Below 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 Life Care Center Of Omaha during CMS and state inspections, most recent first.
The facility failed to complete and document a discharge plan for a cognitively intact resident with multiple comorbidities, including generalized muscle weakness, gait difficulty, cognitive communication deficit, type 2 DM, morbid obesity, HTN, and CHF. Despite facility policy requiring early identification of discharge goals, incorporation into the care plan, and confirmation that the discharge destination met health, safety, and preference needs, the resident’s care plan contained no discharge plan. The resident independently applied for an independent living apartment and arranged A&D waiver services, while documentation showed a care plan conference noting no discharge plans and non-attendance by the resident. An MDS LPN later confirmed via email that the resident had been approved for independent living with a caregiver, and the SSD documented that the resident discharged to independent living, refused SSD assistance, and that the SSD could not confirm the transition or produce any discharge planning documentation.
A resident with a pressure ulcer did not receive timely wound care or recommended nutritional support after hospital readmission. Wound treatment orders were delayed, and the prescribed supplement for wound healing was not provided, resulting in the development of additional wounds and worsening of existing pressure ulcers, as confirmed by staff interviews and record review.
Staff failed to ensure continuous tube feeding for a resident as ordered, with the feeding pump found idle and not restarted as required. Additionally, another resident did not receive feeding tube site care per physician orders, as Vaseline gauze was omitted and the dressing caused discomfort and bleeding, with the LPN confirming the lapse.
Posted nurse staffing information did not include the required total actual hours worked per discipline. Review of 30 days of staffing postings showed the daily records lacked the total hours worked for the different staff types, and the Administrator confirmed the hours had not been calculated or documented on the postings.
Psychotropic medication monitoring was incomplete for multiple residents. One resident receiving clonazepam, duloxetine, trazodone, and zolpidem had no documented behavior monitoring or sleep diary/test, another resident receiving Depakote and Lexapro had no documented side effect monitoring, PRN antipsychotic orders for a resident were not stopped after the 14-day limit, and AIMS testing for a resident on risperidone was not completed.
Failure to Provide Bed-Hold Notices and Ombudsman Notification: The facility did not provide required bed-hold notices to three residents during hospital transfers and did not notify the State LTC Ombudsman of the transfers. One resident was sent to the ER for tachycardia and low O2 sats, another for a psych eval after self-harm behavior, and a third had multiple paid hospital leaves; records did not show the required notices were given to the resident or representative or that Ombudsman notification was completed.
Failure to revise a resident’s CCP for fluid restriction. A resident with ESRD and HF, who was cognitively intact and receiving HD, still had a CCP intervention for sips of fluid only between meals even though the fluid restriction had ended and no current order was found in the EHR. The RDCR confirmed the CCP was not updated after the latest MDS.
A resident with severe cognitive impairment and a history of multiple falls had an unwitnessed fall, and the neuro check record was left incomplete. The EMR showed the initial checks and several timed assessments were documented, but the remaining 8-hour checks and final 24-hour check were blank. The DON confirmed the neuro checks were not completed and should have been.
Surveyors cited the facility for failing to monitor TSH labs for a resident receiving thyroid replacement medication and for administering hydralazine to another resident even when SBP was below the ordered hold parameter. One resident had moderate cognitive impairment and no TSH results were found in the record despite repeated pharmacy requests, while another resident with severe cognitive impairment received hydralazine multiple times when BP readings were below 110 systolic; the DON confirmed the medication should have been held.
A resident was discharged home, but the care plan did not include a discharge plan focus area or interventions, and the baseline care plan did not have the discharge plan box checked. The discharge paperwork noted the resident’s health had improved sufficiently and that the resident requested discharge, but the RNC confirmed a discharge plan had not been completed.
Incorrect MDS Coding for Resident Oral Status: A resident's MDS was coded inaccurately for oral/dental status. The assessment recorded that the resident was not edentulous and did not have loosely fitting dentures, but survey observation found the resident was edentulous, and the resident stated the dentures were too big. The facility's reimbursement director confirmed the coding error.
Failure to Prevent Accidents and Maintain Required Supervision: A resident with schizoaffective disorder attempted to swallow a bingo cap and was later sent to the ER by non-emergency transport without a staff escort, despite 1:1 supervision being initiated after the event. Another resident with weakness, convulsions, and dependence for mobility had a bruise linked to wheelchair positioning, yet required wedges and other positioning devices were not in use during observations, and staff confirmed the interventions were not being followed.
Medication error rates exceeded the allowed limit after 2 errors were found in 25 opportunities for error, resulting in an 8% rate. An LPN crushed hydralazine and baclofen together, mixed them with water, and administered both through a resident’s feeding tube even though there was no order for the medications to be crushed and given together; the DON confirmed the medications should not have been administered that way.
Two residents were emergently transferred to the hospital without the facility providing required reports on their care needs to the receiving institution. One resident, with complex care needs including dialysis and an infectious disease, and another resident, who was unresponsive and required total assistance, were both sent to the hospital without staff communicating their clinical information. Both an LPN and the DON confirmed that the expected transfer reports were not provided.
Licensed staff provided care to a resident who was required to wear an external cardiac defibrillator (Life Vest) without having received prior training on the device. Multiple LPNs confirmed they had not been trained and had no access to training materials, and the DON verified that no training had occurred before care was provided.
Staff did not follow required contact and enhanced barrier precautions for infection control, including not wearing gowns during high-contact care for a resident with C. difficile and two residents with indwelling devices or MDROs, despite facility policy and posted signage.
A resident with severe cognitive impairment and protein calorie malnutrition received a tube feeding formula (Isosource) that did not match the physician's order for Nepro, and water flushes were administered without a physician's order. The feeding bags were not properly labeled or dated, and staff confirmed the discrepancies between the orders and care provided.
Surveyors observed that the facility's medication error rate exceeded 5%, with three errors out of 29 administrations. Two residents were affected: one did not receive prescribed eye drops due to unavailability, and another missed an allergy medication and received an eye medication late. These errors were confirmed by nursing staff and were not in accordance with the facility's medication administration policy.
Surveyors observed that 10 insulin pens in use for three residents were not labeled with the date they were opened, contrary to facility policy requiring all insulin pens to be dated upon initial use. A RN confirmed the absence of opened dates, which is necessary to ensure insulin is not used beyond its 28-day expiration period.
Facility staff failed to include a resident and their family in the quarterly care planning process, as required. A family member reported not being invited or aware of the process, and the Social Services Director confirmed the absence of documentation for the care planning. This indicates a failure to involve residents and families in person-centered care plans.
The facility failed to implement fall prevention interventions for three residents, as outlined in their care plans. A resident did not have a fall mat in place, another was observed sitting on a sling without a fall mat, and a third resident also lacked a fall mat, despite these being required interventions. These deficiencies were confirmed by facility staff.
The facility reported a medication error rate of 11.76%, affecting three residents. Errors included late administration of Atorvastatin and missed Metamucil for a resident, unavailability of Diltiazem for another, and early administration of Calcium Carbonate for a third resident. Staff confirmed these errors during interviews.
A facility failed to complete a PASARR Level II for a resident with Bipolar Disorder, a serious mental illness, which was not identified during the initial PASARR Level I screening. The resident's medical records and MDS assessment confirmed the diagnosis, but the facility did not make the required referral for a Level II evaluation. The Social Services Director acknowledged the oversight, which was contrary to the facility's PASARR policy.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident's electronic medical record showed no care plan was created, which was confirmed by the ADON. This omission violated the facility's policy on person-centered care planning, which aims to ensure continuity of care and resident safety.
A facility failed to complete a Comprehensive Care Plan (CCP) for a resident after a comprehensive assessment. The resident required assistance with various activities, but the CCP only addressed Advanced Directives and lacked necessary care information. An interview with the ADON confirmed the CCP was incomplete, violating the facility's policy on person-centered care planning.
A resident with dysphagia and anoxic brain damage was not provided with activities that met their needs and interests. Despite a care plan goal for participation in activities, the resident was often observed in bed without activities, and minimal participation was documented. The Activity Director noted potential discrepancies in recorded visits, but the resident's preferences for music and group activities were not adequately addressed.
A resident with a history of falls and medical conditions was not provided with adequate fall prevention measures as outlined in their care plan. Despite having interventions such as a fall mat and bed positioning, the resident was found in unsafe positions, and staff confirmed that necessary equipment like wedges was not consistently used.
A resident with dysphagia and anoxic brain damage received enteral feeding not in accordance with physician orders. The nurse administered an extra feeding earlier than scheduled and did not follow the prescribed water flush protocol, as confirmed by the ADON.
A resident with severe cognitive impairment and a history of attempting to leave the facility unattended was identified as at risk for elopement and equipped with a Wanderguard bracelet. Despite orders to check the bracelet's placement and function every shift, there were multiple instances where the resident attempted to leave the facility without the bracelet triggering an alarm. Incident reports documented the resident being found outside the building on two occasions, with the Wanderguard not functioning properly. Documentation revealed a lack of consistent monitoring and documentation of the bracelet's function, highlighting gaps in the facility's elopement prevention measures.
The facility failed to report two elopement incidents involving a resident with severe cognitive impairment to Adult Protective Services and did not submit an investigation to the state agency within the required 5 working days. Despite being identified as an elopement risk and having a care plan in place, the resident was found outside the facility on two separate occasions. The Administrator confirmed that the elopements were not reported because the resident did not leave the facility grounds.
The facility failed to ensure that two nurse aides completed the required 12 hours of yearly in-service training. One nurse aide completed only 1.95 hours of continuing education without any training on abuse prevention or dementia, while another completed only 1.03 hours. The DON confirmed these deficiencies.
The facility failed to ensure the posting of daily nursing staffing information. Observations revealed that the daily nursing staffing posting was outdated, and the Administrator confirmed the issue, noting that a new scheduler had just been hired.
Failure to Complete and Document Discharge Planning for Cognitively Intact Resident
Penalty
Summary
The facility failed to complete and document discharge planning for one cognitively intact resident. Facility policy required that discharge planning begin upon or shortly after admission, be incorporated into the baseline and comprehensive care plans, address the resident’s discharge goals and treatment preferences, identify the discharge destination, and ensure it met the resident’s health and safety needs and preferences. Record review showed that this resident, who had generalized muscle weakness, difficulty walking, a cognitive communication deficit, type 2 diabetes, morbid obesity, hypertension, and congestive heart failure, had no discharge plan initiated on the care plan. The resident’s Discharge MDS showed a BIMS score of 15, indicating intact cognition, and staff interviews confirmed the resident was able to make needs known. Documentation revealed the resident independently completed a rental application for an independent living apartment and later had a care plan conference record indicating no discharge plans and that the resident did not attend the conference. An email from the MDS LPN to the SSD, Administrator, DON, and Business Office Manager confirmed that the MDS LPN had received confirmation the resident was approved for independent living with a caregiver and was working with the Office on Aging to set up caregiver services. A progress note by the SSD on the discharge date stated the resident discharged to an independent living facility and refused assistance from SSD, and SSD was unable to confirm the transition. In interview, SSD stated there was no established discharge plan, that the resident had arranged the discharge and A&D waiver services independently, that SSD did not learn of the discharge plans until the day of discharge, and that the part‑time social services assistant had been collaborating with the resident. SSD was unable to provide any documentation of a discharge plan and confirmed they could not prove that discharge planning documentation had been completed.
Failure to Timely Implement Pressure Ulcer Treatment and Nutritional Interventions
Penalty
Summary
The facility failed to implement timely and appropriate treatment and interventions to promote healing and prevent new pressure ulcers for a resident who was identified as having a pressure ulcer upon readmission from the hospital. Upon return, the resident was noted to have an open wound to the coccyx, but there was no clear documentation of the unit of measurement, and no wound treatment order was in place until five days after the wound was identified. During this period, the resident did not receive wound care as per facility policy, and the recommended nutritional supplement for wound healing, Prosource, was not ordered or administered despite a registered dietician's recommendation. Subsequent wound assessments documented a decline in the resident's skin condition, with the development of additional wounds and progression of an existing wound from stage 2 to stage 3. The treatment administration records and medication administration records showed inconsistencies and delays in implementing wound care orders and nutritional interventions. There was also a lack of documentation for wound assessments on certain dates, and new treatment orders were not consistently reflected in the resident's records. Direct observation and interviews confirmed the presence of multiple pressure ulcers at different stages and locations, and staff acknowledged the delay in initiating wound care and the failure to implement the recommended nutritional support. The resident's wounds increased in number and severity during this period, indicating a lack of adherence to the facility's skin integrity and pressure ulcer prevention policy and failure to follow professional standards for wound management.
Failure to Provide Continuous Tube Feeding and Proper Site Care
Penalty
Summary
Facility staff failed to ensure continuous tube feeding for one resident who was assessed as requiring total assistance for all activities of daily living and had a physician's order for Jevity 1.5 at 40 ml per hour, 24 hours a day. Observations revealed that the resident's tube feeding pump was not running and had been idle for at least 10 minutes on two separate occasions. The nurse responsible confirmed that the tube feeding was not running as ordered and had not been restarted within the last hour. Additionally, staff did not provide feeding tube site care according to the practitioner's orders for another resident with moderate cognitive impairment and total care needs. The treatment order specified cleansing the site and applying Vaseline gauze followed by split gauze twice daily. During observation, the old dressing was found to lack Vaseline gauze, and bright red blood was present at the insertion site. The LPN confirmed the absence of Vaseline gauze and that the old dressing had adhered to the resident's skin, causing discomfort.
Posted Nurse Staffing Information Missing Required Hours
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information included the required total number of actual hours worked per discipline. Record review of 30 days of posted nurse staffing between 8/10/25 and 9/10/25 showed that the daily postings did not contain the total number of actual hours worked for the different types of staff. The facility had a census of 98 residents. During an interview on 9/15/25 at 1:02 PM, the Administrator confirmed that the nurse staffing postings did not contain the total number of actual hours worked per discipline and that the hours had not been calculated or documented on the posted nurse staffing, although they should have been.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure behavior monitoring was completed for a resident who was receiving multiple psychotropic medications, including clonazepam, duloxetine, trazodone, and zolpidem tartrate. The resident’s record showed diagnoses and assessments indicating cognitive awareness, but the care plan did not include staff monitoring for target behaviors related to the psychotropic medications. The order summary included side effect monitoring, but it did not include target behavior monitoring, and the electronic medical record did not show specific behavior monitoring for the ordered psychotropic medications. The regional nurse consultant confirmed the facility did not have behavior monitoring for this resident’s psychotropic medications. The facility also failed to monitor for side effects for another resident who was receiving Depakote and Lexapro. That resident’s record showed cognitive awareness and use of antidepressant and anticonvulsant medications, but the care plan did not include staff monitoring for medication side effects. The order summary did not include side effect monitoring orders for Depakote or Lexapro, and the electronic medical record did not show side effect monitoring for either medication. The regional nurse consultant confirmed the facility did not have psychotropic side effect monitoring for this resident. In addition, the facility failed to ensure a sleep diary or sleep test was completed for the resident receiving zolpidem tartrate for difficulty sleeping. The care plan addressed sedative/hypnotic therapy and included an intervention to evaluate other causes of insomnia before initiating hypnotic therapy, but the record did not show a sleep test or sleep diary to monitor the medication’s effectiveness. The facility also failed to ensure PRN antipsychotic orders for one resident had a stop date 14 days after first issuance, and failed to complete baseline and ongoing AIMS testing for another resident receiving risperidone. The PRN Seroquel and haloperidol orders remained active beyond the 14-day limit, and the resident receiving risperidone had an in-progress AIMS and an incomplete initial AIMS in the record. The regional nurse consultant confirmed the PRN orders were not stopped after 14 days and that the AIMS tests were not completed.
Failure to Provide Bed-Hold Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide bed-hold notices to Residents 7, 100, and 111 during hospital transfers and failed to notify the State LTC Ombudsman of facility-initiated transfers for those residents. The facility’s Bed-Hold Policy required a notice at admission and a second notice at the time of transfer, or within 24 hours for an emergency transfer, and the Ombudsman policy required notice before or as close as possible to the time of transfer, with documentation in the medical record. Review of the records showed that these notices were not documented for the sampled residents. Resident 100 was transferred to the ER for tachycardia and low oxygen saturations, and the transfer form listed altered mental status; the record did not show a bed-hold notice was given to the resident or representative, and the Ombudsman was not notified. Resident 111 was transferred to the ER for a psychiatric evaluation after an attempt at self-harm; the SBAR and eINTERACT forms documented the hospital transfer for behavior symptoms, but the record did not show a bed-hold notice or Ombudsman notification. Resident 7 had multiple paid hospital leaves, and the electronic record and progress notes did not show that bed-hold information was provided to the resident or family or that the Ombudsman was notified of the hospital admission.
Failure to Revise Care Plan for Fluid Restriction
Penalty
Summary
The facility failed to revise the comprehensive care plan for one resident related to fluid restriction. The resident was admitted on 2/24/23 and had diagnoses including end-stage renal disease and heart failure. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness, and also documented that the resident received hemodialysis. The resident’s comprehensive care plan, printed 9/10/2025, included an intervention for sips of fluid only in between meals dated 3/6/2023. However, review of the resident’s EHR, including physician orders, progress notes, and scanned documents, did not reveal an order for fluid restriction. During interview on 9/15/2025, the RDCR confirmed the resident’s fluid restriction ended in May 2025 and that the care plan was not revised after completion of the 8/27/2025 MDS, although it should have been.
Incomplete Neurological Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to complete neurological evaluations after an unwitnessed fall for one resident. The resident’s MDS dated 08-22-2025 showed a BIMS score of 3, indicating severe cognitive impairment, along with set-up assistance needs for dressing, toileting, and hygiene, independence with dressing, toileting, and ambulation, use of an antipsychotic medication, and a history of 2 or more falls in the prior 3 months. The facility incident log showed the resident had an unwitnessed fall on 06-16-2025. Review of the resident’s EMR showed the neurological check form had entries completed for the initial check, the next three 15-minute checks, the next four 30-minute checks, the next four 2-hour checks, and the next four 4-hour checks, but the remaining four 8-hour checks and the final check 24 hours after the last 8-hour check were blank. The DON confirmed in interview that the neurological checks were not completed for the unwitnessed fall and should have been.
Failure to Monitor Thyroid Labs and Hold BP Medication
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was cited after surveyors found the facility failed to monitor lab values related to thyroid medication for Resident 30 and failed to hold hydralazine when blood pressure was below the ordered parameter for Resident 71. The facility policy on unnecessary medication stated that only medications required to treat the resident's assessed condition should be used and that medication management should support monitoring for efficacy and adverse consequences. Resident 30 had moderate cognitive impairment with a BIMS score of 10 and was receiving thyroid replacement medication; pharmacy consultation reports noted that a TSH level was not found in the record and requested a TSH on the next convenient lab day and at least annually, with the physician later directing that TSH be drawn on the next lab day and every 6 months thereafter. The record showed no TSH results from 03-06-2025 through 09-10-2025, and the RNC confirmed the TSH had not been done and should have been. Resident 71 had severe cognitive impairment with a BIMS score of 3 and was receiving hydralazine 25 mg, one-half tablet every 8 hours for HTN with instructions to hold if SBP was below 110. The MAR documented multiple administrations when the recorded SBP was below the ordered hold parameter, including readings of 102/60, 103/66, 102/50, 103/78, 98/68, 94/56, 109/64, and 102/64, yet the medication was still documented as given. The DON confirmed hydralazine was not held on the identified dates and should have been.
Failure to Complete Discharge Plan
Penalty
Summary
The facility failed to complete a discharge plan for Resident 102, who was discharged to home. The resident’s progress notes documented the discharge to home, and the Notice of Resident Transfer or Discharge stated the resident’s health had improved sufficiently and that the resident no longer needed the facility’s services. The discharge summary also stated the resident was discharged to home for patient request and that the resident was educated on the discharge process and was not expected to return. However, the resident’s care plan did not include a discharge plan focus area or interventions, and the baseline care plan did not have the discharge plan box checked. In interview, the Regional Nurse Consultant confirmed that a discharge plan had not been done for the resident and should have been completed.
Incorrect MDS Coding for Resident Oral Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for Resident 13. The MDS dated [DATE] documented a BIMS score of 15, indicating the resident was cognitively intact, and recorded that the resident required limited assistance with upper body dressing, extensive assistance with bed mobility and lower body dressing, and total assistance with toileting, bathing, and transfers. The same assessment also coded the resident's oral and dental status as not having edentulous status or loosely fitting dentures. However, an observation on 09-08-2025 at 10:36 AM found Resident 13 to be edentulous, and during that observation the resident stated the dentures were too big. A later interview with the Regional Director of Clinical Reimbursement confirmed the MDS was coded incorrectly for the resident's oral status.
Failure to Prevent Accidents and Maintain Required Supervision
Penalty
Summary
The facility failed to implement interventions to prevent accidents for two residents. One resident had diagnoses including schizoaffective disorder, alcohol abuse, traumatic subdural hemorrhage without loss of consciousness, and speech and language deficits following cerebrovascular disease. The resident’s MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and the resident was receiving antipsychotic, antianxiety, and antidepressant medications. The care plan identified the resident as at risk for behavior problems related to schizoaffective disorder and included interventions such as administering medications as ordered and anticipating and meeting the resident’s needs. During a bingo activity, the resident placed an orange bingo cap in the mouth in an attempt to swallow it. Staff removed the cap, and the resident appeared tearful, rocked back and forth, and was emotionally distressed. The resident was then provided 1:1 supervision. The resident was later arranged for transport to the hospital emergency room for evaluation, but the resident was sent by a non-emergency medical transportation driver without a staff escort. The hospital ER nurse later called the facility to express frustration that the resident had been sent unaccompanied. Staff interviews confirmed that no facility staff went with the resident to the ER, and the driver was not informed that the resident had attempted self-harm. A second resident had diagnoses including muscle weakness, need for assistance with personal care, convulsions, and abnormal posture. The resident’s MDS showed a BIMS score of 13, indicating cognitive intactness, and the resident required supervision while eating and was dependent on staff for transfers and mobility. After a bruise was found on the left front shoulder, the facility determined the cause was related to wheelchair positioning. The resident’s care plan included use of an abductor wedge between the knees and a wedge between the resident and the right armrest while in the wheelchair, but observations showed only a standard foam cushion in the wheelchair and no wedge or abductor wedge in place. Staff interviews and the DON confirmed the positioning devices were not in use, and the DOR stated the wedge between the resident and the right side of the wheelchair was no longer an active intervention.
Medication Administration Error Rate Exceeded Allowed Limit
Penalty
Summary
Medication error rates were not maintained at 5 percent or less, with 2 medication administration errors identified out of 25 opportunities for error, resulting in an 8% error rate. The facility census was 98. The cited deficiency was based on observation, interview, and record review related to medication administration through an enteral tube. Resident 3’s MDS showed the resident required total assistance with eating, hygiene, bathing, dressing, toileting, transfers, and bed mobility, and had a feeding tube for nutrition, fluids, and medications. During an observation, an LPN removed hydralazine 75 mg and baclofen 5 mg from medication cards, crushed both tablets together in a clear pouch, and then poured the crushed medications into a medicine cup. The LPN added water, stirred the medications until dissolved, and administered both medications together through Resident 3’s feeding tube after flushing the tube. An LPN who was training the administering nurse stated the physician had ordered the medications to be crushed and given together through the feeding tube, but the DON confirmed Resident 3 did not have an order for the medications to be crushed and administered together and confirmed they should not have been crushed and administered together.
Failure to Provide Required Transfer Reports to Receiving Hospitals
Penalty
Summary
The facility failed to provide required reports to the receiving healthcare institution following emergent transfers for two of four sampled residents. For one resident, who was alert, oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions, the facility did not document or communicate the resident's care needs to the hospital after the resident and spouse requested hospital transfer due to body pain. The nurse responsible for the transfer confirmed that no report was given to the hospital. For another resident, who was rarely understood, required total assistance with all activities of daily living, and had a urinary catheter, the facility also failed to document or communicate the resident's care needs to the hospital after the resident was found unresponsive and sent to the hospital via 911. The Director of Nursing confirmed that staff are expected to call the hospital and provide a report, but this was not done in this case.
Lack of Staff Training on External Cardiac Defibrillator
Penalty
Summary
Facility staff failed to ensure that licensed nurses had received training on the use of an external cardiac defibrillator (Life Vest) prior to providing care for a resident who was required to wear the device at all times following hospital discharge. Record review showed that the resident was alert and oriented, receiving dialysis, required extensive assistance with transfers, and had an active infectious disease requiring transmission-based precautions. Multiple LPNs who provided care to the resident confirmed in interviews that they had not received any training on the Life Vest, nor were there training materials available for staff reference. The Director of Nursing also confirmed that no training on the Life Vest had occurred prior to the resident's admission and care.
Failure to Follow Contact and Enhanced Barrier Precautions for Infection Control
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for residents requiring contact precautions and enhanced barrier precautions (EBP). For one resident with an active C. difficile infection, staff did not follow posted contact precaution protocols. Specifically, a housekeeper was observed mopping the resident's room without wearing a gown, despite signage and facility policy requiring both gown and gloves for entry and cleaning in such cases. The housekeeper confirmed not wearing the required gown, and the regional nurse consultant verified that this was not in accordance with the resident's isolation status and facility policy. For two other residents, both of whom required EBP due to the presence of indwelling medical devices or multidrug-resistant organisms (MDROs), staff did not wear gowns during high-contact care activities. In one instance, two nursing assistants provided post-shower care, perineal care, and dressing changes to a resident with a urinary catheter and a wound dressing, without wearing gowns. Both staff members stated they were unaware that gowns were required or that the resident was on EBP. In another case, two nursing assistants transferred a resident with an MDRO and a vascular access port for dialysis, and one continued to provide perineal care and a brief change, all without wearing a gown. The staff involved and a registered nurse confirmed they were not aware of the EBP requirement for this resident. Facility policy required the use of gowns and gloves for contact precautions and EBP during high-contact activities for residents with certain infections or indwelling devices. Observations and staff interviews confirmed that these protocols were not followed for the residents in question, despite clear signage and policy directives. The failure to adhere to these precautions was acknowledged by both the staff involved and the regional nurse consultant.
Failure to Administer Enteral Feedings and Water Flushes per Physician Orders
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 3, had a diagnosis of protein calorie malnutrition and required total assistance with all activities of daily living. The resident had a physician's order for Nepro enteral feeding at 45 ml per hour, to be administered continuously over 24 hours. However, observation revealed that the resident was receiving Isosource formula instead of Nepro, and the feeding bag in use was not properly labeled or dated. Additionally, a second feeding bag containing clear liquid (water) was found without a label or date, and the water flushes were being administered at 300 ml every 6 hours without a corresponding physician's order. Interviews with nursing staff confirmed that the tube feeding being administered did not match the physician's order, and that there was no order for the water flushes being provided. The facility's registered dietician also confirmed that Nepro and Isosource formulas are not interchangeable and that Isosource should not have been given to the resident. Review of facility policy indicated that enteral nutrition therapy should be provided in accordance with physician orders and professional standards, which was not followed in this case.
Medication Error Rate Exceeds Regulatory Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required by regulation, with an observed error rate of 10.34% during the administration of 29 medications. Specifically, for one resident, a registered nurse did not administer the prescribed Refresh Tears Solution eye drops at the scheduled time because the medication was unavailable. This omission was confirmed by the nurse during an interview. Additionally, another resident did not receive two of their scheduled medications—Certirizine and Timolol Maleate—at the designated administration time. The LPN responsible confirmed that Certirizine was not administered and that Timolol Maleate was given late. These errors were identified through direct observation and staff interviews, and the facility's own medication administration policy requires adherence to physician orders and the correct timing of medication administration.
Insulin Pens Not Dated Upon Opening
Penalty
Summary
During an observation of a medication cart, surveyors found that 10 insulin pens for three residents were not labeled with the date they were opened, as required by facility policy and professional standards. Specifically, three Lantus pens and two lispro pens for one resident, three lispro pens for another resident, and one Lantus pen and one lispro pen for a third resident were all missing opened dates. Facility policy states that all insulin pens should be dated upon opening and that opened Lantus and lispro insulin expire 28 days after being opened. A registered nurse confirmed that the insulin pens in question did not have a date indicating when initial use began.
Failure to Include Resident and Family in Care Planning Process
Penalty
Summary
The facility staff failed to include a resident and their family member in the quarterly care planning process, as required by regulations. This deficiency was identified during a record review and interviews. Resident 2, who was admitted to the facility and later discharged, did not have a documented quarterly care planning process completed as of the review date. The last recorded care planning process for this resident was completed over a year prior. During an interview, a family member of Resident 2 reported not being invited or aware of the quarterly care planning process, despite being involved in planning care for the resident. Additionally, the Social Services Director confirmed that Resident 2's record did not reflect the completion of the care planning process and was unaware of any such process being completed for the resident. This oversight indicates a failure to adhere to the regulatory requirement of involving residents and their families in the development and implementation of person-centered care plans.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility staff failed to implement assessed interventions to prevent accidents and falls for three residents. Resident 1's Comprehensive Care Plan (CCP) indicated the need for a fall mat next to the bed, among other interventions, to prevent serious injury. However, observations revealed that Resident 1 did not have a fall mat in place, which was confirmed by an LPN. Similarly, Resident 3's CCP required the removal of a sling after being positioned in a chair and the presence of a fall mat at the bedside. Observations showed that Resident 3 was seated on a sling in a wheelchair and did not have a fall mat next to the bed, as confirmed by both an LPN and an RN. Resident 4's CCP also identified the need for a fall mat at the bedside and a low bed when asleep to prevent serious injury. Observations indicated that Resident 4 did not have a fall mat next to the bed, which was confirmed by an RN. These deficiencies highlight the facility's failure to adhere to the planned interventions outlined in the residents' care plans, potentially compromising the safety and well-being of the residents.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in an observed error rate of 11.76%. This deficiency affected three out of five sampled residents. For Resident 10, the medication administration record (MAR) indicated that Atorvastatin was to be given at 5:00 PM, but it was administered late at 7:33 PM. Additionally, Metamucil was not given as ordered. Licensed Practical Nurse (LPN) A confirmed these errors during an interview. Resident 11's medication order included Diltiazem to be given at bedtime, but during observation, the medication was not available for administration. Registered Nurse (RN) B confirmed the unavailability of the medication as an error. For Resident 13, the MAR indicated that Calcium Carbonate was to be administered at 10 AM and 3 PM, but it was given early at 7:23 AM. RN D confirmed this early administration as an error during an interview.
Failure to Complete PASARR Level II for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II was completed for a resident with a serious mental disorder. The deficiency was identified during a review of records and an interview with the facility's Social Services Director. The resident in question, referred to as Resident 6, was admitted to the facility with a diagnosis of Bipolar Disorder, a serious mental illness. However, this diagnosis was not identified during the initial PASARR Level I screening, which incorrectly indicated no signs of a serious mental illness or intellectual disability. Upon admission, Resident 6's medical records showed a diagnosis of Bipolar Disorder dated shortly after the initial screening. The Minimum Data Set (MDS) assessment for Resident 6 confirmed the presence of Bipolar Disorder, along with other conditions such as anxiety and depression. Despite these findings, the facility did not make a referral for a PASARR Level II evaluation, which is required when a serious mental disorder is identified after admission. The Social Services Director confirmed that a referral should have been made once the omission was recognized. The facility's policy on PASARR, dated 9/25/2023, outlines the procedures for ensuring that potential admissions are screened for serious mental disorders or intellectual disabilities. It specifies that a positive Level I screen necessitates a Level II evaluation by the state-designated authority. The policy also requires the facility to incorporate recommendations from the PASARR Level II determination into the resident's care plan. In this case, the facility did not adhere to these procedures, resulting in a failure to coordinate the necessary assessments and referrals for Resident 6.
Failure to Develop Baseline Care Plan for Resident
Penalty
Summary
The facility failed to complete a baseline care plan for a resident within 48 hours of admission, as required by their policy and regulatory standards. The resident, identified as Resident 79, was admitted on a specific date, but a review of their electronic medical record revealed that no baseline care plan was developed or implemented in the Point Click Care system. This omission was confirmed during an interview with the Assistant Director of Nursing, who acknowledged that the baseline care plan for Resident 79 was blank and lacked necessary information about the resident's physical or medical needs, goals, or interventions. The facility's policy on person-centered care planning mandates that each resident should have a comprehensive care plan developed to meet their preferences and goals, addressing medical, physical, mental, and psychosocial needs. The baseline care plan is intended to ensure continuity of care and communication among staff, increase resident safety, and prevent adverse events immediately after admission. However, in this case, the facility did not adhere to its own procedures, resulting in a deficiency in care planning for Resident 79.
Incomplete Comprehensive Care Plan for a Resident
Penalty
Summary
The facility staff failed to complete a Comprehensive Care Plan (CCP) for a resident, identified as Resident 79, after the completion of a comprehensive assessment. This deficiency was identified during a record review and interview process. Resident 79's Minimum Data Set (MDS) indicated the need for setup or clean-up assistance with oral hygiene and substantial/maximal assistance with transferring, showering, toileting, and lower body dressing. Despite these identified needs, the CCP for Resident 79, dated 06/22/2024, only included a focus area related to Advanced Directives and lacked information addressing the resident's care needs. An interview with the Assistant Director of Nursing (ADON) confirmed that Resident 79's CCP had not been completed. The facility's policy on Person-Centered Care Planning, dated 08/22/2023, requires that each resident have a comprehensive care plan developed to meet their preferences and goals, addressing medical, physical, mental, and psychosocial needs. The facility's procedure outlines that the CCP should include measurable goals, timeframes, and interventions to assist the resident in achieving their highest practicable well-being. However, these requirements were not met for Resident 79, as the CCP was incomplete and did not reflect the necessary interventions and goals based on the comprehensive assessment.
Failure to Meet Resident's Activity Needs
Penalty
Summary
The facility failed to provide activities that met the needs and interests of a resident with a diagnosis of dysphagia and anoxic brain damage. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs due to immobility, with a goal of participating in activities at least 1-2 times weekly. However, observations revealed that the resident was often in bed with no activities occurring, and the resident's participation in activities was minimal, with only a few 1-1 visits documented over several months. Interviews with the Activity Director indicated that more 1-1 visits might have been provided than recorded, but the resident was not consistently brought to activities when out of bed. The resident's preferences included listening to music, engaging in group activities, and going outside for fresh air, yet these interests were not adequately addressed. The facility's failure to ensure the resident's participation in activities as per their care plan and preferences led to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent potential falls for a resident identified as being at risk for falls. The resident, who was admitted with dysphagia and anoxic brain damage, had a care plan that included several interventions to mitigate fall risks, such as keeping the call light within reach, using a fall mat, and ensuring the bed was in a low position when appropriate. Despite these measures, the resident experienced two incidents where they were found on the fall mat next to the bed, indicating that the interventions were not effectively implemented. Observations revealed that the resident was often found in positions that increased the risk of falling, such as having feet off the edge of the bed without wedges in place to prevent this. Interviews with staff confirmed that wedges were not consistently used, and the bed was not always in the low position as required by the care plan. The facility's policy on fall management emphasized assessing residents for fall risks and implementing appropriate interventions, but these were not adequately followed for the resident in question.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that enteral feeding was provided in accordance with the physician's order for a resident with a diagnosis of dysphagia and anoxic brain damage. The resident was receiving more than 51% of their total calories from enteral tube feeding. The physician's orders specified that the resident should receive Jevity 1.5 formula via G-tube with specific water flushes at scheduled times. However, on a particular day, a registered nurse administered an extra feeding of Jevity 1.5 bolus at 9:10 AM, which was not due until 12 PM, and did not follow the prescribed water flush protocol. During the observation, the registered nurse encountered difficulty administering the tube feeding and initially flushed the tube with less water than ordered. The nurse left the room to consult with the nurse practitioner and later realized the error in the timing of the feeding. The Assistant Director of Nursing confirmed that the timing for the administration of the resident's tube feeding was not followed, indicating a failure to adhere to the practitioner's order as outlined in the facility's Enteral Tube Feeding Checklist.
Inconsistent Monitoring of Wanderguard Bracelet for Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure monitoring of a Wanderguard bracelet for Resident 1, who was at risk for elopement due to severe cognitive impairment and a history of attempting to leave the facility unattended. Despite being identified as at risk for elopement and having a Wanderguard bracelet in place, there were multiple instances where Resident 1 attempted to leave the facility without the bracelet triggering an alarm. Incident reports documented Resident 1 being found outside the building on two occasions, with the Wanderguard not functioning properly or alarming as intended. Documentation revealed that while there were orders in place to check the Wanderguard bracelet's placement and function every shift, there was a lack of consistent monitoring and documentation of this task. The facility's policy on elopement highlighted the risks associated with residents leaving the premises without supervision and emphasized the need for regular review and revision of care plans for residents at risk of elopement. Interviews with staff members revealed gaps in monitoring Resident 1's Wanderguard bracelet, with no evidence of consistent monitoring between the bracelet being placed and the deficiency being identified. The deficiency in ensuring the proper monitoring of the Wanderguard bracelet for Resident 1 highlights a critical lapse in supervision and safety measures for a resident at high risk of elopement. Despite the facility's policies and procedures in place for elopement prevention, the lack of consistent monitoring and documentation of the bracelet's function put Resident 1 at risk of leaving the facility unsupervised. The repeated instances of Resident 1 attempting to exit the building without the alarm sounding raise concerns about the effectiveness of the facility's elopement prevention measures and the need for improved monitoring protocols to ensure resident safety.
Failure to Report Elopement Incidents
Penalty
Summary
The facility failed to report two elopement incidents involving a resident with severe cognitive impairment to Adult Protective Services and did not submit an investigation to the state agency within the required 5 working days. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with a BIMS score of 3, indicating severe cognitive impairment. Despite being identified as an elopement risk and having a care plan in place with interventions such as frequent monitoring and a Wanderguard bracelet, the resident was found outside the facility on two separate occasions. On one occasion, the resident was found walking up a hill and was retrieved by staff, and on another occasion, the resident was found walking outside the building by housekeeping staff. In both instances, the resident did not sustain any injuries, and the Wanderguard bracelet was found to be working properly. The facility's policy on missing residents and actual elopement events defines elopement as a resident leaving the premises or a safe area without authorization and necessary supervision. The policy also requires the Executive Director or designee to report such events to all appropriate agencies. However, the Administrator confirmed that the elopements were not reported because the resident did not leave the facility grounds. This failure to report and investigate the incidents as required by the facility's policy and state regulations constitutes a deficiency in the facility's compliance with reporting requirements.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that two nurse aides, identified as Nurse Aide C and Nurse Aide D, completed the required 12 hours of yearly in-service training. Specifically, Nurse Aide C, who was hired on 11/28/17, completed only 1.95 hours of continuing education between 11/28/22 and 11/28/23, with no training on abuse prevention or dementia. Similarly, Nurse Aide D, hired on 10/5/18, completed only 1.03 hours of continuing education between 10/5/22 and 10/5/23. The Director of Nursing confirmed these deficiencies during an interview. The facility had a total census of 85 residents at the time of the survey.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the posting of daily nursing staffing information. Observations on 4/2/24 at 1:00 PM revealed that the daily nursing staffing posting was dated 3/13/24. A review of the facility staff posting confirmed that the census and staffing hours were from 3/13/24. In an interview on 4/2/24 at 1:11 PM, the Administrator confirmed that the daily nursing staffing posting was not up-to-date and reported that a new scheduler had just been hired.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 384 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quality Living, Inc. | 0.7 mi | ★★★★★ | 0 | 0 |
| Keystone Ridge Post Acute Nursing And Rehabilitati | 1.5 mi | ★★★★★ | 2 | 0 |
| Maple Crest Health Center | 2.1 mi | ★★★★★ | 25 | 0 |
| Emerald Nursing & Rehab Legacy Pointe Llc | 2.6 mi | ★★★★★ | 2 | 0 |
| Florence Home | 2.8 mi | ★★★★★ | 10 | 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.