two residents. The RN believed priming was only needed when the pen was first opened, leading to incorrect insulin administration. The DON confirmed the policy deviation.
A resident was found to have Nystatin Powder stored insecurely in their room, accessible to others. The resident had a physician order to self-administer the medication but lacked a completed self-administration assessment. The DON confirmed the medication should have been stored securely.
Missing Required Annual Education for Medication Aides
Penalty
Summary
The facility failed to ensure that 12 hours of required ongoing education was documented for nurse aides and medication aides who had been employed longer than one year. Surveyors reviewed facility policies stating that existing staff would receive annual education through planned in-services and as needed, and that the nursing facility must provide a safe, clean, comfortable environment so residents can receive care and services safely. In an interview, the Facility Administrator stated that the DON had the information related to continuing education for employees, including the 12 hours of mandatory education required for nurse aides and medication aides. During a confirmation interview, the DON stated that all medication aides and nurse aides must have 12 hours of continuing education every year based on each employee’s hire date anniversary. The DON confirmed that Medication Aide E, Medication Aide F, and Medication Aide G did not have 12 hours of continuing education documented in their employee files. The DON also stated that education hours from 2024 were missing and unaccounted for, so the facility could not show that the employees had received any education during that time frame. Record review showed MA-E had 6.74 documented hours, MA-F had 9.55 documented hours, and MA-G had 6.17 documented hours in the previous year, all below the required 12 hours.
Improper Medication Refrigerator Storage
Penalty
Summary
The facility failed to ensure that items in the medication room refrigerator were stored separately by route of administration and that food stuff items were not stored with medication items. During an observation of the medication room, a square dorm-sized refrigerator contained multiple boxes of insulin pens, medication bottles with suppositories, and 8-ounce plastic containers of liquid nutritional supplement drinks on the same bottom shelf. The facility policy titled Medication Storage stated that medications are stored separately to ensure proper sanitation and segregation. In an interview, the DON confirmed that items stored in the medication room refrigerator should be stored separately by route of administration and that food stuff items should not be stored with medication items, and that they were stored together.
PBJ Staffing Data Not Submitted by Deadline
Penalty
Summary
The facility failed to ensure that the Payroll Based Journal (PBJ) staffing data was submitted for the first quarter of 2026 by the required due date of February 14, 2026. Record review of the CMS PBJ Staffing Data Report showed that the PBJ data for the period October 1, 2025 through December 31, 2025 was not submitted to or received by CMS by the deadline. The facility census was 29. During an interview on 4/20/2026, the Facility Administrator stated that the matter would be looked into because the information should have been submitted and received by CMS before it was due. In a follow-up interview on 4/21/2026, the Business Office Manager confirmed that the PBJ report for 10/01/2025 to 12/31/2025 had not been submitted to CMS by the required date.
Unsanitary Meal Delivery and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure that staff delivered resident meals in a sanitary manner during meal service. During observation in the dining room, a Dietary Aide repeatedly handled plated meals, drink glasses, utensils, condiment containers, and resident items without performing hand sanitization between resident contacts or after touching potentially contaminated objects. The aide also carried plates with thumbs on the food-contact surface of the plates and, at times, touched tables, wheelchair handles, and resident equipment before continuing meal delivery. The observed meal service included delivery of plated meals and beverages to multiple residents, including Residents 11, 22, 28, 19, 10, 35, 27, 15, 20, 17, 16, 23, 21, 18, 25, and 9. The aide placed meals on tables, poured drinks, refilled a resident’s tea, handled used utensils, and used a resident’s knife and fork to cut chicken into bite-sized pieces. The aide also retrieved tartar sauce and barbecue sauce from drawers and used a resident’s knife to remove sauce from the containers and place it on the resident’s meat. A Nursing Assistant was also observed carrying a plated meal with a thumb on the top of the plate before placing it in front of a resident, then performing hand sanitization afterward. The Dietary Manager confirmed that staff are required to perform hand sanitization between resident contacts during meal delivery, after touching objects that may be contaminated, and that plates are to be carried without thumbs or fingers on the top food surface. The facility census was 29, and the deficient practice affected 15 of 22 residents in the dining room.
Psychotropic Medication Lacked Approved Indication
Penalty
Summary
The facility failed to ensure that a prescribed psychotropic medication had an approved diagnosis or indication for use for one resident, Resident 5, out of five sampled residents. The resident was admitted with diagnoses of dementia, psychotic disturbance of mood, anxiety, and depression. Review of the facility policy on psychotropic medication showed that an adequate indication for use means the medication administered is consistent with manufacturer recommendations. Resident 5's April 2026 MAR showed orders for Seroquel 25 mg once daily for an indication of mild dementia with agitation and Quetiapine 25 mg once daily at bedtime for an indication of depression, and both medications were documented as administered every day of the month. A review of FDA prescribing information listed approved uses for Seroquel/Quetiapine as schizophrenia, bipolar I disorder, and bipolar disorder. In interview, the DON confirmed that the resident's listed indications of mild dementia with agitation and depression did not meet the facility policy's definition of adequate indication for use because they were not manufacturer recommended uses.
Missing Discharge Summary for a Resident
Penalty
Summary
The facility failed to complete a summary or recapitulation of stay for one resident, Resident 32, upon discharge. Record review showed the resident was admitted on 02/05/2026 and discharged on 02/14/2026 to the resident's private home with the spouse present. Progress notes documented that personal belongings, discharge instructions, and a medication list were provided to the spouse at discharge, but there was no documentation of a summary or recapitulation of the resident's stay in the progress notes. During interview, the DON confirmed that Resident 32 was discharged from the facility and that the required summary or recapitulation of the resident's stay was not completed and should have been.
MDS Coding, CAA, and PPS Discharge Assessment Errors
Penalty
Summary
The facility failed to accurately code the MDS for two residents. For one resident, the comprehensive MDS dated 01/14/2026 did not code use of a non-invasive mechanical ventilator in Section O, even though the treatment administration record showed a physician order for CPAP to be applied every night at bedtime for sleep apnea and documented that it was performed as ordered every night during January 2026. The DON confirmed the resident used a CPAP machine every night and that the MDS was not coded correctly. For another resident, the comprehensive MDS dated 02/10/2026 coded a mechanically altered diet in Section K 0520, but the physician orders and interviews with the Dietary Manager and DON showed the resident was prescribed and received a regular diet with regular texture and liquid consistency and had no dietary restrictions. The DON confirmed the MDS was not coded correctly because the resident did not receive a mechanically altered diet. The facility also failed to comprehensively complete the CAA for one resident. The CAA worksheet for the comprehensive MDS lacked narrative or description in multiple areas, including cognitive loss or dementia, visual function, communication, urinary incontinence, psychosocial well-being, falls, nutritional status, pressure ulcer or injury, and psychotropic drug use. In addition, the facility failed to complete a PPS Discharge assessment for another resident when the resident’s primary payor source changed from Medicare to Medicaid, and the DON confirmed no PPS Discharge MDS assessment was completed as required.
Baseline Care Plan Not Completed or Shared as Required
Penalty
Summary
The facility failed to complete a baseline care plan within 24 hours of admission for Resident 15. Record review showed Resident 15 was admitted on 12/5/25 at 10:45 AM, with siblings present during admission, but the baseline care plan was not completed and signed by the nurse until 12/7/25, two days after admission. The facility policy stated that the baseline care plan was to be developed within 24 hours in Nebraska and was to include the minimum healthcare information needed to properly care for the resident, including initial goals, physician orders, dietary orders, therapy services, and social services. The facility also failed to provide a written summary of the baseline care plan to Resident 16 or the resident representative. Resident 16 was admitted on 9/5/25, and the baseline care plan was completed and signed that same day, but the medical record contained no documentation that the plan was reviewed with the resident or representative and no documentation that a written summary was provided. The DON confirmed that the written summary was required to be reviewed with and provided to the resident and/or resident representative before completion of the comprehensive care plan, and stated there had been gaps in the facility process to ensure this occurred.
Incomplete Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan that included all resident care needs identified in the comprehensive assessment for 2 of 2 residents reviewed. For one resident, the record showed diagnoses of dehydration, overactive bladder, and UTI, with the admission MDS documenting an active UTI and antibiotic use. Progress notes also showed treatment for UTI, including a positive UTI report from the clinic, confusion, foul odor in a saturated brief, and another antibiotic order for probable UTI. However, the current comprehensive care plan did not include toileting ability or need for assistance, a care focus for UTI or risk for UTI, or interventions to monitor for or prevent UTI. For the second resident, the record showed diagnoses of diabetes and edema, with the admission MDS documenting active high blood pressure, edema, and diabetes. Physician orders included insulin four times daily, and progress notes documented admission after hospital treatment for hyperglycemia and weakness, as well as ongoing edema in the feet and legs. The current comprehensive care plan did not include a focus area for diabetes or edema. The DON confirmed that care needs identified in the MDS assessment are to be included in the resident's comprehensive care plan.
CCP Not Updated to Include Bed and Chair Alarms
Penalty
Summary
The facility failed to ensure that Resident 5’s Comprehensive Care Plan was revised to reflect a current fall prevention intervention. Resident 5 had a history of falls, and the record showed that on 04/07/2026 the provider approved an order for a bed alarm and chair alarm. The Medication Administration Record for April 2026 documented an order to maintain the bed fall alarm and chair fall alarm twice daily, and this was signed as completed from 04/07/2026 through 04/21/2026. During observation on 04/21/2026, Resident 5 was lying in bed with both legs over the edge of the bed on the floor, and an alarm was sounding in the room while staff entered to assist with care needs. A Medication Aide stated that one of the resident’s fall prevention interventions was to have a personal alarm to alert staff when the resident attempted to self-transfer. Review of the resident’s CCP showed the focus was risk for falls, but it did not include an intervention for a chair and bed alarm. The DON confirmed that bed and chair alarms were being used as a fall prevention intervention and that this was not listed on the resident’s CCP.
Unmeasured topical gel applied contrary to provider order
Penalty
Summary
The facility failed to ensure a topical Diclofenac Sodium External Gel 1% was applied in the amount ordered by the provider for one resident. The resident’s order on 04/21/2026 directed that 2 grams be applied topically to joints every 6 hours as needed. During an observation of medication administration, Medication Aide F squeezed an unmeasured amount of the gel onto a gloved hand and rubbed it onto the resident’s left hip, then repeated the same unmeasured application to the left shoulder and left elbow. During interview, Medication Aide F confirmed the gel applied to the resident’s hip, shoulder, and elbow was Diclofenac Sodium Gel and stated the prescribed amount was 2 grams per joint, to be measured with the clear marked measuring device before application. The aide acknowledged that the amount applied was not measured and that the ordered 2 grams was not ensured for each joint. The DON later confirmed that Medication Aide F should have used the clear measuring device to measure each dose and did not, and that the provider’s orders were not followed.
Failure to Ensure Safe Food Storage, Preparation, and Service
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in accordance with professional standards, as required by policy and regulation. Multiple observations and record reviews revealed that refrigerator and freezer temperatures were not consistently recorded, with numerous dates missing entries for both morning and evening checks. Food temperature logs were also incomplete, with sporadic documentation and several meals lacking any recorded temperatures. Additionally, there were instances where food items in the refrigerators were not labeled or dated, including nacho cheese, turkey, and dessert cups, contrary to facility policy requiring all food to be appropriately dated and labeled for proper rotation and safety. Staff interviews and direct observations highlighted further lapses in food safety and hygiene practices. One cook was observed handling food without following proper hand hygiene between glove changes and did not wash tomatoes before slicing them for meal preparation. Another dietary aide was seen handling cleaning equipment and then preparing coffee without washing hands. Staff also had difficulty locating a food thermometer, and when found, it was not consistently used to check food temperatures prior to serving. The dietary manager confirmed that temperature logs were incomplete and that neither the manager nor other dietary staff had completed Serve Safe training at the time of the survey. Residents reported that hot foods were often not served at appropriate temperatures, especially when delivered to rooms, with one resident specifically noting that food was not very warm when served on a tray. Observations confirmed that food items such as oven-baked French fries were served below recommended temperatures. The dietary manager, who was also responsible for environmental services and housekeeping, expressed feeling overwhelmed and was unsure of proper dietary department procedures, further contributing to the deficiencies in food safety and handling.
Failure to Report Allegations of Misappropriation and Abuse
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of resident property within the required time frame, as outlined in its own Abuse and Neglect Reporting policy. One resident reported multiple concerns, including staff opening mail, missing clothing, personal items being taken without consent, and feeling targeted by facility administration. The resident specifically noted that a candle warmer was taken from the room on two separate occasions without notification, and a welcome sign was also removed and later returned. The resident expressed feeling picked on and unable to communicate honestly with the Administrator. Interviews with facility staff confirmed that the candle warmer was removed from the resident's room by Environmental Services staff due to it being considered a fire hazard, but the resident was not informed at the time of removal. Staff also acknowledged that the resident's side of the room had not been cleaned for several days due to fear of being accused of theft. The Business Office Manager admitted to accidentally opening the resident's mail. Despite these incidents and the resident's grievances, the Director of Nursing and Administrator did not report the allegations to the state as required by policy. The facility's policy mandates immediate reporting of suspected abuse, neglect, exploitation, or misappropriation of property, including notification to appropriate authorities within specified time frames. However, the Administrator and Director of Nursing chose not to report the incidents, even after internal discussions and confirmation that items were taken from the resident's room without consent or notification. The lack of timely reporting and communication with the resident regarding the removal of personal property constituted a failure to protect the resident from the wrongful use of belongings and money.
Improper Food Handling and Preparation Practices
Penalty
Summary
The facility failed to prepare and serve food in a safe manner, as observed during multiple meal services. Dietary Aides were seen wearing gloves while handling food, but they did not change gloves between different tasks, such as handling food, opening refrigerators, and managing dietary cards. This practice was observed over several days, indicating a consistent failure to maintain proper hygiene standards. Additionally, the Dietary Aides did not wash their hands between glove changes, further increasing the risk of cross-contamination. During meal preparation, a Dietary Aide was observed cooking meatballs without following a recipe, leading to improper ingredient measurements and cooking methods. The aide used a knife to cut into raw ground beef, some of which was frozen, and attempted to thaw it in a microwave, which is not an appropriate method. The meat was not cooked to the correct internal temperature initially, and the aide did not measure seasonings or follow the recipe's egg requirements. Furthermore, the aide did not check the temperatures of other foods, such as peas and potatoes, before serving them. Interviews with the Dietary Manager revealed that the staff was not fully aware of the proper food handling procedures, including the necessity of temping all foods and the inappropriateness of thawing meat in a microwave. The facility's policy on food handling emphasized minimizing the risk of foodborne illness through proper hygiene, cooking, and food storage practices, but these were not adhered to during the observed meal services. This deficiency had the potential to affect all residents consuming meals prepared in the facility's kitchen.
Deficiency in Nurse Aide Continuing Education Hours
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides completed the required continuing education hours. The facility census was 28. A review of the facility's Course Completion History documents revealed that Nurse Aide M completed only 2.37 hours, Nurse Aide N completed 1.63 hours, and Nurse Aide O completed 4 hours of continuing education from January 1, 2024, to February 10, 2025. During an interview, the Director of Nursing confirmed that these nurse aides had not met the minimum requirement of 12 hours of continuing education annually, as required by the facility's standards.
Non-Functional Ventilation in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the ventilation system was operational in several rooms, specifically rooms 7, 8, 9, 10, 11, 14, 15, and 19. This deficiency affected the bathrooms used by 13 residents out of a total facility census of 28. Observations conducted on multiple occasions revealed that the ventilation systems in these bathrooms were not functional, as demonstrated by the inability of a 1-ply square of toilet paper to adhere to the ventilation cover, indicating no air draw. The Administrator confirmed the non-functionality of the ventilation system during an interview, acknowledging that the system should be operational.
Failure to Complete Timely Resident Assessments
Penalty
Summary
The facility failed to ensure a comprehensive resident assessment was completed annually for one resident and a quarterly assessment was completed every 92 days for another resident. Specifically, Resident #8 did not have a comprehensive assessment completed within the required 366-day period, as the last assessment was completed on 01/27/2023, and no subsequent assessment was scheduled as of 02/06/2025. This was confirmed by the facility's Minimum Data Set (MDS) coordinator and the Administrator, who acknowledged the lapse in meeting the regulatory guidelines for annual assessments. Additionally, Resident #4 did not receive a quarterly assessment within the required 92-day interval. The last quarterly assessment was completed on 10/10/2023, and the next comprehensive assessment was not conducted until 07/01/2024, resulting in a gap of 265 days without a quarterly assessment. This oversight was also confirmed by the MDS coordinator and the Administrator, who recognized the failure to adhere to the regulatory requirements for quarterly assessments.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their medical records. For Resident #8, the Quarterly MDS inaccurately documented that the resident received insulin injections daily during the look-back period. However, a review of the Medication Administration Record for the same period revealed that the resident was actually receiving Victoza, a non-insulin injectable medication, rather than insulin. This error was confirmed by the facility's MDS coordinator during an interview. Similarly, Resident #25's Quarterly MDS was incorrectly coded to indicate that the resident was taking an anticoagulant medication. Upon reviewing the Medication Administration Record, it was found that the resident was receiving Aspirin, a nonsteroidal anti-inflammatory medication, instead of an anticoagulant. This discrepancy was also confirmed by the MDS coordinator. Both errors were attributed to the same LPN, who was no longer responsible for completing MDS assessments at the facility.
Failure to Ensure Resident's Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications, as evidenced by the concurrent use of two antifungal medications on the same area of the resident's body. Resident #25 had physician orders for Ketoconazole External Cream 2% to be applied topically at bedtime and Nystatin External Powder to be applied every morning and at bedtime under the right breast. The resident self-applied the Nystatin Powder when experiencing redness and itchiness, while the nursing staff applied the Ketoconazole Cream to the same area at night. Interviews with the resident, a registered nurse, and the Director of Nursing confirmed the simultaneous use of both medications on the same area, which was not recommended. The Director of Nursing acknowledged that both medications should not be used on the same area, indicating a failure to ensure the resident's drug regimen was free from unnecessary medications.
Incorrect Diagnosis for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that an antipsychotic medication was prescribed with the correct diagnosis for a resident. Specifically, Resident #3 was receiving Seroquel, an antipsychotic medication, for a diagnosis of depression, despite not having a diagnosis of schizophrenia or bipolar disorder, which are the indicated uses for Seroquel. This discrepancy was identified during a review of the resident's physician orders and confirmed by the Director of Nursing during an interview. Resident #3 was admitted to the facility with diagnoses including Alzheimer's Disease, Dementia, and Altered Mental Status, but not depression. The resident's Quarterly Minimum Data Set indicated daily use of an antipsychotic medication. The facility's policy on Behavioral Assessment Intervention and Monitoring states compliance with regulatory requirements related to medication use, yet the prescribed use of Seroquel for depression did not align with the approved indications for the medication.
Medication Error Due to Improper Insulin Pen Priming
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 7% during a survey. This deficiency affected two residents out of six observed medication administrations. The issue was identified during the administration of insulin using insulin pens. The facility's policy required that insulin pens be primed with 2 units before each use, but this procedure was not followed by the registered nurse (RN) administering the medication. During the observation, the RN did not prime the insulin pens before administering doses to two residents. The RN mistakenly believed that priming was only necessary when the pen was first opened. This misunderstanding led to the incorrect administration of insulin doses to the residents. The Director of Nursing confirmed that the facility's policy was to prime the insulin pens with 2 units before each use, indicating a deviation from the established protocol by the RN.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were securely stored, affecting one resident out of three sampled. During an observation, a bottle of Nystatin Powder with a pharmacy label was found on the over-bed table and later on the back of the toilet in the resident's shared bathroom. The resident stated that the doctor had approved them to keep the medication in their room and apply it independently. However, the resident denied receiving any staff education on keeping the medication secure and out of reach of others. The Director of Nursing confirmed that the resident had a physician order to self-administer the Nystatin powder and to keep it in their room. However, a self-administration of medication assessment was not completed to ensure the resident was safe to self-administer and store the medication. The DON acknowledged that all medications should be stored securely and confirmed that the observed storage locations were not secure, as they were accessible to other residents.
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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 Callaway
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookestone View | 16.8 mi | ★★★★★ | 8 | 0 |
| Hilltop Estates | 26.6 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Cozad | 29.3 mi | ★★★★★ | 1 | 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.