Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Gordon Countryside Care during CMS and state inspections, most recent first.
The facility inaccurately coded the MDS for two residents. One resident’s MDS listed pneumonia as an active dx even though the record showed no diagnosis, treatment, or meds for pneumonia, and the MDSC confirmed it should not have been included. Another resident’s MDS coded unplanned wt loss, but the record showed the wt change was tied to planned diuresis after a hospitalization when Bumex was restarted.
Failure to follow bowel management protocol for a resident with a history of constipation. The resident was continent of bowels and needed substantial help with toileting hygiene, with orders for PRN Milk of Magnesia and Miralax. Records showed multiple days without a BM, but there were no bowel assessments, interventions, or PRN laxative use documented, and the DON confirmed no interventions were implemented.
A resident at risk for falls due to deconditioning, knee pain, and occasional incontinence had a care plan intervention added after two falls, including placing a fall mat beside the bed when in bed. Surveyors observed the resident resting in bed while the mat was tucked underneath the bed, and an NA confirmed it should have been beside the bed.
Improper Hand Hygiene and Glove Use During Food Prep: A CDM prepared a resident’s grilled cheese sandwich without gloves or handwashing, handling bread, cheese, and butter with bare hands before placing the sandwich in a frying pan. The CDM later acknowledged the error and stated gloves should have been worn.
The facility failed to notify emergency contacts of two residents about significant changes in their medical conditions. One resident required a hospital transfer for intravenous antibiotics due to worsening symptoms, while another experienced a fall and respiratory issues necessitating emergency care. In both cases, the registered nurse confirmed that the emergency contacts were not informed, contrary to the facility's policy.
The facility failed to ensure proper food storage and hand hygiene practices, affecting all 26 residents. Observations revealed expired food items and improper storage, with food not dated or stored six inches off the floor. The CDM demonstrated inadequate hand hygiene during meal prep, not washing hands after contamination and misunderstanding glove use, contrary to the Nebraska Food Code.
The facility failed to disinfect multi-use equipment during medication administration for three residents and did not implement proper infection control practices during wound care for a resident. A Medication Aide used tweezers without disinfecting them between uses, and a Registered Nurse did not follow CDC guidelines for handwashing and glove use during wound care.
A resident's oxygen concentrator was left running unattended while they were out of their room, contrary to the facility's oxygen safety policy. Observations confirmed the concentrator was on during the resident's absence at facility activities, and staff acknowledged it should have been turned off.
A resident was prescribed nitrofurantoin for UTI prevention without a specified duration, continuing for months without reevaluation. Additionally, cephalexin was prescribed based on a urinalysis showing mixed flora, not meeting UTI criteria. The facility failed to follow its Antibiotic Stewardship Program, leading to unnecessary antibiotic use.
The facility exceeded the acceptable medication error rate of less than 5%, with errors involving two residents. A resident received Basaglar insulin earlier than the prescribed time, and another resident was given levothyroxine without observing the instruction to administer it on an empty stomach. These errors were due to staff not adhering to prescribed administration times and instructions.
Inaccurate MDS Coding for Active Diagnosis and Weight Loss
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for Resident 14 by coding an active diagnosis of pneumonia when the record did not support that diagnosis. The resident’s quarterly MDS indicated pneumonia as an active diagnosis, but a review of the resident’s diagnoses, progress notes from 4/21/2025 through 7/22/2025, and medication administration records for April through July 2025 found no evidence of pneumonia being diagnosed or treated. During interview, the MDS Coordinator stated the resident had been admitted with pneumonia that never got resolved and confirmed the diagnosis should not have been included on the MDS completed on 7/8/2025. The facility also failed to accurately code weight loss for Resident 1 on the quarterly MDS. The MDS indicated the resident had lost 5% or more in the last month or 10% or more in the last 6 months and was not on a prescribed weight-loss regimen. However, the resident’s weight record showed fluctuations, including a rise to 127 pounds after hospitalization and then a decrease after Bumex, a diuretic, was restarted. A provider note documented that the resident returned from hospitalization without an order for Bumex, developed lower-extremity edema, and then received a new order for Bumex 1 mg daily. A nutrition note stated the resident’s weight increase was related to the lack of a diuretic after hospitalization and then trended back down after diuresis was reinitiated. The MDS Coordinator confirmed the resident’s MDS should not have coded unplanned weight loss because the resident had planned diuresis upon return from hospitalization.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its bowel management policy for one resident with a history of constipation. The policy required staff to document the absence of bowel movements for 3 days or more and begin the constipation intervention protocol, including monitoring and encouraging bowel movement on Day 1, giving prescribed stool softeners or laxatives on Day 2, reassessing and considering a suppository on Day 3, and notifying the physician and considering an enema or other medical interventions on Day 4 or later. Resident 4’s record showed the resident was always continent of bowels, required substantial assistance with toileting hygiene, and had a care plan directing staff to monitor and document bowel movements and administer medications as ordered. Resident 4 had physician orders for Milk of Magnesia 30 milliliters every 12 hours as needed for constipation and Miralax 17 grams every 24 hours as needed for constipation. The bowel elimination record showed no bowel movements for 4 days in August and 5 days in September, but the progress notes contained no evidence of bowel assessments or interventions during those periods. The medication administration records for August and September showed no use of the as-needed Milk of Magnesia or Miralax, and the DON confirmed there were no interventions implemented for the resident’s constipation during those timeframes.
Fall Mat Not Implemented as Planned
Penalty
Summary
The facility failed to ensure that developed fall interventions were implemented for Resident 19, who was identified as being at risk for falls due to deconditioning, knee pain, and occasional incontinence. The resident's care plan documented a fall on 8/29/2025 when the resident attempted to get up from bed unassisted and another fall from bed on 9/16/2025 that caused a bruise to the center of the forehead. After the second fall, an intervention was added to place a fall mat beside the bed when the resident was in bed. However, during observations on 9/18/2025 at 11:00 AM, 11:25 AM, and 11:30 AM, the resident was resting in bed and the floor mat was observed tucked underneath the bed rather than placed beside it. During an interview at 11:35 AM, a nurse aide confirmed the mat was tucked under the bed and stated it should be beside the bed when the resident was in bed.
Improper Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
The facility failed to ensure staff followed proper glove use and hand hygiene practices before food preparation and between tasks during meal service, in accordance with the food code and CDC guidelines. The deficiency was identified during an observation of kitchen operations, where the Certified Dietary Manager entered the kitchen and stated they would take care of a grilled cheese sandwich order for a resident. The CDM retrieved bread, cheese, and butter from the walk-in refrigerator, placed them on the preparation table, and began preparing the sandwich without wearing gloves or performing handwashing. The CDM buttered two pieces of bread, placed cheese between the slices, and put the sandwich into a frying pan using bare hands. The CDM then washed down the counter, used a spatula to turn the sandwich, and later plated and covered the grilled cheese sandwich before washing hands and leaving the kitchen. During interview, the CDM acknowledged the error in touching the food with bare hands and stated gloves should have been worn.
Failure to Notify Emergency Contacts of Residents' Condition Changes
Penalty
Summary
The facility failed to notify the emergency contacts of two residents regarding significant changes in their medical conditions, as required by their policy. Resident 1 was admitted to the facility on March 21, 2024, and had two emergency contacts listed. On October 16, 2024, a registered nurse documented that Resident 1 showed no improvement in their right lower extremity, with increased redness and swelling, necessitating a hospital transfer for intravenous antibiotics. However, there was no evidence that Resident 1's emergency contact was informed of this change in condition, which was confirmed by the nurse during a telephone interview. Similarly, Resident 2, admitted on September 8, 2023, had an emergency contact listed as a friend. On November 25, 2024, Resident 2 experienced a fall, followed by audible wheezing and low oxygen levels, requiring oxygen administration and a transfer to the Emergency Department for potential respiratory failure. Again, there was no evidence that Resident 2's emergency contact was notified of the change in condition, which was also confirmed by the same registered nurse during an interview. These incidents highlight the facility's failure to adhere to its policy of notifying resident representatives or responsible parties of significant changes in residents' conditions.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which had the potential to affect all 26 residents. During a kitchen tour, it was observed that several food items were not dated with an open or use-by date, and some were past their best-by dates. These included French-Fried Onions, Whole Oysters, Texas Toast, Deviled Egg Potato Salad, Macaroni Salad, Fat Free Milk, and Strawberry Yogurt. Additionally, a bottle of Strawberry Syrup was found with an expired best-by date. The Certified Dietary Manager (CDM) confirmed that these items should have been dated and consumed or discarded by their use-by dates. The facility also failed to store food at least six inches off the floor as required by their policy. During the kitchen tour, four cardboard boxes of food were found stored on the floor of the freezer. The CDM confirmed that all food should be stored at least six inches above the floor, indicating a lapse in adherence to the facility's food storage policy. Furthermore, the facility did not implement proper hand hygiene practices to prevent cross-contamination and foodborne illness. Continuous observation of the CDM during meal preparation revealed multiple instances of inadequate hand hygiene, such as not washing hands after touching contaminated surfaces, using gloves improperly, and not washing hands for the required 20 seconds. The CDM was observed touching potentially contaminated surfaces and food items without performing hand hygiene, and there was a misunderstanding regarding when gloves should be used. The CDM believed hands should be washed for only 15 seconds, contrary to the 20 seconds required by the Nebraska Food Code.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration and wound care, as observed in the cases of three residents. During medication administration, a Medication Aide (MA-B) used a pair of tweezers to handle medications for three residents without disinfecting the tweezers before or after each use. This action was contrary to the facility's policy, which requires patient care equipment to be cleaned after each use. MA-B confirmed the need for cleaning or sanitizing the tweezers after each use during an interview. In a separate incident, a Registered Nurse (RN-A) did not follow proper infection control practices during wound care for a resident. The RN washed their hands for only 15 seconds, less than the 20 seconds recommended by the CDC. Additionally, RN-A contaminated their gloves by touching their hair, the trashcan, and a drawer while wearing them. The facility's policy on wound care did not align with CDC guidelines, as it lacked specific instructions on handwashing duration and the necessity of wearing a gown for Enhanced Barrier Precautions. RN-A was unaware of the correct handwashing duration and acknowledged the contamination of gloves during the procedure.
Failure to Turn Off Unattended Oxygen Concentrator
Penalty
Summary
The facility failed to ensure that a resident's oxygen concentrator was turned off when not in use and left unattended, which is a violation of their own policy on oxygen administration. The policy, revised in October 2010, mandates that residents, their families, visitors, and roommates be instructed on oxygen safety precautions, including turning off the oxygen when not in use. Despite this, observations on two separate occasions revealed that the oxygen concentrator for a resident with non-Alzheimer's dementia, pulmonary hypertension, and hypoxia was left running at 3 Liters Per Minute (LPM) while the resident was not in their room. On both occasions, interviews with facility staff confirmed that the resident was attending facility activities and not present in their room, yet the oxygen concentrator remained on. The first observation occurred when the resident had been away since 10:00 AM, and the second when the resident had been out since 2:00 PM. Both the Registered Nurse and the Director of Nursing acknowledged that the concentrator should have been turned off while the resident was not using it, indicating a lapse in adherence to the facility's safety protocols.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the resident was prescribed nitrofurantoin for UTI prevention without a specified duration, and this prescription continued for several months without reevaluation or documentation of its necessity during physician visits. Additionally, the resident was prescribed cephalexin for a suspected UTI based on a urinalysis that did not meet the criteria for a UTI diagnosis, as it showed mixed flora and lacked an antibiotic susceptibility report. The facility's policy required that all antibiotic prescriptions specify dose, duration, and indication, and that resident responses and lab results be monitored to determine the continued need for antibiotics. The resident experienced increased confusion and decreased appetite, prompting a urinalysis that revealed mixed flora, which is typically considered contaminated. Despite this, the resident was started on cephalexin without supporting documentation for its clinical use. The facility's failure to adhere to its Antibiotic Stewardship Program and the McGeer Criteria for infection surveillance resulted in the unnecessary use of antibiotics for the resident. An interview with a registered nurse confirmed that there was no discussion with the primary provider regarding the reduction of unnecessary antibiotic use for the resident.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered at the correct times for two residents, leading to a medication error rate of 5.4%, which exceeds the acceptable threshold of less than 5%. For Resident 15, Basaglar insulin was ordered to be administered at 9:00 AM, but RN-A administered it at 7:29 AM, citing the resident's early wake-up time as the reason for the deviation. This action was confirmed during an interview with RN-A, who acknowledged awareness of the prescribed administration time but chose to override it. For Resident 1, there was an order for levothyroxine to be taken on an empty stomach. However, an observation revealed that Resident 1 was in the dining room with a plate of food, having already consumed about 25% of it, when MA-B attempted to administer the medication. Resident 1 initially refused the medication, but the DON was later able to administer it. An interview with MA-B revealed that they did not notice the instruction to administer the medication on an empty stomach, contributing to the medication error.
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What surveyors actually found near you
We read the 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Nursing homes near Gordon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oglala Sioux Lakota Nursing Home | 14.7 mi | ★★★★★ | 9 | 0 |
| Pioneer Manor Nursing Home | 26.4 mi | ★★★★★ | 4 | 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.