Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Gold Crest Retirement Center during CMS and state inspections, most recent first.
Several residents with cognitive impairment and physical limitations did not receive required oral care assistance, as evidenced by consistently dry toothbrushes, uncleaned dentures, and staff admissions that oral care was not performed as per facility policy. Staff also lacked necessary supplies and clear protocols for oral care, particularly for residents with dentures.
Surveyors found that medication and treatment carts, as well as a drug room refrigerator containing controlled substances, were left unlocked or open, making drugs accessible to unauthorized individuals. Staff interviews confirmed that these storage areas should have been secured according to facility policy.
Staff did not consistently follow infection control protocols, including proper hand hygiene, glove changes, PPE use, and cleaning of shared equipment. For example, staff were observed feeding multiple residents without hand hygiene between them, performing catheterization without full PPE or proper handwashing, and conducting perineal care without changing gloves or cleaning equipment as required. These deficiencies were confirmed by staff interviews and review of facility policies.
The facility failed to revise care plans for three residents, leading to deficiencies in their care. One resident's CPAP use was not documented, another's pressure injury was not addressed, and a third resident's falls and interventions were not updated in the care plan. The DON confirmed these omissions.
The facility failed to notify a resident's physician of a deterioration in the condition of a pressure injury. Despite regular documentation of the wound's measurements, there was no evidence of physician notification after the initial assessment, even when the wound worsened. The Director of Nursing confirmed the oversight, which was against the facility's policy requiring physician notification if there is no healing within four weeks.
The facility failed to ensure accurate MDS documentation for two residents. One resident's MDS did not reflect their oxygen therapy, despite physician orders and staff confirmation. Another resident's MDS incorrectly indicated no falls, despite multiple documented incidents, including one with serious injuries.
The facility failed to ensure that a Discharge Minimum Data Set (MDS) was certified as complete for a resident with acute respiratory failure upon discharge. The MDS was marked as in process, with several sections unmarked and pending signatures, and the RN Assessment Coordinator's signature was missing. This deficiency was confirmed by the MDS Coordinator.
The facility failed to change and properly store oxygen tubing for a resident with multiple diagnoses, including heart failure and a history of COVID-19. The tubing, dated 02/01/2024, was found on the floor and had not been replaced in March as required by the facility's policy. Staff interviews revealed a lack of awareness and adherence to the oxygen policy.
Failure to Provide Required Oral Care and ADL Assistance
Penalty
Summary
The facility failed to provide necessary oral care and assistance with activities of daily living (ADLs) for several residents who were unable to perform these tasks independently. Facility policy and staff orientation documents indicated that oral care, including brushing teeth and cleaning dentures, should be provided at least twice daily for all residents, especially those requiring assistance. However, observations and interviews revealed that oral care was not consistently provided to four residents who required varying levels of assistance due to cognitive impairment, dementia, impaired mobility, and other health conditions. For multiple days, surveyors observed that the toothbrushes of these residents remained dry, and dentures were left soaking without evidence of cleaning. Staff interviews confirmed that oral care was not performed as required, and some staff were unaware of or did not follow the facility's oral care protocols. In some cases, staff admitted that oral care had not been done for residents on the memory care unit, and there was a lack of necessary supplies such as toothettes for residents unable to use regular toothbrushes. Additionally, the facility lacked a specific policy regarding oral care for residents with dentures. The residents involved had documented needs for assistance with oral hygiene due to conditions such as mild to severe cognitive impairment, dementia, impaired vision, arthritis, and limited mobility. Care plans for these residents specified the need for staff to encourage and assist with oral care as part of their daily ADLs. Despite these documented needs and care plan instructions, the facility did not ensure that oral care was provided, as evidenced by repeated observations of unused oral care supplies and staff confirmations of missed care.
Failure to Secure Medications and Controlled Substances
Penalty
Summary
Surveyors observed multiple instances where medications and controlled substances were not properly secured in accordance with professional standards and facility policy. On one occasion, a treatment cart was left open and unattended in a hallway, with insulin supplies visible and accessible for at least six minutes. The cart was positioned in front of a door labeled 'Drug,' which was also open. Both the Director of Nursing (DON) and a Registered Nurse (RN-F) acknowledged during interviews that the treatment cart and the drug room door should have been locked and closed, respectively. Further observation confirmed that unless the drug room door was manually closed by staff, it would remain open. Additionally, surveyors found that the refrigerator inside the locked drug room, which contained several boxes of Alprazolam vials (a Schedule IV controlled substance), did not have a lock on its door and could be easily opened. Facility policy requires that medication carts be either visible to authorized staff or locked at all times. The facility reported having two medication carts and one treatment cart. These lapses resulted in medications, including controlled substances, being accessible to unauthorized individuals.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to consistently follow infection prevention and control protocols, including proper hand hygiene, glove use, use of personal protective equipment (PPE), and cleaning of equipment between residents. During meal assistance, nursing staff were observed feeding multiple residents without performing hand hygiene or using hand sanitizer between residents, and sometimes used the same hand to assist different residents, increasing the risk of cross-contamination. Staff interviews confirmed awareness of the need for hand hygiene between residents, but this was not practiced during the observed events. During catheterization procedures, a registered nurse did not adhere to the facility's handwashing policy, performing hand hygiene for less than the required 20 seconds and shutting off faucets with bare hands. The nurse also failed to use the recommended PPE, such as gown, mask, and face shield, during the procedure, using only sterile gloves. The infection preventionist confirmed that full PPE should have been used and that proper handwashing technique was not followed. The resident involved required intermittent self-catheterization with staff assistance due to neuromuscular bladder dysfunction and had a history of urinary tract infection and retention. In multiple instances of perineal care, staff did not perform hand hygiene after removing soiled gloves and before donning new gloves, and reached into clean wipe containers with contaminated gloves. Staff also failed to disinfect shared equipment, such as mechanical lifts, after use between residents. Interviews with staff and the infection preventionist confirmed that these actions were not in accordance with facility policies, which require hand hygiene after glove removal, proper glove changes, and cleaning of equipment between uses. Several residents involved were at risk for skin breakdown, had incontinence, or required substantial assistance with hygiene, making adherence to infection control protocols critical.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident 10, diagnosed with sleep apnea, had a physician's order for CPAP use at bedtime, but the care plan did not document this requirement. Both the RN and the DON confirmed the omission during interviews. The facility's policy mandates that care plans be updated quarterly and as necessary, but this was not adhered to in this case. Resident 4, with a history of heart failure and other conditions, developed a pressure injury that was initially assessed and documented in the progress notes. However, the care plan was not updated to reflect this new condition, and the long-term goal remained unchanged, focusing on preventing skin breakdown rather than addressing the existing injury. The DON confirmed that the care plan should have been revised to include the pressure injury. Resident 21, with a history of falls and multiple diagnoses, experienced several falls within the facility. Each fall had specific interventions documented in the event reports, but these interventions were not incorporated into the care plan. The care plan remained focused on preventing falls without addressing the new interventions or the resident's injuries. The DON acknowledged that the care plan was not updated to reflect the falls and the necessary interventions. The facility's policy requires care plans to be updated with any changes, but this was not followed.
Failure to Notify Physician of Pressure Injury Deterioration
Penalty
Summary
The facility failed to notify Resident 4's physician of a deterioration in the condition of a pressure injury. Resident 4, who had a primary diagnosis of heart failure and other conditions including dementia with behavioral disturbances, was initially assessed with a pressure injury on 12/05/2023. The wound measurements were documented regularly, showing fluctuations in size and healing status. However, there was no documented evidence of the physician being notified of the wound's status after the initial notification on 12/05/2023, despite the wound measurements indicating deterioration in early March 2024. The Director of Nursing confirmed that the provider should have been notified of the change in the wound's condition but was not, as per the facility's policy which requires physician notification if there is no evidence of healing within four weeks of treatment. A review of the resident's medical records and progress notes revealed that the wound measurements had increased on 03/07/2024, but there was no documentation of the provider being informed. Additionally, a 60-day check by the resident's medical provider on 02/07/2024 did not mention the pressure injury, indicating a lack of communication regarding the resident's condition. The facility's policy on pressure injuries mandates re-evaluation and physician notification if there is no healing within four weeks, which was not adhered to in this case.
Inaccurate MDS Documentation for Oxygen Therapy and Falls
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for two residents. For Resident 4, the Quarterly MDS did not indicate that the resident had received oxygen therapy in the 14 days prior to the assessment, despite physician orders and documentation showing that the resident was on oxygen therapy during that period. Interviews with the resident, a medication aide, and a registered nurse confirmed that Resident 4 wore oxygen at night and sometimes during the day. The Executive Director also confirmed that oxygen was not coded on the quarterly MDS as it should have been. For Resident 21, the Discharge-Return Anticipated MDS incorrectly marked that the resident had not had any falls since admission or the prior assessment. However, a review of incident reports revealed that Resident 21 had multiple falls, including one that resulted in a subdural hematoma and a broken nose. The Executive Director confirmed that these falls were not coded on the Discharge-Return Anticipated MDS. Both deficiencies indicate a failure to accurately document and assess the residents' conditions and treatments, which is critical for providing appropriate care.
Incomplete Discharge MDS for Resident
Penalty
Summary
The facility failed to ensure that a Discharge Minimum Data Set (MDS) was certified as complete for Resident 41 upon discharge. Resident 41, who had a primary diagnosis of acute respiratory failure, was discharged from the facility on 12/05/2023. A review of the MDS 3.0 Resident Assessments page for Resident 41 revealed that the Discharge-Return Not Anticipated MDS was marked as in process on the discharge date. Further examination showed that only Sections K and X were marked as completed, while other sections remained unmarked. Additionally, the MDS section Z Assessment Administration question Z0400 indicated that several sections were dated as completed on 12/06/2023 but had pending signatures, and the RN Assessment Coordinator's signature verifying assessment completion was missing. This incomplete documentation was confirmed by the MDS Coordinator during an interview on 03/28/2024 at 3:43 PM. According to the Minimum Data Set 3.0 Resident Assessment Instrument User's Manual, a Discharge-Return Not Anticipated MDS should be completed no later than 14 days after the discharge date, which in this case was 12/19/2023. The failure to complete and certify the MDS for Resident 41 within the required timeframe constitutes a deficiency in the facility's compliance with regulatory requirements for resident assessments. This affected 1 of 13 residents reviewed for MDS completion, with the facility census being 42 at the time of the survey.
Failure to Change and Properly Store Oxygen Tubing
Penalty
Summary
The facility failed to ensure that oxygen tubing for Resident 4 was changed as required and stored properly to prevent cross-contamination. Resident 4, who has diagnoses including heart failure, high blood pressure, mitral valve insufficiency, anxiety, and a history of COVID-19, was observed with oxygen tubing dated 02/01/2024, indicating it had not been changed in March as required by the facility's policy. The tubing and nasal cannula were also found on the floor behind the concentrator on multiple occasions, which is against the facility's policy to keep excess oxygen tubing secured in an IP-Pouch. Interviews with staff revealed a lack of awareness and adherence to the facility's oxygen policy. A Medication Aide admitted to not knowing where the resident's oxygen tubing was stored and confirmed that the tubing was on the floor and outdated. A Registered Nurse also confirmed that the tubing should have been changed monthly and stored properly, acknowledging that the tubing dated 02/01/2024 had not been replaced in March. This deficiency affected the quality of care provided to Resident 4, who relies on oxygen therapy.
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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 Adams
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beatrice Health And Rehabilitaion | 16.3 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Beatrice | 16.9 mi | ★★★★★ | 12 | 0 |
| Southlake Village Rehabilitation & Care Center | 19.6 mi | ★★★★★ | 8 | 0 |
| Eventide Williamsburg | 22.1 mi | ★★★★★ | 10 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 22.6 mi | ★★★★★ | 27 | 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.