Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Emerald Nursing & Rehab Cozad during CMS and state inspections, most recent first.
A resident with a history of falls and confusion was not provided with a documented head-to-toe assessment, vital signs, or timely physician and family notification after a fall from a sit-to-stand lift. Required post-fall procedures and documentation were not completed, as confirmed by staff and record review.
The facility failed to ensure operational exhaust fans in four resident bathrooms and did not maintain cleanliness in the laundry area. Observations revealed non-functional fans and significant buildup of materials in the laundry area, confirmed by the Maintenance and Housekeeping Supervisors.
The facility failed to implement non-pharmacological interventions before administering as-needed psychotropic medications for three residents. A resident with dementia received Lorazepam multiple times without documented non-pharmacological interventions. Another resident with similar conditions also received Lorazepam without such documentation. Additionally, a resident on multiple psychotropic medications did not have a Gradual Dose Reduction (GDR) or documented contraindications for certain medications, as confirmed by the Director of Nursing.
Two residents were not treated with dignity in separate incidents. A resident with dementia was loudly instructed by a nursing assistant in the dining area, while another resident was exposed in front of an uncovered window during care. Both incidents involved staff acknowledging the inappropriate handling of the situations.
A resident with type 1 diabetes experienced multiple instances of significantly abnormal blood sugar readings, but the facility failed to notify the physician as required. Despite the care plan's directive to alert the physician of ongoing low or high blood sugar readings, there was no documentation of such notifications or follow-up interventions. Interviews confirmed the nursing staff's failure to adhere to the facility's policy on notifying changes in the resident's condition.
The facility failed to implement fall prevention interventions for two residents, leading to potential injuries. One resident, at risk due to conditions like Parkinson's, lacked prescribed dycem in their wheelchair, resulting in a major injury from a fall. Another resident, with dementia and coordination issues, had their wheelchair placed incorrectly, contrary to their care plan, leading to multiple falls, including one with a major injury. Staff interviews revealed a lack of awareness and conflicting information about these interventions.
A resident experienced medication administration errors when an LPN failed to follow proper procedures. The LPN administered Cholestyram Powder with other medications and gave Simethicone after the resident had eaten, contrary to the prescribed instructions. The LPN also prematurely signed off the medications in the EMAR. The DON confirmed these actions as errors.
A facility failed to ensure proper hand hygiene during care for a resident with dementia and palliative care needs. Observations revealed a nurse aide washed hands for only 8 seconds instead of the required 20 seconds, and another aide did not sanitize hands before gloving or change gloves when moving from soiled to clean areas. These lapses were confirmed by the aides and the DON.
Failure to Follow Post-Fall Procedures and Documentation
Penalty
Summary
The facility failed to follow its own Falls Management policy after a resident experienced a fall while being transferred with a sit-to-stand lift. According to the facility's policy, a complete head-to-toe assessment, vital signs, physician and family notification, and documentation of these actions are required after any fall. For the incident in question, there was no documentation of a post-fall assessment, vital signs, or notifications to the physician or family in the resident's medical record. The progress notes did not mention the fall or any follow-up, and the required documentation was missing from both the progress notes and risk management records. The resident involved had a history of multiple falls, confusion, and weakness, and was identified as being at risk for falls with interventions added to the care plan after previous incidents. Staff confirmed that the resident fell out of the lift, and interviews with the DON and Facility Administrator verified that the required post-fall procedures and documentation were not completed. The deficiency was identified through record review and staff interviews, which confirmed that the facility's policy was not followed for this resident's fall.
Deficiencies in Bathroom Ventilation and Laundry Area Cleanliness
Penalty
Summary
The facility failed to ensure the operational status of exhaust fans in four resident bathrooms, specifically in rooms 101, 103, 105, and 107. During an observation, it was noted that the exhaust fans in these rooms were not functional as they could not pull up a single ply piece of tissue. This was confirmed through an interview with the Maintenance Supervisor and the Housekeeping Supervisor, who acknowledged the non-operational status of the exhaust fans. Additionally, the facility did not maintain cleanliness in the laundry area. Observations revealed cracked and chipped tiles with black and brown dry crumbly material buildup, as well as gray and black moist buildup on the drainpipes and floor behind the washing machines. The lint compartments of the industrial-sized dryers were found to have a significant buildup of fuzzy white-gray material, despite documentation indicating that the lint filters had been cleaned. This was confirmed by both the Maintenance Supervisor and the Housekeeping Supervisor.
Failure to Implement Non-Pharmacological Interventions and Conduct GDR
Penalty
Summary
The facility failed to implement non-pharmacological interventions before administering as-needed psychotropic medications for three residents. Resident #10, who was admitted with dementia and other conditions, was documented as severely cognitively impaired and exhibited various behaviors such as agitation and wandering. Despite these behaviors, the facility's records showed that Lorazepam, an anti-anxiety medication, was administered eight times without any documentation of non-pharmacological interventions being attempted prior to its use. The Director of Nursing confirmed the lack of documentation for these interventions. Similarly, Resident #34, also diagnosed with dementia and other conditions, was documented as severely cognitively impaired and exhibited behaviors such as yelling and rejection of care. The resident's care plan included non-pharmacological interventions to prevent or reduce behaviors, but the facility's records showed that Lorazepam was administered 11 times without documentation of such interventions being attempted. A nurse aide confirmed being unaware of the required non-pharmacological interventions for this resident. For Resident #21, who had no cognitive impairment and was on multiple psychotropic medications, the facility failed to conduct a Gradual Dose Reduction (GDR) or document contraindications for certain medications. The resident's care plan included consulting with pharmacy and medical staff for dosage reductions when clinically appropriate, but there was no evidence of GDR attempts for Buspirone and Venlafaxine. The Director of Nursing acknowledged the lack of GDR or documented contraindications for these medications.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat two residents with dignity, as observed in separate incidents. Resident #10, who was admitted with dementia and other conditions, was observed in the dining area interacting with other residents' food trays. A nursing assistant (NA-A) called out loudly to the resident from a distance, instructing them not to touch the trays and to sit at their table. The resident, who was severely cognitively impaired, continued to wander and sit at a different table, while NA-A continued to address them loudly, acknowledging that this approach was inappropriate. In another incident, Resident #34, also with severe cognitive impairment and requiring substantial assistance, was exposed in front of an uncovered window during a transfer from a wheelchair using a mechanical lift. The nurse aide (NA-C) did not provide privacy by closing the curtains, resulting in the resident's bare buttocks being exposed. Both the nurse aide and the Director of Nursing (DON) acknowledged that privacy should have been ensured by covering the window before providing care.
Failure to Notify Physician of Abnormal Blood Sugar Readings
Penalty
Summary
The facility failed to ensure proper follow-up for a resident with abnormal blood glucose readings, as per physician orders. The resident, who has a diagnosis of type 1 diabetes mellitus with unspecified complications, was admitted on 10/09/2020 and requires 24/7 supervision due to their condition. The resident's care plan included interventions to alert the physician of ongoing low or high blood sugar readings. However, the facility did not adhere to these interventions. The resident's blood sugar summary for several months in 2024 showed multiple instances of significantly low and high blood sugar readings, including readings of 600 mg/dL and as low as 33 mg/dL. Despite these abnormal readings, there was no documentation in the resident's electronic medical record or progress notes indicating that the physician was notified. Additionally, there were no records of nursing interventions, responses to interventions, or follow-up blood sugar tests to assess improvement. Interviews with the MDS Coordinator, LPN, and DON confirmed that the facility's nursing staff failed to notify the physician about the significant blood sugar readings. The facility's policy on notification of changes requires that changes in a resident's condition be immediately reported to the attending physician. However, this policy was not followed, resulting in a deficiency in the care provided to the resident.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to prevent falls were in place for two residents, leading to potential fall-related injuries. Resident 14, who was at risk for falls due to conditions such as dizziness, severe obesity, and Parkinson's Disease, did not have the prescribed dycem in their wheelchair to prevent slipping. Observations on multiple occasions confirmed the absence of dycem, and staff interviews revealed a lack of awareness about this intervention. Resident 14 had previously experienced falls, one of which resulted in a major injury, a fracture of the right foot, indicating that the intervention was not effectively communicated or implemented. Resident 36, diagnosed with dementia, anxiety, and lack of coordination, was also at risk for falls. The care plan required the resident's wheelchair to be placed by the bed with wheels locked to prevent self-transfer attempts. However, observations showed the wheelchair was often placed far from the bed, contrary to the care plan. Staff interviews revealed conflicting information about the correct placement of the wheelchair, with some staff indicating it should be placed far from the bed to prevent the resident from getting up unassisted. Resident 36 had a history of multiple falls, including one that resulted in a major injury requiring hospitalization. The Director of Nursing confirmed that the facility's expectation was to adjust or add interventions after each fall and to communicate these interventions to the caregiving teams. However, the lack of proper implementation and communication of fall prevention strategies for Residents 14 and 36 highlights a deficiency in the facility's fall management practices, potentially compromising resident safety.
Medication Administration Errors Identified
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with 2 errors out of 40 opportunities resulting in a 5.0% error rate. This affected one resident out of six sampled. The errors were identified during an observation of medication administration by an LPN to a resident. The LPN prepared the medications by comparing the pharmacy label to the EMAR and placed them into a medication cup. However, the LPN signed off the medications in the EMAR before the resident had taken them, which is against the facility's policy. The specific errors involved the administration of Cholestyram Powder and Simethicone. The Cholestyram Powder was supposed to be administered separately from other medications, but the LPN mixed it with water and gave it to the resident along with other medications. The Simethicone, which was to be taken before meals, was given after the resident had finished eating. The LPN acknowledged not following the provider's directions for these medications. The DON confirmed these were medication errors and that medications should not be signed out as administered until they are actually given to the resident.
Inadequate Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during personal care for a resident, as observed by surveyors. The facility's policy on infection control and standard precautions requires handwashing for at least 20 seconds and the use of hand sanitization before and after direct contact with residents, among other situations. However, during an observation, a nurse aide was seen washing hands for only 8 seconds instead of the required 20 seconds before assisting another aide in providing care to a resident. The resident involved was admitted with diagnoses including dementia, hypertension, and was receiving palliative care. The resident was severely cognitively impaired and required substantial assistance with daily activities. During the care process, another nurse aide failed to sanitize hands before applying gloves and did not change gloves or sanitize hands when moving from a soiled to a clean area. This was confirmed in interviews with the nurse aides and the Director of Nursing, who acknowledged the lapses in following the facility's hand hygiene policy.
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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 Cozad
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hilltop Estates | 9.9 mi | ★★★★★ | 0 | 0 |
| Elwood Care Center | 20.6 mi | ★★★★★ | 0 | 0 |
| Callaway Good Life Center, Inc | 29.3 mi | ★★★★★ | 15 | 0 |
| Bertrand Nursing Home | 30.4 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.