Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Christian Homes Health Care Center during CMS and state inspections, most recent first.
Surveyors found unlabeled and undated foods in the kitchen and walk-in refrigerator, along with soiled storage containers, drawers, and a food scale with residue. A cook was observed preparing multiple menu items without hand hygiene, using bare hands on frozen foods, handling foods and sauces without temperature checks, and retrieving rice from the dirty pan area. During meal service, staff served residents with the same gloved hands after touching doors, resident items, and other potentially contaminated surfaces, and the DM confirmed gloves do not replace HH.
Meals were not served consecutively to residents seated at the same table, affecting multiple residents observed during the noon meal. A dietary staff member served some residents at one table while leaving tablemates waiting, and one plated meal was even carried out of the dining room to a resident room before all dining room residents were served. The DM and a dietary cook confirmed the expectation is to serve all residents at one table before moving to the next table.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Alternatives: Surveyors found that the DON confirmed residents receiving psychotropic meds were not given signed forms or advance discussion of risks, benefits, and alternatives before administration. Records for several residents with diagnoses such as dementia, depression, schizoaffective disorder, bipolar disorder, Alzheimer’s disease, and Down syndrome showed orders for antipsychotics and antidepressants, but no evidence that the resident and/or representative was informed in advance of care.
Failure to complete baseline care plans and provide written summaries to residents or their representatives. The facility did not complete baseline care plans within the required timeframe for multiple residents, and EMR review showed missing or blank baseline care plan documentation for several admissions. The SSD and DON confirmed that written summaries were not provided or reviewed with the resident or representative as required.
The facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. Record review showed that two residents had an emergency hospital transfer or discharge, but neither resident was included on the monthly transfer forms sent to the Ombudsman. The SSD confirmed the events were not reported as required.
MDS coding was inaccurate for two residents. One resident with Type 2 DM was incorrectly coded as having an ostomy and as receiving an insulin injection during the lookback period, even though the EMHR showed no ostomy and no insulin orders. A second resident with Type 2 DM was also incorrectly coded as receiving an insulin injection during the lookback period, despite no EMHR evidence of insulin orders; the MDSC confirmed the errors.
A CCP failed to include a resident’s stated discharge goal to return home after a stage 3 pressure ulcer healed, even though the resident and spouse both identified that plan. Another resident’s CCP did not match the current pureed diet order and also omitted the resident’s antipsychotic medication use and monitoring needs, despite MDS, physician orders, EMAR, and staff interviews confirming the diet change and ongoing Risperidone administration.
Failure to Administer PRN Midodrine as Ordered: A resident with orthostatic hypotension and a care plan for fall risk had a provider order for PRN Midodrine when BP was below 100, but repeated BP checks showed readings below that threshold without evidence the medication was given. The MAR and BP summary documented multiple low readings over two months, and an LPN, the CCC, and the DON confirmed the PRN medication was not being administered as ordered.
A facility failed to identify a resident’s preference for dental services during admission. The resident was edentulous, had not worn dentures for a long time because they no longer fit, and was on a modified texture diet due to coughing and choking at meals. The resident said they were not offered dental services on admission and wanted new dentures. An LPN was unaware of any dental appt, and the SSD stated the resident should have been asked about dental services.
An LPN failed to perform hand hygiene between glove changes while providing catheter care and wound care for a resident with a stage 3 pressure ulcer. During the observation, wound care supplies were placed directly on the resident’s bed, gloves were removed and replaced multiple times without hand hygiene, and a Q-tip and measuring device that had been on the bedding were used during wound care. The LPN and CCC confirmed hand hygiene should have been done after glove removal and before donning new gloves.
An unqualified individual who was not an employee assisted with food preparation in the kitchen due to a staffing shortage. The Dietary Manager confirmed the individual was not qualified to work in the kitchen, and the Administrator was unaware of this occurrence. This had the potential to affect all residents in the facility.
The facility did not notify the State Agency of a change in the DON position within the required timeframe, as confirmed by record review and administrator interview. This delay had the potential to impact all residents in the facility.
A resident reported being hit and restrained by an unidentified individual during the night. The DON investigated the allegation and deemed it unfounded but failed to report it to the State Agency as required by the facility's policy.
The facility failed to identify specific target behaviors for psychotropic medications in several residents, as required by policy. This deficiency was observed in residents prescribed antidepressants, antianxiety, and antipsychotic drugs, with no documentation of targeted behaviors in their care plans. Additionally, PRN orders for psychotropic medications lacked necessary stop dates. Staff interviews confirmed a lack of awareness and documentation, indicating non-compliance with the facility's medication management policy.
The facility did not provide the required SNF ABN and NOMNC to two residents in a timely manner. These notices, which inform residents about costs and appeal rights related to Medicare Part A coverage, were signed after the Last Covered Day for both residents. Interviews confirmed the delay in providing these notices.
A facility failed to report a suspected abuse allegation involving a cognitively intact resident with multiple medical conditions. The resident reported feeling uncomfortable due to a nursing assistant's actions, which was communicated to the ADON by a family member. Despite awareness of the allegation, the facility did not report the incident to the state agency within the required timeframe, as confirmed by a review of reportable incidents.
A resident reported feeling uncomfortable due to a nursing assistant's actions, but the facility failed to investigate or report the alleged abuse. Despite the resident being cognitively intact and the incident being reported to staff and a family member, no investigation was conducted, violating the facility's abuse policy.
The facility failed to accurately code the MDS for a resident with a Level II PASARR evaluation for SMI and ID, marking 'No' instead of 'Yes'. Additionally, another resident's MDS did not reflect the use of an antibiotic, despite it being administered as per the eMAR. These discrepancies were confirmed by the MDS Consultant.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked details on managing antidepressant, antianxiety, and anticoagulant medications, while another resident's care plan did not address an actual fall incident despite being at risk for falls. These deficiencies were confirmed by facility staff.
The facility failed to update the Comprehensive Care Plans for three residents, leading to deficiencies in addressing their current medical needs. A resident with obstructive sleep apnea had a BiPAP order not reflected in their care plan, while another resident's CPAP use was similarly omitted. Additionally, a resident who experienced a fall did not have their care plan updated to address the incident. These oversights were confirmed by the ADON.
The facility failed to implement Enhanced Barrier Precautions for a resident with an MDRO and an indwelling catheter, as staff did not wear gowns or perform proper hand hygiene during care. Additionally, the facility did not ensure daily cleaning of a CPAP device for another resident, as required by physician orders. These deficiencies highlight lapses in infection control practices.
The facility did not designate a licensed RN to work full-time as the Director of Nursing (DON) while the previous DON was on maternity leave. During this period, the ADON, an LPN, and the ADM, who was not a nurse, performed some of the DON's responsibilities. The facility census was 61, and the deficiency had the potential to affect all residents.
Food Labeling, Sanitation, and Hand Hygiene Failures During Meal Preparation and Service
Penalty
Summary
The facility failed to label and date multiple foods stored in the kitchen and walk-in refrigerator. During the initial kitchen inspection, surveyors observed trays and pans of desserts, fruit cups, and a sealed bag of cornbread that were not labeled or dated. The inspection also found soiled food storage containers, drawers with dried food residue, and a food scale covered with grease-like film and food particles. The dietary manager confirmed that foods were supposed to be labeled before being placed in refrigerators and that the drawers and dry food containers needed cleaning. Surveyors also observed multiple food preparation practices that did not follow the facility’s own procedures or basic food handling expectations. A dietary cook prepared chicken with teriyaki sauce using a paint brush, kept the sauce covered on an unheated stove without cooling or hot holding it, and repeatedly handled foods and equipment without performing hand hygiene. The cook handled frozen hamburger patties and hot dogs with bare hands, mixed rice, vegetables, eggs, and sauces without obtaining temperatures at several points, and used rice retrieved from the dirty pan area after it had already been discarded there. The cook also used a food scale and other equipment that had not been cleaned or sanitized after use. During meal service, surveyors observed dietary staff serving residents while wearing gloves but not changing gloves or performing hand hygiene after touching potentially contaminated items. One aide handled a door, resident cups, and plates with the same gloved hands, including placing gloved thumbs on the food-contact surface of a plate. The dietary manager also handled jelly packets, touched a resident’s shoulder, and then continued serving meals without removing gloves or performing hand hygiene. Another aide handled a resident’s personal cell phone with gloved hands and then served desserts and meals to residents without removing the gloves or performing hand hygiene. The dietary manager confirmed that gloves did not replace hand hygiene during meal service.
Meals Not Served Consecutively at Shared Tables
Penalty
Summary
The facility failed to consecutively serve meals to all residents seated at the same table to maintain resident dignity for 10 of 12 residents observed. During the noon meal observation in the Peony dining room, 12 residents were seated at 5 different tables, and the first plated meal was taken from the kitchenette and carried to a resident room before meals were served in the dining room. In the dining room, residents seated together were not consistently served one table at a time; for example, Resident 62 was served first at 12:50 PM while tablemates Residents 47 and 70 had not yet been served, and Resident 41 was served at 12:50 PM while tablemate Resident 27 was not served until 12:55 PM. Additional observations showed similar delays within tables. Resident 35 was served at 12:57 PM while tablemates Residents 31 and 12 were not served until 1:03 PM and 1:04 PM, respectively. Resident 72 was served at 12:58 PM while tablemate Resident 36 was not served until 1:00 PM. Resident 47 was served at 12:59 PM, 9 minutes after tablemate Resident 62, and Resident 70 was served at 1:01 PM, 11 minutes after tablemate Resident 62. The Dietary Manager and a Dietary Cook both confirmed that the expectation is to serve all residents seated at one table before moving to the next table.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Alternatives
Penalty
Summary
The facility failed to inform residents and/or their representatives in advance of care about the risks, benefits, and possible alternatives of psychotropic medications for 5 of 6 sampled residents: Residents 1, 4, 10, 53, and 60. The cited regulation was 175 NAC 12-006.05(D)&(E), and the facility census was 71. Surveyors reviewed records, observed documentation, and interviewed the DON, who confirmed that residents receiving psychotropics were not given a form to sign showing the risks and benefits of these medications and that alternatives were not discussed with the resident or family representatives before the medications were administered. Resident 4 had diagnoses of depression and dementia with agitation and orders for quetiapine 50 mg at 7:00 PM, quetiapine 200 mg twice daily, and sertraline 50 mg daily. The electronic medical record showed no evidence that the resident and/or representative were informed in advance of the risks, benefits, and possible alternative treatments for the antidepressant and antipsychotic medications. Resident 60 had diagnoses of dementia and depression and orders for sertraline 100 mg daily and quetiapine 12.5 mg at 7:00 PM, and the record also lacked evidence of advance notification regarding risks, benefits, and alternatives. Resident 1 was admitted with depression and schizoaffective disorder and received Celexa daily and olanzapine every evening, with no evidence in the EMHR that the resident and/or representative were informed in advance of care. Resident 53 was admitted with bipolar disorder and received buspirone daily and risperidone every evening, with no documentation of advance notification. Resident 10 had diagnoses including Alzheimer’s disease, Down syndrome, depression, and unspecified mood disorder, and received multiple Seroquel and Zoloft orders over time; the DON stated education for medication changes was done at care planning meetings with the POA, but advance notification of the risks, benefits, and possible alternatives of psychotropic medications was not completed prior to dispensing.
Failure to Complete and Share Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed within 24 hours of admission for 7 of 10 sampled residents, including Residents 18, 60, 11, 53, 70, 2, and 9. The report states that the baseline care plan is intended to provide initial effective and person-centered care and to meet a resident’s immediate needs, but record review showed no evidence that a baseline care plan had been completed for several of the residents reviewed. The facility policy titled Care Plans, dated January 2026, stated that a baseline plan of care should be developed within 48 hours of admission, while Nebraska requires it within 24 hours. The facility also failed to provide a written summary of the baseline care plan to the resident or their representative for 9 of 10 sampled residents, including Residents 18, 74, 60, 11, 53, 3, 70, 2, and 9. Interviews with the SSD and DON confirmed that written summaries were not provided as required. Record review showed blank or missing baseline care plan summary and signature sections for some residents, and EMR review for others showed no evidence that a summary had been completed or reviewed with the resident or representative.
Failure to Report Resident Transfers and Discharges to the Ombudsman
Penalty
Summary
The facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. Record review and interview showed that the Social Services Director stated the facility sent a monthly list of emergency transfers to the Ombudsman. However, Resident 74 had an emergency transfer to the hospital on 1/2/2026 at 7:45 AM, and although the January 2026 Emergency Transfers from Facility form was provided to the Ombudsman, Resident 74 was not included. Resident 76 was transferred from the facility on 2/9/2026, but the February 2026 Emergency Transfers from Facility form provided to the Ombudsman did not include Resident 76. In follow-up interview, the Social Services Director confirmed that the discharge for Resident 76 and the transfer of Resident 74 were not reported to the Ombudsman as required.
MDS Coding Errors for Ostomy and Insulin Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for 2 of 18 sampled residents. Facility policy assigned the MDS Coordinator responsibility for completing Section H: Bladder and Bowel, Section N: Medications, and submitting the MDS. The RAI Manual instructions cited in the report state that Section H0100C should be coded if an appliance was used at any time in the 7 days prior to the ARD, and Section N0350A should reflect the number of days insulin injections were received during the 7 days prior to the ARD. For one resident with a diagnosis of Type 2 Diabetes Mellitus, the comprehensive MDS coded Section H0100C as if the resident had an ostomy and coded Section N0350A as 1 for an insulin injection during the 7-day lookback period. Review of the EMHR showed no evidence of an ostomy and no orders for insulin injections during that period, and the MDSC confirmed both codes were incorrect. For a second resident with Type 2 Diabetes Mellitus, the quarterly MDS coded Section N0350A as 1 for an insulin injection during the 7-day lookback period, but the EMHR showed no orders for insulin injections during that period; the MDSC confirmed this code was also incorrect.
CCP Did Not Reflect Discharge Plan, Diet, or Antipsychotic Use
Penalty
Summary
The facility failed to ensure the Comprehensive Care Plan (CCP) reflected the discharge plan and goals for a resident admitted with a stage 3 pressure ulcer. The resident’s MDS documented that the resident and/or significant other provided information and that the overall goal was to discharge to the community. During interviews, the resident stated the plan was to return home after the wound healed, and the spouse stated the goal was for the resident’s wound to heal and then return home. However, the CCP contained no focus, goal, or interventions addressing the resident’s desired discharge plan to return home after healing. The facility also failed to ensure another resident’s CCP accurately reflected the current therapeutic diet. That resident was admitted with epilepsy and had a quarterly MDS indicating no signs or symptoms of swallowing disorders while receiving a mechanically altered diet. The CCP documented a no added salt diet with mechanical soft texture and thin liquids, along with use of a scoop plate and handled cups, and listed a goal to maintain adequate nutritional status. The resident stated they had no teeth or dentures, had been receiving a baby food diet, did not like it, and wanted to eat regular food again. The physician order summary showed a no salt added, pureed texture diet, and an LPN confirmed the diet had been changed to puree due to coughing during meals. The CCC confirmed the CCP did not accurately reflect the current pureed diet order. The same resident’s CCP also failed to reflect antipsychotic medication use. The quarterly MDS showed routine antidepressant and antipsychotic medication use, and the physician order summary listed Buspirone daily and Risperidone every evening. The EMAR showed the resident had been receiving the antipsychotic as ordered since admission. The CCP included a psychosocial wellbeing focus related to bipolar disorder and an intervention to administer an antidepressant medication, but it did not include the antipsychotic medication or the need to monitor for possible side effects. The CCC confirmed that the antipsychotic use and possible side effects were not listed on the care plan and should have been.
Failure to Administer PRN Midodrine as Ordered
Penalty
Summary
The facility failed to follow a provider’s order for PRN Midodrine for a resident admitted with orthostatic hypotension and a care plan focus for fall risk related to hypotension. The physician order directed that 1 tablet of Midodrine be given by mouth every 8 hours as needed for hypotension when blood pressure was below 100. Record review showed the resident had repeated blood pressure readings below 100 during February and March 2026, including readings as low as 70/46, 73/44, 75/48, and 76/50, yet there was no evidence that the PRN Midodrine was administered on those occasions. The MAR and blood pressure summary documented multiple instances in which the resident’s blood pressure was below the ordered threshold without a corresponding medication administration entry. In February, low readings were recorded on several dates, including 75/48, 92/57, 98/62, 86/57, 96/64, 94/58, 82/54, 73/44, 80/50, 91/57, 95/63, 86/54, 99/76, and 88/63, with only one documented administration on 02/20/2026 despite a continued low blood pressure reading afterward. In March, additional low readings were documented, including 76/50, 95/60, 92/66, 86/62, 75/49, 88/52, 95/63, 99/60, 96/62, 84/56, 94/62, 88/56, and 70/46, again without evidence of the PRN medication being given as ordered. During interview, the LPN stated staff obtained the resident’s blood pressure daily and, when low, advised the resident to be careful when sitting, standing, or walking and to use the call light to prevent falls. The LPN denied knowledge of the PRN Midodrine order until reviewing the physician orders and confirming it had not been administered as ordered. The CCC and DON also confirmed that the resident had an order for PRN Midodrine for blood pressures less than 100 and that the medication was not being administered according to the provider’s order.
Failure to Identify Resident’s Dental Service Preference on Admission
Penalty
Summary
The facility failed to identify Resident 53’s preference to have or not have dental services during admission, as required for routine and 24-hour emergency dental care. Record review showed the facility policy stated residents and/or their representatives are to be notified during the admission process about available dental services under the State Plan and any potential charges for outside dental care. The deficiency was identified based on the facility not documenting whether Resident 53 wanted dental services on admission. Resident 53 told the surveyor they were eating a modified texture diet because they had no teeth and were not sure how long it had been since they last used dentures. The resident stated their dentures had stopped fitting a while ago and they stopped wearing them, and they were not offered dental services on admission. The resident also stated they would like to get new dentures so they could eat regular food again. An LPN stated Resident 53 was edentulous, did not have dentures on admission, was on a modified texture diet due to coughing and choking at meals, and did not have a dental appointment that the nurse was aware of. The SSD stated staff ask residents about dental services during admission, but they did not ask Resident 53 and should have.
Hand Hygiene Not Performed Between Glove Changes During Wound and Catheter Care
Penalty
Summary
The facility failed to perform hand hygiene between glove changes during catheter care and wound care for one resident with a stage 3 pressure ulcer. The resident was admitted with a diagnosis of a stage 3 pressure ulcer on the right buttock, and provider orders directed dressing changes that included removing the old dressing and packing strip, cleansing the wound with wound cleanser, placing gauze packing strip in Vashe wound solution, packing the wound bed, and covering it with a 4x4 gauze secured with a Mepilex dressing. During an observation of wound care, an LPN placed wound care supplies directly on the resident’s bed without a barrier, provided suprapubic catheter care with gloved hands, removed gloves, and then put on new gloves without first performing hand hygiene. The LPN later removed soiled wound dressing material, removed gloves again, and put on another pair of gloves without hand hygiene. After cleansing the wound, the LPN again removed gloves and donned new gloves without hand hygiene. The LPN also used a Q-tip and a clear plastic measuring device that had been placed directly on the resident’s bedding and used the measuring device on the wound and surrounding skin. The LPN and the facility Clinical Care Coordinator both confirmed that hand hygiene should have been completed after removing gloves and before putting on new gloves.
Unqualified Individual Assisted in Kitchen Due to Staffing Shortage
Penalty
Summary
The facility failed to ensure that only qualified dietary staff worked in the kitchen, as required by licensure regulations. Record reviews showed that an individual, SR-A, who was not an employee of the facility and did not meet the qualifications outlined in the Dietary Aide job description, was present in the kitchen assisting with food preparation by peeling potatoes. This occurred due to a shortage of staff in the kitchen. The Dietary Manager confirmed that SR-A was not qualified and should not have been working in the kitchen, and the Administrator was unaware of SR-A's involvement until after the fact. This deficiency had the potential to affect all 75 residents residing in the facility.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the State Agency of a change in the Director of Nursing (DON) position within the required five-day timeframe. Record review showed that the DON was changed on 11/8/24, but the notification to the State Agency was not received until 1/15/25. During an interview, the Administrator confirmed that the notification was not sent within the required period. This lapse had the potential to affect all 75 residents residing in the facility.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, as required by their Abuse Policy and Procedures. The incident involved a resident who was reported by a Nursing Assistant to have been difficult to arouse during the night. The resident later complained that an unidentified individual was hitting and pounding on their chest, instructing them not to get up until the day shift staff arrived. Despite the resident's inability to provide further details, the incident was documented in the resident's progress notes. The Director of Nursing (DON) was informed of the allegation on the same day it was made. An investigation was conducted by the DON, who concluded that the allegation was unfounded. However, the DON did not report the allegation to the required State Agency, as mandated by the facility's policy. A review of the facility's records confirmed that no reports of staff-to-resident abuse investigations were submitted to the state agency for the month in question.
Failure to Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to identify specific target behaviors for the use of psychotropic medications in several residents, which is a requirement for monitoring the effectiveness of these medications. This deficiency was observed in five residents who were prescribed various psychotropic medications, including antidepressants, antianxiety, and antipsychotic drugs. The facility's policy requires that target behaviors be documented and monitored, yet this was not done for the residents in question. Interviews with staff, including a Medication Aide and a Registered Nurse, revealed a lack of awareness regarding the behaviors to be monitored, and the Assistant Director of Nursing confirmed the absence of documentation for targeted behaviors in the residents' electronic health records. Resident 35 was prescribed multiple antidepressants and an antianxiety medication, but their Comprehensive Care Plan (CCP) did not include any care plan related to the psychotropic medication uses or identification of targeted behaviors. Similarly, Resident 37 was prescribed an antidepressant without any identification of targeted behaviors in their CCP. Resident 44, who was prescribed both an antidepressant and an antipsychotic, also lacked documentation of targeted behaviors in their care plan. Interviews with staff confirmed the absence of this critical information, which is necessary for assessing the effectiveness of the medications. Additionally, the facility failed to include stop dates for PRN orders of psychotropic medications, as required by their policy. Resident 53 had a PRN order for Ativan without a stop date, and Resident 55 had a PRN order for Buspirone, which should not have been a PRN order and also lacked a stop date. The Assistant Director of Nursing confirmed these oversights, indicating a failure to adhere to the facility's policy on psychotropic medication management.
Failure to Provide Timely SNF ABN and NOMNC Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) to two residents, Resident 3 and Resident 44, or their representatives, in a timely manner. These notices are essential for informing residents about the costs of continuing skilled services and their right to appeal the decision to end Medicare Part A coverage. For Resident 3, the Last Covered Day (LCD) for Medicare Part A services was on 10/05/2024, but the SNF ABN was signed on 10/07/2024. Similarly, for Resident 44, the LCD was on 11/03/2024, but the SNF ABN was signed on 11/07/2024. Interviews with the Social Services Director confirmed that the notices were not signed within the required timeframe prior to the LCD for both residents.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report a suspected allegation of abuse involving a resident to the state agency within the required time frame and did not report the follow-up investigation within the mandated five working days. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 13, and had multiple medical conditions including atrial fibrillation, unspecified psychosis, depression, hypothyroidism, Meniere's disease, unspecified convulsions, chronic kidney disease, and hearing loss. The resident reported to a family member that a nursing assistant had made them feel uncomfortable by rubbing up against them in the bathhouse. The family member communicated this allegation to the facility's Assistant Director of Nursing (ADON). Despite being aware of the allegation, the facility staff, including the ADON, did not report the incident to the state agency as required. A review of the facility's reportable incidents confirmed that no report of the alleged abuse had been made in the last six months. The facility's policy and procedures, revised in January 2024, clearly state that allegations of abuse should be investigated and reported to the Department of Health and Human Services, a responsibility designated to the Administrator or the Director of Nursing.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility staff failed to investigate an alleged incident of abuse involving a resident, identified as Resident #53, who was part of a sample of 16 residents in a facility with a census of 61. The facility's abuse policy and procedures, revised in January 2024, require that allegations of abuse be investigated and reported to the state. However, a review of the facility's reportable incidents revealed no report of the alleged abuse involving Resident #53 and a nursing assistant, NA-H, in the last six months. Interviews with facility staff, including a medication aide and a licensed practical nurse, confirmed that the resident had reported feeling uncomfortable due to NA-H's actions, and the matter was brought up in risk management. Despite this, the Assistant Director of Nursing confirmed that no investigation had been conducted. Resident #53, who was admitted with multiple medical conditions including atrial fibrillation, unspecified psychosis, depression, hypothyroidism, Meniere's disease, unspecified convulsions, chronic kidney disease, and hearing loss, was cognitively intact with a BIMS score of 13. The resident reported to a family member and a medication aide that NA-H had made them feel uncomfortable by rubbing up against them in the bathhouse. The family member contacted the facility to report the allegation, but the facility failed to follow through with an investigation or report the incident as required by their policy.
Inaccurate MDS Coding for PASARR and Antibiotic Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected the Level II PASARR status for a resident with serious mental illness (SMI) and intellectual disability (ID). The resident had a PASARR Level 2 evaluation indicating these conditions, but the MDS was incorrectly marked as 'No' for the presence of SMI and/or ID. This discrepancy was confirmed during an interview with the MDS Consultant, who acknowledged that the MDS should have been marked 'Yes' to reflect the resident's PASARR Level 2 status. Additionally, the facility did not accurately code the use of an antibiotic for another resident. The resident's electronic Medication Administration Record (eMAR) showed a new order for Rifaximin, an antibiotic, which was administered as prescribed. However, the MDS did not indicate that the resident was taking an antibiotic during the 7-day look-back period. This oversight was also confirmed by the MDS Consultant, who stated that the antibiotic should have been checked as taken on the MDS.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, which accurately reflected their care needs. For Resident 35, the admission Minimum Data Set (MDS) indicated the use of antidepressant, antianxiety, and anticoagulant medications. However, the comprehensive care plan did not include any resident-centered plan related to these medications. This omission was confirmed by the MDS Consultant during an interview, highlighting a gap in medication management and mood and behavior considerations as per the facility's policy. For Resident 3, the facility did not address an actual fall in the resident's care plan. Despite being identified as at risk for falls on a Fall Risk Evaluation, the care plan for falls was not initiated until after the resident experienced an unwitnessed fall. The resident, who had a BIMS score indicating cognitive intactness, reported a fall while reaching for food, which resulted in a visit to the emergency room. The Assistant Director of Nursing confirmed that the care plan for falls was delayed, failing to address the resident's actual fall incident.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to revise the Comprehensive Care Plans (CCPs) for three residents, which led to deficiencies in addressing their current medical needs. Resident 14, who was diagnosed with dementia, leukemia, type 2 diabetes, high blood pressure, irregular heartbeat, and obstructive sleep apnea, had an order to use a BiPAP device at night. However, the CCP did not include the use of this device, as confirmed by the Assistant Director of Nursing (ADON). Similarly, Resident 62, diagnosed with obstructive sleep apnea among other conditions, had an order for a CPAP device, but this was not reflected in their CCP. Observations confirmed the presence of CPAP equipment, yet the care plan remained unupdated. Additionally, Resident 2, who had diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder, experienced a fall resulting in abrasions to the left temple. Despite this incident, the CCP for Resident 2 was not updated to address the fall. The ADON confirmed the fall occurred, yet the care plan did not reflect this event. These oversights in updating the CCPs for the residents indicate a failure in maintaining accurate and current care plans, which are essential for providing effective and person-centered care.
Inadequate Infection Control Practices for Residents with MDRO and CPAP Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for Resident 3, who had a history of infection with a multi-drug resistant organism (MDRO) and an indwelling catheter. Despite having an order for staff to wear gowns and gloves during catheter care, observations revealed that staff did not wear gowns during these procedures. Additionally, hand hygiene was not performed appropriately, as staff did not wash their hands before donning gloves, between glove changes, or when moving from contaminated to clean body sites. The facility's policy on EBP did not address all high-contact resident care activities, and personal protective equipment (PPE) was not readily available in the resident's room. Resident 3, who was cognitively intact with a BIMS score of 15, reported that staff only wore gloves during catheter and peri care, not gowns. Observations confirmed the absence of EBP signage and gowns in the resident's room. During peri and catheter care, staff failed to perform hand hygiene at critical points, such as before care, between glove changes, and after handling contaminated objects. The Assistant Director of Nursing (ADON) confirmed that the facility's EBP policy was incomplete and that PPE was not easily accessible. The facility also failed to ensure proper cleaning of a CPAP device for Resident 62, who had a diagnosis of obstructive sleep apnea and other medical conditions. Observations showed that the CPAP humidity reservoir was not emptied and cleaned daily as required by the physician's order. The ADON confirmed that the CPAP equipment had not been cleaned according to the facility's policy, which mandates daily cleaning to prevent infection. This oversight in infection control practices highlights deficiencies in the facility's adherence to established protocols.
Failure to Designate RN as Director of Nursing During Leave
Penalty
Summary
The facility failed to designate a licensed Registered Nurse (RN) to work full-time as the Director of Nursing (DON) during a period when the previous DON, RN E, was on maternity leave. The record review of the Archived Time Card Report forms for RN E showed that RN E clocked out in early May and did not return until August, with a Leave of Absence noted during this period. During RN E's absence, the Assistant Director of Nursing (ADON), who was a Licensed Practical Nurse (LPN), and the Administrator (ADM), who was not a nurse, performed some of the DON's responsibilities. The facility census was 61, indicating that this deficiency had the potential to affect all residents. Interviews with the DON, ADM, and ADON confirmed that while RN E was on leave, the ADON, an LPN, was performing the responsibilities of the DON, such as attending meetings and managing staff. The ADM confirmed that the ADON was the designee during this period, and RN E was available by phone if needed. However, the facility did not have an RN designated to perform the duties of the DON while RN E was on leave, which was a requirement according to the licensure reference number 175 NAC 12-006.04(D)(i).
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holdrege
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holdrege Memorial Homes, Inc | 2.5 mi | ★★★★★ | 0 | 0 |
| Bertrand Nursing Home | 13.2 mi | ★★★★★ | 0 | 0 |
| Brookestone Gardens | 22.9 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Society - Colonial Villa | 23.1 mi | ★★★★★ | 12 | 0 |
| Bethany Home, Inc | 24 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.