Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Douglas County Health Center during CMS and state inspections, most recent first.
Three residents experienced significant medication errors, including administration of an anticoagulant against physician orders, inappropriate holding of a nerve pain medication, and multiple errors involving sedative, opioid, and cardiac medications. These incidents resulted from miscommunication, incorrect pharmacy labeling, and failures in medication administration and verification processes.
Two residents did not receive pain medications as ordered: one experienced abrupt discontinuation of both gabapentin and Lyrica due to a pharmacy hold, leading to withdrawal symptoms and increased confusion, while another did not have a buprenorphine patch changed as scheduled, resulting in a missed dose. Both incidents were confirmed by staff and documented in medical records.
Dietary staff with facial hair exceeding policy limits were repeatedly observed preparing and serving food without wearing required beard restraints, in violation of both state food code and facility policy. This noncompliance was confirmed by the Dietary Manager and had the potential to impact nearly all residents receiving meals.
A resident with dementia was prescribed Quetiapine Fumarate, but the facility did not identify or monitor target behaviors as required. Physician orders called for daily behavior monitoring, yet neither the MAR nor TAR included prompts or documentation for this, and the care plan lacked identified target behaviors. This was confirmed by staff interview and was not in accordance with the facility's psychotropic medication policy.
A resident admitted with dementia, anxiety disorder, and PTSD did not have PTSD documented in the MDS admission assessment. The assessment only listed dementia and anxiety, omitting PTSD, even though it was an established diagnosis at admission. Staff interviews confirmed the diagnosis should have been included.
A resident with dementia, anxiety disorder, and PTSD was admitted and exhibited confrontational behavior and war-related hallucinations. The MDS assessment failed to include PTSD as a diagnosis, and the care plan did not address the resident's PTSD, despite facility policy requiring all identified needs to be included. Staff confirmed the omission, resulting in the resident's mental health needs not being fully addressed.
A resident with impaired mobility and incontinence developed multiple open wounds that were not consistently evaluated or measured as required by facility policy. Staff failed to document wound measurements during weekly skin assessments, and some wounds were not evaluated at all. Direct observation confirmed the presence of several open lesions, and staff interviews revealed a lack of knowledge regarding wound treatment.
A resident with an existing pressure ulcer and a physician's order for heel offloading was repeatedly observed lying in bed without their heels offloaded. The care plan did not specify interventions for heel protection, and staff confirmed the omission, despite facility policy requiring such measures for pressure injury prevention.
A resident with severe cognitive impairment and total dependence on staff for ADLs was repeatedly observed in a tilt-in-space wheelchair without proper leg or head support, despite physician orders for leg rests and a headrest. Staff did not consistently attach or adjust the leg rests or headrest, and the wheelchair components provided were not suitable for the resident's body size, resulting in inadequate support. The facility did not contact the hospice agency to reevaluate the wheelchair.
A resident with congestive heart failure and obstructive sleep apnea used a BiPAP machine without facility staff obtaining physician orders for its use or settings, and required cleaning protocols for the device were not implemented until several days after admission, contrary to facility policy.
A resident with frequent, severe pain received scheduled Tramadol without assessment of pain levels prior to administration or monitoring of the medication's effectiveness. Documentation and physician orders did not include requirements for pain assessment, and the care plan intervention to evaluate pain relief was not implemented.
A resident with dementia, anxiety disorder, and PTSD, who showed confrontational behavior and war-related hallucinations, did not receive a trauma-informed care assessment or have PTSD addressed in the care plan. Facility policy required identification of trauma triggers and individualized interventions, but these were not implemented.
Staff failed to secure a catheter drainage bag and oxygen tubing for two residents, leaving both items on the floor in violation of infection control protocols. One resident with an indwelling catheter and another receiving oxygen therapy were observed with their medical equipment improperly placed, and staff confirmed these practices did not meet facility policy for maintaining clean, non-sterile items.
A resident with moderate cognitive impairment was subjected to racial slurs, derogatory language, and threats by another resident, leading to feelings of shock and unsafety. Staff intervened to prevent physical harm, but facility leadership did not report the incident to APS or state authorities as required, citing a belief that the remarks did not constitute reportable abuse. The Administrator later acknowledged the event was reportable, highlighting a lapse in timely reporting procedures.
A resident with cognitive impairment was subjected to racial slurs, derogatory language, and threats by another resident, leading to a physical confrontation that was stopped by staff. Despite facility policy requiring investigation and reporting of such incidents, nursing leadership did not investigate or report the event, only recognizing its reportable nature after administrative review.
Three residents did not receive a required face-to-face visit by a physician within the first 30 days after admission, as only NPs conducted the initial assessments and there was no facility policy ensuring physician visits. Staff interviews confirmed that the Medical Director relied on NPs for initial care and only became involved if concerns were identified.
A resident in an LTC facility experienced a delay in receiving appropriate care for a shoulder fracture due to the facility's failure to ensure timely follow-up with the physician. Despite the resident's repeated complaints of shoulder pain, the facility did not promptly contact the physician or follow up on x-ray recommendations. This resulted in a 30-day delay between the initial x-ray showing a possible fracture and the follow-up x-ray confirming a healing fracture.
A facility failed to maintain a care-planned intervention for a resident with severe cognitive impairment, leading to repeated altercations with another resident. Despite an active care plan intervention to use a magnetic barrier to prevent room entry, the barrier was removed during remodeling and not reinstalled, resulting in incidents where the resident pushed another resident, causing falls and injuries. Staff interviews revealed inconsistent adherence to the care plan, with no documentation supporting the barrier's removal.
The facility failed to store foods for residents in a sanitary manner, with staff not labeling and dating resident foods, clearing spoiled foods, or maintaining temperature logs for nourishment refrigerators. This affected six neighborhoods and potentially 153 residents.
A resident, who was cognitively intact and expressed a desire to participate, was not invited to their care conferences. Despite facility policy and staff expectations, the resident was excluded from the care planning process, with only their family member participating via phone calls.
A resident's hospice and primary care provider were not informed of an abnormal C&S lab result until a week after it was reported to the facility, delaying necessary antibiotic treatment. The resident had multiple diagnoses and was receiving hospice services. Facility staff failed to follow policy requiring immediate notification of the physician for abnormal lab results.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in care. Both residents, who had mobility issues and were dependent on staff for assistance, were observed with their call lights on the floor and out of reach. Staff confirmed the call lights should have been accessible, and the facility had ordered clips to secure the call lights, but they had not yet been installed.
The facility failed to update PASRRs for two residents after they were diagnosed with new mental illnesses and prescribed psychotropic medications. Despite the facility's policy requiring new PASRRs for significant changes in status, the Admissions Clinical Liaison and Chief Nursing Officer were unaware of the new diagnoses, resulting in non-compliance with state requirements.
A resident in a locked behavioral unit was found with medications left unattended at their bedside. The resident, who was cognitively intact, indicated that it was common for the nurse to leave medications in their room. Staff interviews confirmed that this practice posed risks, and the facility's policy required nurses to observe residents taking their medications.
A facility failed to ensure staff performed proper hand hygiene and did not touch medications with their bare hands when administering medication to a resident with severe cognitive impairment. The RN involved did not use hand sanitizer or wash their hands between resident contacts and touched medications with bare hands, contrary to the facility's hand hygiene policy.
The facility failed to ensure that the most recent survey results were readily accessible to all residents and that posted notices of the availability of the survey results were in a prominent and accessible area. The survey book was not updated with the latest recertification survey, and no signs were posted to indicate its location.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving three residents. For one resident with a history of traumatic cerebral hemorrhage and severe cognitive impairment, there was a physician order to hold apixaban, an anticoagulant, until cleared by neurosurgery. Despite this, the resident received 21 doses of apixaban due to a miscommunication between the facility, pharmacy, and nursing staff. The medication was dispensed and administered based on an incorrect pharmacy label and a lack of proper verification against the actual physician order, which resulted in the resident receiving the medication prior to neurosurgical clearance. Another resident, who had moderate cognitive impairment and was being treated for nerve pain, experienced a medication error when Lyrica, a prescribed medication, was held for several days without a physician order. This occurred after the pharmacy placed a hold on the medication following a neurology appointment that only called for discontinuation of gabapentin, not Lyrica. Despite attempts by facility staff to clarify the order with the pharmacy, the resident missed nine doses of Lyrica, leading to increased confusion and withdrawal symptoms until the medication was restarted. A third resident, with a diagnosis of congestive heart failure and who was receiving opioid and hypnotic medications, experienced several medication errors. These included administration of a sedative-hypnotic at the wrong time, omission of a scheduled buprenorphine patch change, administration of another resident's medications, and administration of Entresto despite blood pressure readings below the ordered threshold for holding the medication. These errors were confirmed through record review and staff interviews, indicating failures in medication administration, documentation, and adherence to physician orders.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain medication according to practitioner orders for two residents. For one resident with moderate cognitive impairment and significant assistance needs, gabapentin was discontinued per neurology orders, but Lyrica, which was to be continued, was incorrectly placed on hold by the pharmacy. Despite staff contacting the pharmacy multiple times, the Lyrica was not reinstated, resulting in the resident missing nine doses over several days. The resident subsequently became more confused and stopped eating, and it was noted that the abrupt discontinuation of both medications led to withdrawal symptoms. For another resident with congestive heart failure and extensive care needs, there was a failure to change a prescribed buprenorphine patch for chronic pain management as ordered. The patch, which should have been changed weekly, remained in place for twelve days, resulting in a missed dose. This omission was confirmed by facility staff and documented in the resident's medical records.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Dietary staff members were observed on multiple occasions preparing and plating food in the facility kitchen without wearing required beard restraints, despite having facial hair such as goatees and mustaches exceeding the length specified in facility policy. Specifically, one dietary aide was seen at the service line and another at the short-order grill, both with facial hair and not wearing beard nets, during several morning meal preparations. These observations were made over several days and involved staff directly handling and serving food. A review of the Nebraska Food Code and the facility's own Dress Code Policy confirmed that beard restraints are required for food employees with facial hair longer than half an inch. The Dietary Manager acknowledged that the staff members in question had facial hair that necessitated the use of beard restraints. The failure to comply with these standards had the potential to affect the majority of residents receiving food from the kitchen.
Failure to Identify and Monitor Target Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to identify and monitor target behaviors for the use of an antipsychotic medication for a resident diagnosed with dementia. Record review showed that the resident had physician orders for Quetiapine Fumarate, including instructions to monitor behaviors daily, but the orders did not specify time values. Further review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the relevant month revealed that target behaviors were not identified, and there was no indication or prompt for staff to record behavior monitoring related to the use of Quetiapine Fumarate. Additionally, the resident's care plan did not include any identified target behaviors, and an interview with a registered nurse confirmed that neither target behaviors nor prompts for behavior monitoring were present on the MAR or TAR. The facility's policy on the use of psychotropic medications requires ongoing evaluation of the effects of such medications, including behavior monitoring, but this was not followed in the case of this resident.
Failure to Accurately Document PTSD Diagnosis in MDS Admission Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) comprehensive assessment accurately identified all current diagnoses for a resident upon admission. Specifically, a resident admitted with diagnoses of unspecified dementia, anxiety disorder, and post-traumatic stress disorder (PTSD) did not have PTSD documented in Section I of the MDS admission assessment. The assessment, completed on 03/18/2025, only listed non-Alzheimer's dementia and anxiety as current diagnoses, omitting PTSD despite it being part of the resident's medical history. Interviews with facility staff revealed that the omission occurred because the MDS coordinator did not include PTSD in the assessment, relying instead on the timing of the resident's appointment with a mental health provider, which took place after the MDS was completed. The lead MDS coordinator confirmed that PTSD should have been included in the admission assessment, as the diagnosis was already established at the time of admission.
Failure to Address PTSD in Resident's Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the mental and psychological needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD). Record reviews showed that the resident was admitted with diagnoses including unspecified dementia, anxiety disorder, and PTSD, and had a moderately impaired cognitive status as indicated by a BIMS score of 10/15. Despite documentation in progress notes of the resident being confrontational and experiencing war-related hallucinations, the admission assessment on the Minimum Data Set (MDS) did not include PTSD as a diagnosis in Section I. The lead MDS Coordinator confirmed that PTSD should have been included in the assessment. Further review of the resident's care plan revealed no evidence that the PTSD diagnosis was addressed. Interviews with facility staff, including the social worker, confirmed that the comprehensive care plan did not include interventions for PTSD. Facility policies required that all identified problems, including those found in the MDS and other assessments, be addressed in the care plan with specific goals and interventions. The failure to include PTSD in both the MDS and the care plan resulted in the resident's mental health needs not being fully addressed as required by facility policy and regulatory standards.
Failure to Evaluate and Monitor Resident Wounds per Policy
Penalty
Summary
Facility staff failed to properly evaluate and monitor open lesions for one resident with significant risk factors for impaired skin integrity, including impaired mobility, incontinence, and anemia. The resident's care plan included interventions such as weekly skin assessments, use of pressure reduction devices, and prompt notification of providers for skin concerns. However, record reviews showed that open wounds on the resident's buttocks and gluteal area were not consistently evaluated or measured as required. Several weekly skin assessments lacked documentation of wound measurements, and in some instances, the wounds were not evaluated at all. Direct observation confirmed the presence of multiple open wounds on the resident's buttocks and upper thigh, with staff interviews revealing a lack of awareness regarding the treatment for these wounds. The facility's own policy required comprehensive weekly skin assessments with detailed documentation, including wound measurements and descriptions, which was not followed. The unit manager confirmed that the wounds had not been measured weekly as required by policy.
Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
Facility staff failed to implement ordered interventions to offload the heels of a resident who was at risk for pressure ulcer development and already had a pressure ulcer present. The resident, who was cognitively intact and required extensive to total assistance with mobility and activities of daily living, had a physician's order to offload heels while in bed. However, multiple observations revealed the resident lying in bed with heels resting directly on the mattress, without any offloading devices or supports in place. The resident's care plan addressed pressure ulcer prevention and treatment but did not include specific interventions for heel offloading. The resident reported that while hospitalized, staff offloaded their heels using a pillow, but this was not done at the facility. A registered nurse confirmed during wound care that the heels were not offloaded as required. Facility policy required evidence-based interventions, including heel offloading, for residents at risk or with existing pressure injuries, but these were not implemented for this resident.
Failure to Ensure Proper Wheelchair Positioning and Support
Penalty
Summary
Facility staff failed to ensure proper wheelchair positioning and support for a resident with severe cognitive impairment who was dependent on staff for all activities of daily living and receiving hospice care. Despite physician orders for a tilt-in-space wheelchair with leg rests, repeated observations showed the resident seated without leg rests, resulting in unsupported, dangling legs. The headrest was consistently positioned against the resident's upper shoulders or back, leaving the head unsupported. Even when leg rests were attached, they were too short for the resident's long legs, causing the knees to be elevated and not in contact with the wheelchair seat. The headrest repeatedly failed to stay in position to support the head, and staff did not consistently attempt to reposition it or the resident's legs when they became unsupported. The unit manager confirmed that the facility had not contacted the hospice agency to reevaluate the wheelchair, as it was provided by hospice and selected based on height and weight. Staff interviews and observations indicated a lack of ongoing assessment and adjustment of the wheelchair and its components to ensure proper support and positioning for the resident, despite clear orders and the resident's total dependence on staff for mobility and positioning.
Failure to Obtain Orders and Implement Care for BiPAP Use
Penalty
Summary
Facility staff failed to obtain and implement physician orders for the use of a non-invasive ventilator, specifically a BiPAP machine, for a resident diagnosed with congestive heart failure and obstructive sleep apnea. The resident, who was cognitively intact and required assistance with several activities of daily living, had a BiPAP machine at the bedside, but there were no documented orders specifying its use or settings in the resident's medical record. The care plan included a focus on BiPAP therapy, but interventions were limited to encouraging use, without reference to specific orders or settings. Additionally, the facility did not implement the required daily, weekly, and monthly cleaning protocols for the BiPAP machine until several days after the resident's admission. The Unit Manager confirmed that cleaning procedures were not followed initially because the machine belonged to the resident and not the facility. Facility policy outlined specific cleaning requirements for CPAP/BiPAP equipment, but these were not adhered to until after the deficiency was identified.
Failure to Assess and Monitor Pain Management
Penalty
Summary
The facility failed to assess a resident's pain prior to administering scheduled pain medication and did not monitor the effectiveness of the pain management provided. Record review showed that the resident had a physician's order for scheduled Tramadol HCL 50 mg three times daily for pain, and the resident's Minimum Data Set (MDS) assessment indicated frequent pain rated as 8 out of 10, which limited daily activities. However, the Medication Administration Record for the resident did not include any documentation of pain level assessments at the time of medication administration. Additionally, there was no physician's order in place to assess the resident's pain or to monitor the effectiveness of the scheduled pain medication. The resident's care plan included an intervention to evaluate the effectiveness of pain-relieving interventions, but this was not implemented as required. An interview with a registered nurse confirmed that there was no order or process in place for pain assessments or monitoring the effectiveness of the scheduled pain medication for this resident.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with dementia, anxiety disorder, and post-traumatic stress disorder (PTSD). The resident, who had moderately impaired cognition as indicated by a BIMS score of 10/15, exhibited confrontational behavior and hallucinations related to war, as documented in progress notes by an LPN. Despite these symptoms and the PTSD diagnosis, there was no evidence in the medical record that a trauma-informed care assessment had been completed for the resident. Further review and interviews revealed that the resident's care plan did not address the PTSD diagnosis, and no assessment had been conducted to identify potential triggers that could cause re-traumatization. The facility's own policy required the use of a multi-pronged approach to identify trauma history and triggers, as well as collaboration with the resident and relevant professionals to develop individualized care plan interventions. These steps were not followed for the resident in question.
Failure to Secure Catheter Bag and Oxygen Tubing Compromises Infection Control
Penalty
Summary
Facility staff failed to properly secure and maintain medical equipment for two residents, resulting in potential infection control deficiencies. For one resident with an indwelling urinary catheter, observations on two separate occasions revealed that the catheter drainage bag was lying on the floor without a cover or barrier. The resident required total assistance with bed mobility, toileting, and bathing, and was unable to complete a mental status interview. A nursing assistant confirmed that the catheter bag was on the floor and acknowledged it should not have been. For another resident receiving oxygen therapy, observations showed that the oxygen tubing and cannula were left lying on the floor in the resident's room while the oxygen concentrator was running. This resident had severe cognitive impairment and required extensive to total assistance with activities of daily living. A nursing assistant confirmed that the oxygen tubing and cannula were on the floor and should not have been. The facility's infection prevention and control policy requires all non-sterile items to be stored and maintained as clean, which was not followed in these instances.
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an alleged verbal altercation between two residents to Adult Protective Services and the Department of Health and Human Services within the required timeframe. The incident involved a resident with moderate cognitive impairment, non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. During the altercation, another resident used racial slurs, derogatory language, and made threats, prompting the affected resident to attempt to physically respond before staff intervened. No physical harm occurred, but the resident who was verbally abused reported feeling shocked and unsafe as a result of the incident. Despite the facility's policy requiring immediate reporting of suspected abuse or neglect, interviews with the Unit Manager, DON, and ADON revealed that they did not consider the verbal remarks or the situation to be reportable and did not initiate an investigation or report the incident. The Administrator, upon review, agreed that the event was reportable, but this determination was made after the fact, indicating a failure to follow established reporting protocols.
Failure to Investigate and Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to investigate an alleged verbal altercation between two residents, one of whom had a history of non-traumatic brain dysfunction, non-Alzheimer's dementia, and a psychotic disorder. The incident occurred in the dining room, where one resident used racial slurs, derogatory language, and threatened physical harm toward another resident, who then attempted to physically retaliate. Staff intervened and separated the residents, and no physical harm was reported. Despite the severity of the verbal altercation and the facility's policy requiring investigation and reporting of suspected abuse, the incident was not investigated or reported to the appropriate authorities. Interviews with the Unit Manager, DON, and ADON revealed that they did not consider the incident reportable or requiring further investigation, even though the facility's policy mandates reporting and investigation of all alleged abuse, including resident-to-resident incidents. The Administrator, upon review, agreed that the event was reportable, but no investigation or reporting had been initiated at the time of the survey.
Failure to Ensure Timely Physician Face-to-Face Visits After Admission
Penalty
Summary
The facility failed to ensure that three out of seven reviewed residents received a face-to-face visit by a physician within the required first 30 days after admission. Record reviews showed that these residents were only seen by nurse practitioners (NPs) for their initial admission assessments and subsequent care, with no documentation of a physician visit within the mandated timeframe. Specifically, one resident was admitted and seen by an NP for both the initial assessment and recertification, while two other residents were also only seen by NPs for their admission history and physicals. Interviews with facility staff confirmed that there was no policy in place regarding physician visits, and the Medical Director stated that NPs conducted the initial assessments, with the physician only becoming involved if concerns were raised by the NP.
Failure to Ensure Timely Follow-Up for Resident's Shoulder Fracture
Penalty
Summary
The facility failed to ensure timely follow-up with a physician to obtain x-rays for a resident who complained of shoulder pain. The resident, who was cognitively intact and independent in daily activities, reported pain on multiple occasions starting on May 15, 2024. Despite the resident's repeated requests for an x-ray, the facility staff did not attempt to contact the physician between May 15 and May 17, 2024, to expedite the x-ray process. The x-ray was eventually scheduled for May 21, 2024, but the delay in obtaining the x-ray and the lack of immediate follow-up with the physician contributed to the deficiency. The x-ray results from May 21, 2024, indicated a possible non-displaced fracture of the right shoulder, with a recommendation for follow-up radiographs in 10-14 days. However, the facility did not follow up with the physician regarding these recommendations, and no further x-rays were scheduled until June 21, 2024, after the physician inquired about the follow-up. This resulted in a 30-day gap between the initial x-ray and the follow-up, during which time the resident continued to experience pain. Interviews with facility staff, including the Assistant Director of Nursing, a Registered Nurse, and the Director of Nursing, confirmed that there was a lack of timely communication and follow-up with the physician. The facility's policy required immediate notification of the physician for new or severe pain and suspected fractures, but these protocols were not followed. The resident's fracture was not addressed promptly, leading to a delay in appropriate care and treatment.
Failure to Implement Care-Planned Intervention Leads to Resident Altercations
Penalty
Summary
The facility failed to implement a care-planned intervention for a resident with severe cognitive impairment and a history of physical aggression. The resident, who had been admitted with diagnoses of dementia with agitation and major depressive disorder, had an intervention in place since April 2023 to deter other residents from entering their room using a magnetic barrier. Despite this intervention being active in the care plan, the barrier was removed during a remodeling period, and no documentation was found to support the decision to discontinue its use. Subsequent incidents occurred where another resident entered the room, leading to altercations. On two occasions, the resident pushed the intruding resident out of the room, causing them to fall and sustain injuries. These incidents highlighted the failure to maintain the care-planned intervention, as the magnetic barrier was not reinstalled after the remodeling, and the care plan was not updated to reflect any changes or discontinuation of the intervention. Interviews with facility staff revealed a lack of consistent adherence to the care plan. Staff described the interventions as tools that could be used at their discretion, but there was no documentation to support the removal of the barrier due to the resident's stability. The facility's policy required the interdisciplinary team to update and evaluate care plans as needed, but this was not followed, leading to repeated resident altercations.
Failure to Maintain Sanitary Food Storage
Penalty
Summary
The facility failed to ensure that staff stored foods for residents in a sanitary manner. Specifically, staff did not label and date resident foods brought in by visitors, clear the nourishment refrigerators of spoiled foods, and maintain the temperature logs for the nourishment refrigerators. This deficiency was observed across six neighborhoods within the facility, potentially affecting 153 residents. The facility's policy required that all food items brought in by family or visitors be labeled with content and date, and consumed within three days, but this was not adhered to in multiple instances. Observations revealed that nourishment refrigerators in several neighborhoods contained undated and spoiled food items. For example, the Windsong Way neighborhood's refrigerator had undated food containers and an open container of butter spread. Similar issues were found in the Field of Dreams, [NAME] Way, Tranquility Road, Sunshine Gardens, and Safe Harbor neighborhoods, where temperature logs were incomplete, and food items were undated or spoiled. Interviews with staff confirmed that the food items should have been dated and that the dietary department was responsible for maintaining the nourishment refrigerators. The Director of Support Services and the Administrator confirmed that it was the facility's expectation for food items to be labeled and dated, and for refrigerator temperatures to be logged daily. The Assistant Director of Nursing reiterated that the facility's policy required daily checks of the refrigerators to discard any outdated, undated, or spoiled food items. However, these procedures were not consistently followed, leading to the observed deficiencies.
Resident Not Invited to Care Conferences
Penalty
Summary
The facility failed to invite a resident, who was cognitively intact, to attend their care conferences. The resident, diagnosed with chronic atrial fibrillation, unspecified intellectual disabilities, Tourette's disorder, and major depressive disorder, expressed a desire to participate in their care conferences. Despite the facility's policy requiring the involvement of residents in their care planning, there was no documentation indicating that the resident had been invited to any of their care conferences. The resident's family member participated via phone calls, but the resident was not given the opportunity to attend in person. Interviews with facility staff, including the Chief Nursing Officer, Registered Nurse, Social Worker, Assistant Director of Nursing, and the Administrator, revealed a consensus that residents should be invited to their care conferences. However, the Social Worker admitted to not inviting the resident, citing past negative experiences with resident participation. The facility's policy and staff expectations were not followed, resulting in the resident being excluded from their care planning process.
Delayed Notification of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify a resident's hospice service provider of a change in condition. Specifically, Resident #231's hospice and primary care provider were not informed of an abnormal culture and sensitivity (C&S) lab result until a week after it was reported to the facility. This delay resulted in the hospice provider not ordering an antibiotic to treat Resident #231 until a week after the abnormal C&S lab result was reported to the facility. Resident #231 was admitted with diagnoses including neurocognitive disorder with Lewy bodies, dementia, adult failure to thrive, benign prostatic hyperplasia with lower urinary tract symptoms, and retention of urine. The resident had an indwelling catheter and was receiving hospice services. The facility's policy required immediate notification of the physician for laboratory tests revealing a urinary pathogen with symptoms and no treatment. However, the abnormal lab results reported on 11/23/2023 were not communicated to the hospice service provider until 11/30/2023. Interviews with facility staff and the hospice service provider confirmed the delay in notification. The facility's Advanced Practice Registered Nurse (APRN) noted the abnormal results on 11/30/2023, and the hospice service provider received the results the same day. The hospice provider then ordered the necessary antibiotic treatment. The facility's Administrator and Assistant Director of Nursing (ADON) acknowledged that the staff should have notified the physician immediately and followed up within 48 to 72 hours if there was no response, or sooner if the situation was urgent.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency in care. Resident #487, who had a history of falls and difficulty walking, was observed with their call light out of reach, lying on the floor. Despite being dependent on staff for transfers and having a care plan that directed staff to encourage the use of the call light, the resident was unable to access it without assistance. Nursing Assistant D confirmed the call light should have been within reach and acknowledged that all staff were responsible for ensuring this. The resident expressed difficulty reaching the call light when it fell to the floor and requested a clip to secure it, which was missing at the time of the observation. Licensed Practical Nurse E also confirmed the call light should be within reach and noted the absence of the clip. Similarly, Resident #101, who had muscle weakness and a history of falls, was observed with their call light on the floor multiple times. The resident, who needed substantial assistance from staff for mobility, was unable to reach the call light to request help. Nursing Assistant F and LPN E both confirmed that the call light should be within reach and noted the difficulty in keeping it on the bed due to the lack of securing devices. The resident's care plan also directed staff to encourage the use of the call light for assistance, but the absence of a securing mechanism led to repeated instances where the call light was out of reach. Interviews with the Administrator and Chief Nursing Officer revealed that the facility had evaluated the need for clips to secure call lights and remotes, and clips had been ordered but not yet installed. The deficiency was identified through observations and interviews, highlighting a failure to ensure call lights were accessible to residents, as required by the facility's policy and the residents' care plans.
Failure to Update PASRRs for Residents with New Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure new Level I Preadmission and Resident Reviews (PASRRs) were completed after residents were diagnosed with new mental illness diagnoses and prescribed psychotropic medications for two residents. Resident #12 was admitted in 2008 with no initial mental illness diagnoses. However, in 2022, the resident was diagnosed with traumatic brain injury, unspecified psychosis, bipolar disorder, anxiety disorder, and unspecified moderate dementia with agitation. Despite these new diagnoses and the prescription of multiple psychotropic medications, a new PASRR was not completed. The Admissions Clinical Liaison (ACL) and Chief Nursing Officer (CNO) acknowledged that a new PASRR should have been submitted but was not done due to a lack of awareness of the resident's new diagnoses. Similarly, Resident #74 was admitted in 2021 and readmitted in 2022 with no initial mental illness diagnoses. The resident was later diagnosed with alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and delusional disorders. Despite these new diagnoses and the prescription of psychotropic medications, a new PASRR was not completed. The ACL and CNO both stated that a new PASRR should have been submitted but was not done due to a lack of awareness of the resident's new diagnoses. Interviews with the ACL and CNO revealed that the facility's policy required new PASRRs to be completed when residents had significant changes in status or new mental illness diagnoses. Both staff members acknowledged that the PASRRs for Residents #12 and #74 did not reflect their current psychiatric diagnoses or medications, indicating a failure to comply with the facility's policy and state requirements.
Medications Left Unattended at Resident's Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside of a resident in a locked behavioral unit. Resident #102, who was cognitively intact with a BIMS score of 15, was observed with a cup of medication at their bedside. The resident had already taken some medications and had placed others on their over-the-bed table. The resident indicated that it was not unusual for the nurse to leave medications in their room, trusting that the resident would take them. This practice was confirmed by the resident and observed by surveyors on 04/22/2024. Interviews with staff, including a Registered Nurse (RN) and the Chief Nursing Officer (CNO), revealed that leaving medications in a resident's room posed several risks, including the possibility of the resident not taking the medications, spilling them, or other wandering residents taking them. The CNO and the Administrator both stated that nurses were expected to observe residents taking their medications and not leave medications unattended in residents' rooms. The deficiency was identified as a failure to provide adequate supervision to prevent accidents and ensure the safety of all residents in the unit.
Failure to Perform Hand Hygiene and Proper Medication Handling
Penalty
Summary
The facility failed to ensure staff performed proper hand hygiene and did not touch medications with their bare hands when administering medication to a resident. Specifically, a Registered Nurse (RN) was observed preparing medications for a resident without using hand sanitizer or washing their hands after completing a medication pass with another resident. Additionally, the RN touched two medications with their bare hands while placing them into a medication cup. This action was contrary to the facility's hand hygiene policy, which mandates hand hygiene between resident contacts and before handling medications. The resident involved had a medical history that included vascular dementia, type two diabetes mellitus, hypertensive heart disease, unspecified mood disorder, and vitamin D deficiency. The resident's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment. Interviews with other staff members, including another RN, the Chief Nursing Officer (CNO), and the Staff Development Instructor (SDI), confirmed that the facility's policy prohibits touching medications with bare hands due to infection control concerns. The SDI also confirmed that nurses are trained to avoid such practices during their education sessions.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to ensure that the most recent survey results were readily accessible to all residents and that posted notices of the availability of the survey results were in a prominent and accessible area. The facility's policy required that a readable copy of the most recent federal and/or state survey report and plan of correction be maintained in a 3-ring binder in the main lobby and that signs indicating the availability and location of the survey binder be posted throughout the building. However, during the recertification and complaint survey, no signs were observed indicating where the survey results were located, and the survey book did not contain the latest recertification survey from 05/16/2023. The Compliance Officer (CO) confirmed that the survey book was not updated and was located in the lobby at the security desk, but it was the incorrect notebook. Interviews with the facility staff revealed that the CO was responsible for updating the survey notebook and checking it monthly, but this was not done. The Administrator acknowledged that the facility had not put back the signs indicating the location of the survey book after renovations. The Assistant Director of Nursing (ADON) stated that the survey notebook was available in the lobby and the CO's office, but there were no signs on the units to indicate its location. The ADON also mentioned that a handful of residents would ask about the survey results, but none had asked for the recent survey results. The facility's failure to ensure the survey results were readily accessible and properly indicated had the potential to affect all residents in the facility.
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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 Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Cypress At Midtown | 0.4 mi | ★★★★★ | 11 | 0 |
| Emerald Nursing & Rehab Omaha | 1.8 mi | ★★★★★ | 31 | 0 |
| St. Joseph Villa Nursing Center | 2.4 mi | ★★★★★ | 27 | 0 |
| Omaha Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Ambassador Health Of Omaha | 2.6 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.