Above 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 Nye Legacy Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple serious diagnoses had a PRN Lorazepam order written without the required 14-day stop date, contrary to facility policy. The DON confirmed the omission during an interview, and the issue was identified during a review of unnecessary medication use.
The facility failed to date opened food items, including noodles, gravy mix, milk, apples, celery, cheese, sausage, roast beef, french fries, and potato wedges, potentially affecting all 85 residents. The Dietary Manager confirmed the items should have been dated and stored properly.
The facility failed to follow physician orders for oxygen administration and fluid intake restriction for two residents, and did not adhere to its bowel management protocol for two other residents, leading to extended periods without bowel movements.
The facility failed to ensure valid oxygen and PAP orders for several residents and did not prevent oxygen flow restriction due to kinked tubing. Observations and interviews revealed that orders lacked necessary settings and elements, compromising the safety and well-being of residents requiring respiratory care.
The facility failed to ensure the accuracy of the MDS for two residents. One resident's discharge status was incorrectly recorded, and another resident was inaccurately documented as receiving enteral feedings and having a G-tube. These discrepancies were confirmed through record reviews and staff interviews.
A resident with COPD and multiple cancers was discharged without a complete discharge summary. Sections A, B, E, and F of the Recapitulation of Stay/Discharge Summary were not filled out or signed, as confirmed by the Social Services Designee.
The facility failed to ensure that a resident was free from unnecessary medications, specifically acetaminophen, which was administered over the recommended daily dosages. The resident received acetaminophen exceeding the recommended dosages on multiple occasions, and the facility's pain management policy lacked specific guidance on ensuring medications were administered within recommended dosages.
The facility failed to secure medications for a cognitively impaired resident, leaving Cooling Pain Gel 4% and Haldol 2 mg/ml unsecured in the resident's room. The resident's care plan did not include self-administration of medications, and the DON confirmed that the medications should not have been left in the room.
The facility failed to ensure proper infection control measures for several residents, including improper catheter care for a resident with a history of UTIs, failure to clean a CPAP mask daily, and improper storage of nasal cannulas for two residents.
PRN Psychotropic Medication Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure compliance with its policy regarding the use of PRN (as needed) psychotropic medications. Specifically, a review of clinical physician orders for a resident with diagnoses including malignant neoplasm of the prostate, secondary malignant neoplasm of bone, and adult failure to thrive revealed an order for PRN Lorazepam with an indefinite end date. According to the facility's policy, PRN orders for psychotropic drugs must be limited to a 14-day duration unless the prescribing practitioner documents a rationale for extending the order and specifies the duration in the resident's medical record. During an interview, the Director of Nursing confirmed that the PRN Ativan order did not have the required stop date. This deficiency was identified through record review and affected one of three residents reviewed for unnecessary medication use, in a facility with a census of 85 residents.
Failure to Date Opened Food Items
Penalty
Summary
The facility failed to ensure food items were dated upon opening, which could potentially lead to foodborne illness affecting all 85 residents who ate meals from the kitchen. During an observation of the dry storage room, fridge, and freezer, several items were found opened and undated, including a bag of noodles, a brown gravy mix packet, a gallon of milk, a box of apples, a stalk of celery, a bag of cubed cheese, a bag of sausage, a bag of roast beef, a bag of french fries, and a bag of potato wedges. The Dietary Manager confirmed that these items should have been dated upon opening and that the celery should have been in a sealed container. A review of the facility's food storage policy from 2017 indicated that all refrigerated foods should be covered, labeled, and dated.
Failure to Follow Physician Orders and Facility Protocols
Penalty
Summary
The facility failed to ensure that a resident's physician order for oxygen administration was followed. Resident 32, who had severe cognitive impairment and multiple diagnoses including acute respiratory failure and pneumonia, was observed with oxygen saturation levels below the prescribed threshold of 90%. Despite this, the resident was not placed on oxygen as required by the physician's order. This was confirmed through interviews with staff and observations of the resident without oxygen when their saturation levels were critically low. The facility also failed to adhere to a fluid intake restriction for another resident. Resident 36, who had multiple diagnoses including chronic heart failure and chronic kidney disease, had a physician's order for a 2000ml daily fluid restriction. However, records showed that the resident's fluid intake frequently exceeded this limit, sometimes by a significant margin. Interviews with staff and the resident confirmed that the resident did not refuse the fluid restriction, indicating a failure in monitoring and enforcing the physician's order. Additionally, the facility did not follow its bowel management protocol for two residents. Resident 7 and Resident 27 both experienced extended periods without bowel movements, contrary to the facility's guidelines which required interventions and physician notification after specific durations without a bowel movement. Records showed that these interventions were not administered as ordered, and there was no documentation of physician notification. Interviews with the Director of Nursing confirmed these lapses in following the bowel management protocol.
Deficiencies in Respiratory Care Orders and Equipment
Penalty
Summary
The facility failed to ensure that two residents had valid oxygen orders that included settings, and five residents had valid Positive Airway Pressure (PAP) orders that included settings. Additionally, the facility did not ensure that one resident's oxygen tubing was not kinked to prevent flow restriction. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors. The facility's census at the time was 85 residents. Resident 32 was observed with an oxygen nasal cannula on and an oxygen concentrator set at 2 liters per minute (l/m). However, the order summary report did not contain a valid oxygen order with the required elements such as the amount, duration, and delivery device. Similarly, Resident 36 had an oxygen order that was not valid as it lacked the necessary settings and other required elements. Additionally, Resident 36's oxygen tubing was found to be kinked, which would have restricted the oxygen flow to the resident. The facility also failed to provide valid PAP orders for five residents. For instance, Resident 36 used a CPAP device every night, but the order did not specify the machine type and settings. Similar issues were found with Residents 6, 26, 30, and 70, where the orders for their CPAP devices did not include the necessary settings. These deficiencies indicate a failure to adhere to professional standards of practice and ensure the safety and well-being of the residents requiring respiratory care.
Inaccurate MDS Documentation for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for two residents. For Resident 73, the MDS inaccurately recorded the discharge status as 'Short-Term General Hospital' when the resident was actually discharged home. This discrepancy was confirmed by a Registered Nurse during an interview. Resident 73 had a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and additional diagnoses of bone, brain, and lung cancers. For Resident 62, the MDS incorrectly indicated that the resident was receiving enteral feedings and had a gastrostomy tube (G-tube) in place. However, records and interviews with the resident's Power of Attorney (POA), the Dietary Manager, and a Licensed Practical Nurse confirmed that the resident was on a regular diet and no longer had a G-tube. The facility's Director of Nursing confirmed that the MDS was inaccurately coded and acknowledged the need for a modification.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary, including a recapitulation of stay, for Resident 73. The resident, who had a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and additional diagnoses of bone, brain, and lung cancers, was admitted and later discharged without the necessary sections of the discharge summary being filled out or signed. Specifically, sections A, B, E, and F of the Recapitulation of Stay/Discharge Summary were incomplete. This deficiency was confirmed during an interview with the Social Services Designee (SSD) on 05/09/2024.
Failure to Ensure Resident was Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that Resident 175 was free from unnecessary medications, specifically acetaminophen, which was administered over the recommended daily dosages. Resident 175, who was admitted with a primary diagnosis of coronary artery disease and was oriented x4, had multiple orders for acetaminophen for pain control. The orders included a routine dose of 1,000 mg every 8 hours with a maximum of 4,000 mg in 24 hours, and PRN doses with a maximum of 3,000 mg in 24 hours. However, the resident's MAR revealed that between May 1, 2024, and May 13, 2024, the resident received acetaminophen exceeding the recommended dosages on multiple occasions, including a total of 4,500 mg on May 5, 2024. This discrepancy was confirmed by the facility's DON and an LPN during interviews, acknowledging that the resident received more than the ordered and recommended amounts of acetaminophen. The facility's standing orders and the admission medication regimen review by the pharmacy consultant highlighted the need for clear maximum dosage instructions, which were not adequately followed. Additionally, the facility's pain management policy lacked specific guidance on ensuring medications for pain control were administered within recommended dosages. Interviews with the resident and staff revealed that the resident was encouraged to take more PRN acetaminophen instead of oxycodone, further contributing to the over-administration of acetaminophen. This oversight in medication management led to the resident receiving unnecessary and potentially harmful dosages of acetaminophen.
Failure to Secure Medications for Cognitively Impaired Resident
Penalty
Summary
The facility failed to secure medications for one resident, identified as Resident 7, who had a significant cognitive impairment. Resident 7 was admitted with multiple diagnoses, including senile degeneration of the brain, cerebral infarction, and dementia with agitation. The resident's care plan did not include a focus on self-administering medications, and there were no physician orders permitting self-administration. Despite this, an observation revealed that two medications, Cooling Pain Gel 4% and Haldol 2 mg/ml, were left unsecured in the resident's room. The Director of Nursing (DON) confirmed that these medications should not have been left in the room and promptly removed them upon discovery. Further observation revealed a large container of approximately 100 Halls Cough Drops in Resident 7's room. The facility's Medication Storage policy mandates that all drugs and biologicals be stored in locked compartments and only accessible to authorized personnel. An interview with the DON confirmed that Resident 7 was not appropriate to self-administer any medication, and the medications should not have been left in the resident's room. This failure to secure medications is a clear violation of the facility's policy and regulatory requirements.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for several residents. For Resident 63, the facility did not perform indwelling catheter care in a manner that would prevent urinary tract infections (UTIs). Specifically, the nurse aides did not follow the correct procedure for cleaning the catheter and the surrounding area, and the drainage bag was held above the level of the bladder during repositioning, which could lead to backflow of urine. Resident 63 had a history of UTIs and was on multiple antibiotics for treatment and prevention of UTIs, indicating a significant risk that was not adequately managed by the facility's staff. The facility also failed to ensure that the Continuous Positive Airway Pressure (CPAP) mask for Resident 36 was cleaned daily as required. Observations revealed that the CPAP mask had an oily film on the seal and the filter had a gray fuzzy substance, indicating that it had not been cleaned properly. Resident 36 confirmed that the staff did not clean the CPAP mask or supplies, and the Director of Nursing (DON) acknowledged that the mask and filter were not cleaned as they should have been. Additionally, the facility did not store the nasal cannulas for Residents 36 and 175 in a manner that would prevent cross-contamination when not in use. Observations showed that the nasal cannulas were placed on the residents' blankets or touching the oxygen concentrator, rather than being stored in a clean bag. The DON confirmed that the nasal cannulas should not have been touching any surfaces and should have been stored properly to prevent contamination.
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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 Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dunklau Gardens | 0.5 mi | ★★★★★ | 0 | 0 |
| Nye Pointe Health & Rehab Ctr | 1 mi | ★★★★★ | 7 | 0 |
| Arbor Care Center-valhaven, Llc | 12.7 mi | ★★★★★ | 29 | 0 |
| Life Care Center Of Elkhorn | 17.8 mi | ★★★★★ | 27 | 0 |
| Crowell Memorial Home | 18.7 mi | ★★★★★ | 3 | 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.