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 Garden County Hospital & Nursing Home during CMS and state inspections, most recent first.
Food handling and sanitation deficiencies were observed during meal service. A cook transported visibly soiled utensils uncovered through a hallway, placed them with food for serving, wiped sanitizer off a counter instead of allowing it to air dry, and staff handled resident meal items and surfaces during delivery with inconsistent HH. The facility also lacked expiration or best-used-by dates on canned goods, and the report stated the issues had the potential to affect all residents.
Failure to Complete Initial Staff Orientation: The facility failed to ensure that 3 of 4 sampled employees completed initial orientation. Record review showed that a NA, a housekeeper, and a cook were hired, but their employee files contained no evidence of completed orientation. The DON confirmed that initial orientation had not been completed for these staff members.
The facility failed to ensure sampled NAs completed the required annual ongoing training and failed to ensure sampled staff completed the required annual Alzheimer's and dementia care training. Record review showed several NAs had no completed assignments or completed fewer than 12 hours of ongoing training, and RN-A confirmed none of the 5 sampled staff completed the required 4 hours of dementia care training.
Inaccurate MDS weight-loss coding was identified for a resident. The annual and quarterly MDSs both marked weight loss as yes even though the EMR weights showed no qualifying loss and the resident was not on a physician-prescribed weight-loss regimen. The RN/MDS coordinator confirmed the weights were accurate and that the MDSs should not have been coded yes for weight loss.
Two residents experienced significant weight loss due to the facility's failure to implement dietary recommendations and conduct timely assessments. One resident lost 15.83% of their weight over two months, while another lost 13.5% over six months. The facility did not update care plans or notify physicians, and lacked a nutrition policy.
The facility was found deficient in food handling, hygiene, and sanitation practices. Observations revealed expired and unlabeled food items, improper use of beard restraints, and inadequate hand hygiene during meal preparation and service. Additionally, the kitchen environment was unsanitary, with flies present and food preparation surfaces not being sanitized between tasks. These deficiencies had the potential to affect all 26 residents.
The facility failed to follow infection control practices during wound care for a resident with a pressure ulcer, as an LPN did not use a gown and improperly handled treatment supplies. Additionally, a laundry aide left the laundry cart open during distribution, risking cross-contamination, and placed laundry between their legs while performing hand hygiene.
The facility failed to protect private medical information for four residents, as their names were visible on medication containers from a public hallway window. This was confirmed by an LPN, violating the facility's policy on resident privacy.
A resident was not served their lunch meal simultaneously with their table mates, leading to a delay while they watched others eat. This was confirmed by an interview with a cook, who stated that all residents should be served at the same time.
Two residents experienced significant weight loss without their physicians being notified, as required by facility policy. One resident lost 13.5% of their weight over several months, while another lost over 8% in one month and an additional 8.2% the following month. Interviews confirmed the lack of notification to the physicians.
A facility failed to evaluate a resident's ability to remove a gait belt used as a physical restraint. Despite policy stating restraints should be a last resort and require a physician's order, the resident was not assessed for their ability to remove the belt. Observations confirmed the belt's use, and staff interviews revealed the lack of assessment.
The facility failed to develop comprehensive care plans for two residents, both requiring significant assistance with ADLs. Despite assessments indicating the need for total or substantial assistance, the care plans lacked specific details on the level of assistance required. An interview with the MDS Coordinator confirmed the care plans were not comprehensive or person-centered.
A resident with multiple diagnoses, including Congestive Heart Failure and Celiac Disease, experienced a significant weight loss of 13.5% over six months. Despite a dietician's recommendation to start Ensure Clear supplements, the facility did not update the care plan to include this intervention. The MDS Coordinator confirmed the oversight.
The facility failed to implement a physician-ordered ACE wrap for a resident with edema and improperly administered hypertension medication to another resident, despite specific instructions to hold the medication if systolic blood pressure was below 110. The DON confirmed these errors.
A resident's oxygen concentrator was left on and running at 3 LPM while the resident was not in their room, contrary to physician's orders and without specific guidance in the facility's policy. The MDS Coordinator confirmed the observation, highlighting a deficiency in ensuring a safe environment.
A resident with a history of UTIs and an indwelling catheter was prescribed Cephalexin prophylactically without a stop date, contrary to the facility's Antimicrobial Stewardship Program policy. Despite regular reviews by the pharmacist and PCP, the antibiotic continued to be administered, indicating a lapse in policy adherence.
Food Handling and Hand Hygiene Deficiencies During Meal Service
Penalty
Summary
The facility failed to transport and use visibly soiled utensils in a manner that prevented cross contamination. During observation, covered food was removed from the oven and placed on a Hot/Cold serving cart, while serving utensils with visible food debris were placed on a serving tray and then onto the cart. The cart was transported through the hallway and left against the wall outside the dining room with the soiled utensils uncovered. The covered food bins were then moved into the serving room, and the soiled utensils were placed into the steam room and then into the food for serving. In interview, the PM and Cook-J confirmed the utensils should not have been transported uncovered and should have been covered or clean before use. The facility also failed to sanitize counters and thermometers correctly, failed to have expiration or best-used-by dates on canned goods, and failed to ensure staff performed hand hygiene as required during meal delivery. One observation showed Cook-K wiping a counter with sanitizer and then drying it with paper towels within 1 to 2 seconds, and Cook-J confirmed the sanitizer was not left on the counter for the required amount of time and should not have been wiped off. During meal service, Cook-J handled plates, bowls, ketchup, shelves, resident tables, and the fridge while delivering food, including leaning on shelves with hands and touching resident tables, and performed hand hygiene only once during the observed sequence. The report states these issues had the potential to affect all residents.
Failure to Complete Initial Staff Orientation
Penalty
Summary
The facility failed to ensure that 3 of 4 sampled employees completed initial orientation as required. A record review of an undated and untitled facility staff list showed that Nurse Aide B was hired on 8/1/2025, Housekeeper C was hired on 4/7/2025, and Cook D was hired on 8/11/2025. Review of the facility-provided employee files for each of these employees found no evidence that initial orientation had been completed. During an interview on 8/25/2025 at 9:02 AM, the DON confirmed that initial orientation had not been completed for Nurse Aide B, Housekeeper C, or Cook D.
Incomplete Nurse Aide and Dementia Care Training
Penalty
Summary
The facility failed to ensure nurse aides completed the required annual ongoing training and failed to ensure staff completed the required annual Alzheimer's care and dementia care training. Record review showed the facility used the Relias Learning platform for staff training and competencies, with modules completed upon hire and annually, but the sampled nurse aides did not meet the required training hours. NA-F had no completed assignments in Relias, NA-G completed 10.69 hours of ongoing training during the annual period reviewed, NA-H had not completed any trainings during the annual period reviewed, and NA-I completed 10.84 hours of ongoing training during the annual period reviewed. Human Resources confirmed that NA-F, NA-G, NA-H, and NA-I had not completed the required 12 hours of annual ongoing training. The record review also showed the sampled staff did not complete the required 4 hours of annual Alzheimer's care and dementia care training. NA-E completed 0.5 hours of dementia care training, NA-F had no completed assignments, NA-G completed 0.5 hours, NA-H had not completed any trainings, and NA-I completed 0.5 hours. RN-A stated the facility had begun assigning Alzheimer's and dementia care training through its training platform, but it was less than 4 total hours per year, and confirmed none of the 5 sampled staff had completed the required annual dementia care training.
Inaccurate MDS Weight-Loss Coding
Penalty
Summary
The facility failed to submit accurate MDS data related to weight loss for one resident. On the annual MDS, the resident’s most recent weight was recorded as 103 pounds with a height of 60 inches, and the weight-loss item was marked yes even though the resident was not on a physician-prescribed weight-loss regimen. The MDS defined weight loss as 5% or more in the last month or 10% or more in the last six months, but the resident’s EMR showed weights of 105.4 pounds on 5/8/25, 103.8 pounds on 4/9/25, and 100 pounds on 11/7/24, which reflected a 1.5% weight gain over one month and a 5.4% weight gain over six months. The quarterly MDS also identified the resident’s most recent weight as 100 pounds with a height of 60 inches and again marked weight loss as yes despite no physician-prescribed weight-loss regimen. The EMR showed the resident weighed 100 pounds on 2/6/25, 99.1 pounds on 1/9/25, and 103 pounds on 8/5/24, which reflected a 0.9% weight loss over one month and a 2.9% weight loss over six months. During interview, the RN who served as the MDS coordinator confirmed the resident’s recorded weights were accurate and stated that the MDS submissions should not have been marked yes for weight loss on those two occasions.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and implement necessary interventions for two residents, leading to significant weight loss. Resident 11, who had severe cognitive impairment, experienced a weight loss of 15.83% over two months. Despite a dietitian's recommendation to increase Pro-stat intake, there was no evidence that this was implemented. Additionally, Resident 11's care plan and physician's orders were not updated to reflect these recommendations, and there was no documentation of the primary care provider being notified of the weight loss. Resident 8, who had moderate cognitive impairment and required substantial assistance with eating, experienced a severe weight loss of 13.5% over six months. The dietitian had not completed a Nutrition Risk Assessment or a quarterly nutrition assessment for Resident 8 since October 2023, and there was no evidence that the physician was informed of the weight loss. The facility's failure to conduct timely assessments and notify the physician contributed to the resident's nutritional decline. The facility's policy on resident assessments required dietary assessments to be completed annually and with significant changes, but there was no evidence of a nutrition or weight loss policy being located. Interviews with the MDS Coordinator confirmed the lack of assessments and notifications for both residents, highlighting the facility's failure to adhere to its own policies and ensure adequate nutritional care for its residents.
Deficiencies in Food Handling, Hygiene, and Sanitation
Penalty
Summary
The facility failed to adhere to proper food handling and storage protocols, as evidenced by observations of expired and unlabeled food items. During a kitchen tour, various food items were found with expired use-by dates, and some were not sealed or labeled correctly. The Dietary Manager confirmed that items should be disposed of after preparation or opening within seven days and stored in enclosed containers. However, the facility's practices did not align with these standards, potentially affecting all 26 residents. Additionally, the facility did not enforce the use of beard restraints as required by their policy and the Nebraska Food Code. Observations revealed that both the Dietary Manager and a Dietary Aide were not wearing beard restraints while in the kitchen, despite having facial hair. The Dietary Manager believed that beard covers were only necessary during food preparation or service, indicating a misunderstanding of the policy requirements. The facility also failed to implement proper hand hygiene practices during meal preparation and service. A Medication Aide was observed sanitizing and reusing gloves while assisting multiple residents, contrary to the facility's hand hygiene policy. Furthermore, a cook did not perform hand hygiene after removing gloves and before applying new ones, and a Dietary Aide did not perform hand hygiene between resident contacts. The kitchen environment was also unsanitary, with flies present and food preparation surfaces not being sanitized between tasks, as observed with a cook preparing different foods on a contaminated table.
Infection Control Deficiencies in Wound Care and Laundry Distribution
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care for a resident with a stage 2 pressure ulcer. The resident, who had moderate cognitive impairment, required pressure injury care as per their admission Minimum Data Set. During an observation, an LPN did not don a gown as required by Enhanced Barrier Precautions while performing wound care. Additionally, the LPN contaminated the Thera honey cream by touching the tip of the tube to the Opti foam dressing and stored the unused dressing improperly, which violated infection control practices. The facility also failed to prevent potential cross-contamination during laundry distribution. A laundry aide was observed distributing personal laundry with the cart cover left open throughout the process, which could lead to contamination. The aide performed hand hygiene between rooms but placed laundry between their legs while doing so, further compromising infection control standards. These actions were confirmed by the laundry aide during an interview.
Failure to Protect Resident Medical Information
Penalty
Summary
The facility failed to protect private medical information for four residents, as observed during a survey. The facility's policy on resident rights, last reviewed in March 2013, mandates privacy for residents' medical information to ensure confidentiality. However, during an observation on July 18, 2024, at 2:30 PM, it was noted that the names of four residents were visible on medication containers from a public hallway window. Specifically, Resident 2's name was on a bottle of calmoseptine, Resident 15's name on an inhaler device, Resident 22's name on a bottle of glucose testing strips, and Resident 23's name on a bottle of MiraLAX. An interview with an LPN confirmed that these medications were in public view, constituting a violation of the residents' privacy.
Failure to Serve Meals Simultaneously at Resident's Table
Penalty
Summary
The facility failed to provide meal service that enhanced dignity for a resident, as observed during a lunch service. On the specified date, Resident 5 was seated at a table with four other residents. Observations revealed that the other four table mates were served their lunch meals while Resident 5 was left watching them eat. Subsequently, a table of three residents seated behind Resident 5 was also served their meals before Resident 5 received theirs. It was not until several minutes later that Resident 5 was finally served their lunch. An interview with Cook-B confirmed that all residents should be served at one table at the same time, indicating a lapse in the facility's meal service protocol.
Failure to Notify Physicians of Significant Weight Loss
Penalty
Summary
The facility failed to notify the attending physician of significant weight loss for two residents, as required by their policy on Notification of Change in Resident Condition. Resident 8 experienced a weight loss of 16.3 pounds, or 13.5%, over a period from January to July 2024. A review of Resident 8's medical records showed no evidence that the physician was informed of this severe weight loss. An interview with the MDS Coordinator confirmed the lack of notification and acknowledged that the physician should have been informed. Similarly, Resident 11 experienced a weight loss of 8.3% in one month and an additional 8.2% in the following month, without being on a prescribed weight loss plan. The review of Resident 11's electronic and paper health records revealed no evidence of notification to the primary care provider about the significant weight loss. The Director of Nursing confirmed the weight loss and the absence of notification. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicates that such weight changes should prompt a thorough assessment, which was not documented in this case.
Failure to Evaluate Use of Physical Restraint
Penalty
Summary
The facility failed to evaluate the use of a physical restraint for one resident, identified as Resident 13, out of a sample of two residents. The facility's policy on restraints, revised in September 1999, states that restraints should only be used as a last resort and require a physician's order unless in an emergency. However, the facility did not assess Resident 13's ability to remove a gait belt used for positioning around their legs, which was documented in the care plan as removable by the resident. The Minimum Data Set for Resident 13 indicated no restraints were in use, yet observations showed a gait belt secured around the resident's thighs. Interviews with facility staff, including a Medication Aide and the Director of Nursing, confirmed the use of the gait belt for positioning and the lack of assessment regarding the resident's ability to remove it independently. The Director of Nursing admitted to applying the gait belt without prior assessment of the resident's ability to remove it, indicating a failure to adhere to the facility's restraint policy and a lack of proper evaluation of the resident's needs and capabilities.
Inadequate Care Plans for ADLs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which is a requirement under the Activities of Daily Living (ADL) policy. Resident 1, who was admitted with diagnoses including Multiple Sclerosis, Dementia, contractures, and abnormal involuntary movements, had a care plan that lacked specific information regarding the level of assistance needed for eating, dressing, bathing, and personal hygiene. The Minimum Data Set (MDS) assessment indicated that Resident 1 required total assistance for these activities, yet the care plan did not reflect this level of detail. Similarly, Resident 8, who was admitted with diagnoses such as Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease, also had a care plan that was not comprehensive. The MDS assessment showed that Resident 8 required substantial assistance with eating and oral hygiene and total assistance for toileting, bathing, dressing, and personal hygiene. However, the care plan did not specify the level of assistance required for these activities. An interview with the MDS Coordinator confirmed that the care plans for both residents were not comprehensive or person-centered.
Failure to Revise Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to revise the care plan for a resident who experienced significant weight loss, despite recommendations from a dietician. The resident, admitted with diagnoses including Congestive Heart Failure, adjustment disorder with depressed mood, anxiety, and Celiac Disease, showed a 13.5% weight loss over six months. A care conference report recommended starting Ensure Clear supplements, but this intervention was not reflected in the resident's care plan. An interview with the MDS Coordinator confirmed that the care plan was not updated to include the dietician's recommendation.
Failure to Implement Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to implement a physician-ordered treatment for a resident with edema and did not administer hypertension medication according to prescriber's orders for another resident. For the first resident, the provider had ordered an ACE wrap for the left arm due to swelling, along with other treatments such as blood work, x-rays, and Tylenol. However, observations over several days revealed that the ACE wrap was never applied, and the order was not entered into the resident's electronic health records. The Director of Nursing confirmed that the order for the ACE wrap was overlooked during the entry of other orders. For the second resident, who had a history of stroke, congestive heart failure, dementia, and high blood pressure, there was an order for Coreg to be administered twice daily with instructions to hold the medication if the systolic blood pressure was below 110. Despite this, the medication was administered multiple times when the resident's systolic blood pressure was below the specified threshold. The Director of Nursing confirmed that the medication was given in error on numerous occasions, not adhering to the prescriber's specific instructions.
Oxygen Concentrator Left On Unattended
Penalty
Summary
The facility failed to ensure the safe use of an oxygen concentrator for a resident, identified as Resident 12, who was diagnosed with chronic respiratory failure with hypoxia and was receiving oxygen therapy. The deficiency was identified when the oxygen concentrator was observed to be left on and running at 3 liters per minute (LPM) while Resident 12 was not present in their room. This observation was confirmed by the MDS Coordinator, who noted that there was no one in the room at the time. The facility's policy on oxygen administration, last reviewed in 2013, did not provide guidance on turning off oxygen devices when not in use. Additionally, Resident 12's physician's orders specified that the oxygen should be turned off when not in use and the cannula and tubing should be stored in an infection prevention bag. The failure to adhere to these orders and the lack of specific guidance in the facility's policy contributed to the deficiency, creating a potential hazard in the resident's environment.
Failure to Ensure Antibiotic Stop Date for Resident
Penalty
Summary
The facility failed to ensure that an antibiotic prescribed to a resident had a stop date, which is a requirement to prevent unnecessary drug use. The resident, who had a personal history of urinary tract infections and an indwelling urinary catheter, had been taking Cephalexin prophylactically since November 2021. The facility's Antimicrobial Stewardship Program policy, revised in July, aims to ensure proper use and duration of antimicrobials to reduce resistance and adverse reactions. However, the resident's physician's orders did not include a stop date for the antibiotic, contrary to the facility's policy and CDC guidelines. During an interview, a registered nurse confirmed awareness of the resident's long-term use of Cephalexin and acknowledged that no attempt had been made to discontinue the medication. The nurse mentioned that both the pharmacist and the resident's primary care provider review medications regularly, implying that they would have discontinued the medication if deemed unnecessary. Despite these reviews, the antibiotic continued to be administered without a stop date, highlighting a lapse in the facility's adherence to its antimicrobial stewardship policy.
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Nursing homes near Oshkosh
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sedgwick County Memorial Nursing Home | 29.2 mi | ★★★★★ | 7 | 0 |
| Srmc Long Term Care, Llc Dba Pole Creek Estates | 36.5 mi | ★★★★★ | 0 | 0 |
| Indian Hills Manor | 37.6 mi | ★★★★★ | 2 | 0 |
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