Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Eastmont during CMS and state inspections, most recent first.
The facility failed to administer oxygen as ordered for three residents who experienced low O2 saturations. One resident had an O2 saturation of 89% on RA with an order to apply O2 to keep saturations above 90%; staff notified an RN, who assessed the resident, called 911, and prepared transfer paperwork but did not apply O2 or recheck the saturation before transfer. A second resident, care planned as at risk for respiratory distress with orders to maintain O2 saturations above 90%, became lethargic with an O2 saturation in the low 80s on RA; the RN called the POA and 911 and left the room for paperwork, and later could not recall if O2 was applied, with no documentation that it was. A third resident had documented O2 saturations in the high 80s on RA; the RN contacted the provider and believed they may have applied O2 but had no documentation of doing so before ambulance transfer. The DON confirmed that O2 was readily available, that orders required O2 when saturations remained below 90%, and that these residents had documented low O2 saturations without documented O2 administration, and that one resident’s care plan goal for O2 saturation was not met.
Surveyors found that the facility failed to enter and implement PRN oxygen orders for two residents with significant respiratory conditions. One resident with a history of pulmonary embolism and another with COPD each had admission orders from their PCPs for oxygen PRN to maintain O2 sats at 90%, but these orders were not entered into their Order Summaries. For the resident with COPD, documentation showed O2 saturation dropping to 82% with no record that supplemental oxygen was provided. The facility’s medication administration policy requires documentation in accordance with physician orders, and the DON acknowledged that standing orders are expected for all residents but that charts are not consistently reviewed, resulting in the missing PRN oxygen orders in the EMAR.
Food service staff failed to follow hand hygiene, glove-use, hair restraint, labeling, and ice machine sanitation practices. A dietary staff member handled food, gloves, and a cell phone without proper hand hygiene or glove changes, another staff member worked without a hair net or beard net while frosting a cake, and multiple food items were left undated. Surveyors also observed debris and rust-like buildup inside the ice machine, and the CDM was unsure when it had last been cleaned.
The facility failed to complete Adult/child background checks for two MA employees whose personnel files had no central registry documentation. HR confirmed the missing forms, and the facility policy states these checks are required for all new hires to screen for abuse, neglect, and other disqualifying history.
Hand hygiene was not consistently performed during resident care, medication administration, and housekeeping activities. A medication aide prepared and gave meds to a resident without sanitizing or washing hands before or after the task, a housekeeper handled toilet and trash duties in a resident room without hand hygiene and used a bare hand to turn off the faucet, and an LPN entered a resident room, checked BP, touched the resident's arms, and exited without sanitizing or washing hands.
The facility failed to maintain clean exhaust hoods in the kitchen, as observed during inspections. The hoods were coated with a dark brown substance, and the Dietary Manager confirmed they were not cleaned regularly. The cleaning schedule did not include the exhaust hoods, and the last cleaning by an external company was in March, indicating a lack of regular maintenance.
A nurse aide failed to perform adequate hand hygiene during peri-care for a resident with a suspected UTI, washing hands for only 8 seconds instead of the required 20 seconds. The aide did not change gloves or wash hands after touching objects, contrary to the facility's hand hygiene policy. The DON confirmed the deficiency in infection control practices.
The facility did not submit their PBJ data for Q2 2024 on time due to issues with a new payroll vendor. The vendor incorrectly categorized various hours, leading to a delay in submission. The Staffing Coordinator confirmed the report was one week late.
Failure to Administer Ordered Oxygen for Residents With Low O2 Saturations
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy in accordance with physician orders and documented care plans for three residents with low oxygen (O2) saturations. For Resident 2, vital signs on 03/28/2026 at 7:02 AM showed an O2 saturation of 89% on room air, while the medication administration record contained an order to apply oxygen as needed to keep O2 saturations greater than 90%. A medication aide reported the low saturation to the RN by phone and remained with the resident until the RN arrived. The RN confirmed that upon arrival they assessed the resident, then left the bedside to call 911 and prepare transfer paperwork, brought the crash cart to the room area, but did not administer oxygen per the physician’s order and did not recheck the O2 saturation before the resident left the facility. For Resident 6, the admission order dated 11/03/2025 directed staff to apply oxygen as needed to keep O2 saturations above 90%, and the care plan identified the resident as at risk for respiratory distress with a goal to maintain O2 saturations above 88% daily. On 02/18/2026, progress notes documented that at 7:00 AM the resident vomited, appeared tired, and had an O2 saturation of 90% on room air. By 9:30 AM, the resident was lethargic with an O2 saturation of 83% on room air. The RN documented calling the power of attorney and 911, and the resident was transferred out shortly thereafter. In interview, the RN could not recall whether oxygen had been administered, acknowledged leaving the room for an unknown period to obtain transfer paperwork, and there was no documentation that oxygen was applied despite the low saturation and existing orders and care plan goals. For Resident 8, progress notes on 02/18/2026 at 12:30 PM recorded an O2 saturation of 88% on room air, and a call was placed to the provider at that time. Later that day, the Weights and Vitals Summary showed an O2 saturation of 89% on room air, and progress notes indicated the resident was transferred via ambulance to the emergency department that evening. The RN reported calling the primary care provider to report the resident’s condition and stated they asked for an oxygen order, and believed they may have applied oxygen but could not remember. There was no documentation that oxygen was administered prior to transfer. The DON confirmed that oxygen supplies were available on the fourth and fifth floors, that it was their expectation that orders be followed and oxygen applied if O2 saturation remained below 90% after deep breathing and rest, and that record review showed these three residents had O2 saturations below 90% without documented oxygen application before hospital transfer, and that Resident 6’s care plan goal for O2 saturation was not met.
Failure to Enter and Implement PRN Oxygen Orders for Two Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that prescribed PRN oxygen orders were entered into the residents’ Order Summaries and available for use. One resident admitted with a pulmonary embolism had an admission order dated 12/18/2025 from the PCP for oxygen as needed to keep oxygen saturation at 90%, but review of the resident’s Order Summary dated 12/30/2025 showed no corresponding PRN oxygen order. Another resident admitted with COPD had an admission order dated 11/04/2025 for oxygen as needed to keep oxygen saturation at 90%, and the resident’s Comprehensive Care Plan documented risk for respiratory distress with a goal to maintain oxygen saturation above 88%. However, the resident’s Order Summary dated 11/25/2025 did not contain the ordered PRN oxygen. For the resident with COPD, the Weight and Vitals Summary showed an oxygen saturation of 82% on 02/18/2026. Progress notes for that date documented an oxygen saturation of 90% at 7:00 AM and 82% at 9:30 AM, with no documentation that supplemental oxygen was provided. The facility’s policy on Medication Administration, reviewed 11/10/2025, states that all medications are to be documented in accordance with the physician’s order. In interviews, the DON stated that all residents should have standing orders obtained on admission and that these should transfer with residents between levels of care, but acknowledged that charts are not consistently reviewed to ensure all orders are placed and available in the EMAR, and confirmed that the PRN oxygen admission orders for both residents were not entered into their Order Summaries as they should have been.
Food Handling, Labeling, and Hygiene Deficiencies
Penalty
Summary
Kitchen staff failed to follow food safety and hygiene practices during food preparation and service. On observation, Floater-C went from the walk-in refrigerator to the prep table and put on gloves without performing hand hygiene. Later, Dietary Technician (DT)-E washed hands for 15 seconds before serving food, used a hand to turn off the faucet, and applied gloves. DT-E then changed gloves without hand hygiene, served food trays, handled a cell phone while wearing gloves, did not change gloves or perform hand hygiene after the phone call, and later changed gloves again without hand hygiene. DT-E confirmed that hands should have been washed for 20 seconds and between glove changes. Food storage and labeling practices were also not followed. In the kitchenette refrigerator, a pitcher containing tomato juice was covered with saran wrap but was undated, and the sides of the pitcher had hardened red residue where the liquid had previously reached. In the kitchen, an opened package of macaroni and an opened container of graham cracker crumbs were observed without dates. The Certified Dietary Manager stated that tomato juice should be dated and discarded if expired. The facility also failed to ensure proper hair restraints and ice machine cleanliness. Salad/baker-B was observed frosting a cake without a hair net or beard net and stated [gender] was not sure whether those restraints were needed. The ice machine had white debris on the inside of the lid and top of the ice bin, along with rust-looking debris in the upper portion of the bin near the ice shoot. The Certified Dietary Manager was unsure when the ice machine had last been cleaned and stated the staff remove the ice and clean it monthly, although the machine light indicates when it is time to clean.
Missing Adult/Child Background Checks for Two Medication Aides
Penalty
Summary
The facility failed to ensure that Adult/child background checks were completed for 2 of 5 employees sampled, identified as Medication Aide L and Medication Aide M. Record review showed Medication Aide L began employment on 9/5/23 and Medication Aide M began employment on 12/20/23, but neither employee’s personal record contained documentation of an Adult/child central registry check. During an interview on 8/7/25 at 1:10 PM, HR confirmed there was no Adult/child central registry form in either employee’s file. The facility’s Hiring Process policy states that background checks, including adult and child registry checks, are performed for all new employees to verify they do not have evidence of abuse, neglect, or other criminal activities inappropriate for work with senior adults.
Hand Hygiene Not Performed During Resident Care and Housekeeping
Penalty
Summary
The facility failed to ensure infection control practices were followed during resident care, medication administration, and housekeeping activities for Residents 6 and 22. The cited policy required hand hygiene before and after direct resident contact, before preparing or handling medications, after contact with a resident's intact skin, after contact with bodily fluids or objects in the resident's immediate vicinity, and after removing gloves. During observation, a medication aide did not use hand sanitizer before preparing medication for Resident 22, carried the medication to the resident's room, administered it without performing hand hygiene, and then returned to the medication cart without sanitizing or washing hands. The aide confirmed hand sanitizer was not used before setting up or after giving the medication, and the infection control nurse confirmed hand hygiene should be performed before and after medication administration. Housekeeping and nursing care observations also showed missed hand hygiene. A housekeeper flushed the toilet in Resident 22's bathroom, exited into the hallway, and handled cleaning supplies and the housekeeping cart without washing or sanitizing hands; the housekeeper confirmed hand hygiene was not performed after leaving the room. Later, the housekeeper washed hands for 15 seconds and used a bare hand to turn off the faucet, then removed trash from Resident 22's room without gloves and again washed hands for only 10 seconds before using a bare hand to shut off the faucet. In a separate observation, an LPN entered Resident 22's room without sanitizing hands, performed a blood pressure check and touched the resident's arms, and then left without washing or sanitizing hands; the LPN confirmed hand hygiene should have been performed before and after leaving the room.
Failure to Maintain Clean Exhaust Hoods in Kitchen
Penalty
Summary
The facility failed to maintain the exhaust hood over the cooking area in a clean and sanitary condition, which could potentially lead to food-borne illnesses affecting all residents who consumed food from the kitchen. During an observation on July 29, 2024, the exhaust hoods were found to be coated with a dark brown substance. The Dietary Manager confirmed that the hoods were not clean and stated that an external company cleans them twice a year. However, the cleaning schedule did not include the exhaust hoods as an assigned task. Further observations on July 31, 2024, revealed that the exhaust hoods remained unclean. The Dietary Manager confirmed that the cleaning task for the exhaust hoods was not listed on the cleaning schedules provided. A review of the cleaning records showed that the last cleaning by an external company was performed on March 27, 2024, indicating a lack of regular maintenance and oversight in keeping the exhaust hoods clean as per the Nebraska Food Code requirements.
Inadequate Hand Hygiene During Peri-Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during peri-care for a resident, leading to a potential risk of cross-contamination. The incident involved a resident with a history of heart attack, heart failure, Alzheimer's disease, rhabdomyolysis, high blood pressure, and anxiety, who was being treated for a suspected urinary tract infection. During the observation, a nurse aide sanitized their hands, entered the resident's room, and performed various tasks before washing their hands with soap and water for only 8 seconds, which is below the recommended duration. The nurse aide then assisted the resident with peri-care without changing gloves or performing hand hygiene after touching other objects. After completing the care, the aide removed their gloves but did not wash their hands before continuing to assist the resident. The facility's hand hygiene policy requires washing hands for at least 20 seconds, which was not adhered to in this instance. Interviews with the nurse aide and the Director of Nursing confirmed that the handwashing duration was insufficient, highlighting a deficiency in following proper infection control protocols.
Failure to Submit PBJ Data on Time
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data for the second quarter of 2024, which is a requirement for all long-term care facilities to ensure accountability and consistency in staffing information. The PBJ report, covering the period from January 1 to March 31, 2024, was not submitted on time to the Centers for Medicare and Medicaid Services (CMS). This failure was confirmed during an interview with the Staffing Coordinator, who stated that the report was submitted one week late. The delay was attributed to a recent switch to a new payroll vendor, which incorrectly categorized all facility hours, including paid time off, sick leave, and education hours, as worked hours on the floor. This discrepancy prevented the facility from correcting and submitting the report within the required timeframe.
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Gateway Vista | 0.7 mi | ★★★★★ | 20 | 0 |
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