Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nye Pointe Health & Rehab Ctr during CMS and state inspections, most recent first.
Staff did not obtain daily weights as ordered for a resident with heart failure, missing multiple days of required documentation. Additionally, after an unwitnessed fall, neurological checks were not performed for another resident with moderate cognitive impairment, despite facility policy requiring such assessments.
A resident with moderate cognitive impairment, a stage 4 pressure ulcer, and an indwelling urinary catheter was observed on two occasions with catheter tubing not secured to the thigh as ordered. The ADON confirmed the tubing was not properly secured, contrary to the resident's care plan.
Surveyors identified that the facility did not maintain a medication error rate below 5%, with three errors observed out of 25 opportunities. Errors included a resident receiving pantoprazole and ondansetron at the wrong time in relation to meals, and another resident being given a chewable aspirin instead of the prescribed enteric coated formulation. The medication aide confirmed these errors during interviews.
The facility failed to maintain a sanitary kitchen environment, affecting 37 residents. Observations showed cupboards with particles, drawers with food and grease, and walls with debris. The stove, oven, and freezer were coated with grime, and the ice machine had a buildup of dirt. The Dietary Manager confirmed the absence of a cleaning schedule, acknowledging cleaning issues against facility policy.
The facility failed to implement adequate infection control measures, including improper handling of laundry, inadequate hand hygiene after wound care, and poor maintenance of oxygen equipment. Staff did not regularly sanitize laundry carts, used insufficient PPE, and allowed clean linens to contact clothing. Handwashing protocols were not followed, and nasal cannulas and oxygen concentrators were improperly stored and maintained.
A resident with multiple medical conditions, including diabetes and chronic heart failure, did not receive wound care as ordered. The facility's APRN failed to perform proper hand hygiene and did not wash the resident's wounds before applying new dressings, contrary to the facility's wound treatment policy. This resulted in a deficiency due to non-compliance with physician's orders for wound care.
A resident with moderately impaired cognition received PRN Alprazolam without documented anxiety symptoms or non-pharmacological interventions, contrary to facility policy. The DON confirmed the medication was administered without required documentation or interventions.
Failure to Obtain Daily Weights and Perform Neurological Checks After Fall
Penalty
Summary
Facility staff failed to obtain daily weights as ordered for a resident with a diagnosis of heart failure. The resident's Medication Administration Record (MAR) for July and August showed multiple days where daily weights were not recorded, despite a physician's order requiring daily weights and notification if the resident gained more than 3 pounds in a day or 5 pounds in a week. The resident required varying levels of assistance with activities of daily living and was assessed as cognitively intact. The Corporate Nurse confirmed that daily weights were not conducted as required. Additionally, the facility did not implement neurological evaluations after an unwitnessed fall for another resident who had moderate cognitive impairment and required substantial to total assistance with mobility and personal care. The resident's care plan documented an unwitnessed fall, but there was no evidence in the health record that neurological checks were performed following the incident. The Corporate Nurse confirmed that neurological evaluations were not completed as per facility policy, which requires such assessments after unwitnessed falls where a head injury is suspected.
Failure to Secure Urinary Catheter Tubing as Ordered
Penalty
Summary
Facility staff failed to secure a urinary catheter in a manner that would prevent skin trauma for one resident. The resident had moderate cognitive impairment, a life expectancy of six months or less, an indwelling urinary catheter, a stage 4 pressure ulcer, and required significant assistance with activities of daily living. According to the resident's Treatment Administration Record, the catheter tubing was to be secured to the thigh to avoid pulling. However, during two separate observations, the catheter tubing was found lying across the resident's thigh and not secured as ordered. The Assistant Director of Nursing confirmed that the catheter tubing was not secured and acknowledged it should have been.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 3 errors out of 25 observed opportunities, resulting in a 12% error rate. In one instance, a medication aide administered pantoprazole and ondansetron to a resident while the resident was eating breakfast, despite orders specifying that these medications should be given prior to eating. The pantoprazole was also administered in a 20 mg dose instead of the ordered 40 mg dose. The medication aide confirmed during an interview that the medications were not given according to the prescribed timing. In another case, a resident with an order for aspirin 81 mg enteric coated tablet to be taken with food and not crushed was instead given an 81 mg chewable aspirin tablet. The medication aide acknowledged the error, confirming that the wrong formulation of aspirin was administered. Facility policy requires medications to be administered as ordered by the physician and in accordance with professional standards, which was not followed in these instances.
Unsanitary Kitchen Conditions in LTC Facility
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, which had the potential to affect 37 of 38 residents consuming food from this area. Observations revealed that the cupboards contained small particles of varied colors and sizes, and the drawers had food particles, dirt, and grease. The walls along the floor edges and surrounding equipment had a buildup of food particles, hair, grease, and other debris. The floor and areas underneath the equipment were scattered with food particles and debris. The stove and oven were heavily coated with grease and grime, and the upright freezer had dirt and grime on its sides, door handle, and back. Additionally, the dry storage floor had a coffee-like substance along the south wall, and the ice machine had a buildup of dirt and grime. An interview with the Dietary Manager confirmed these findings and acknowledged the absence of a cleaning schedule for the kitchen environment and its equipment. The Dietary Manager admitted that cleaning was an issue and that it was expected to be completed daily according to facility policy and current standards of practice. The lack of adherence to the facility's policy on kitchen sanitation and the absence of a comprehensive cleaning schedule contributed to the unsanitary conditions observed.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, particularly in the handling and transportation of laundry and linens. Observations revealed that laundry carts were not regularly sanitized, and staff did not consistently use personal protective equipment (PPE) such as gowns and eye protection when sorting contaminated laundry. Additionally, clean linens were observed being transported in a manner that allowed them to come into contact with staff clothing, increasing the risk of cross-contamination. The facility also did not adhere to hand hygiene protocols following wound care procedures. An Advanced Practice Registered Nurse (APRN) was observed washing hands for only 7 seconds after completing wound care, contrary to the facility's policy which required at least 20 seconds of handwashing. This lapse in proper hand hygiene was confirmed by the Director of Nursing (DON). Furthermore, the facility failed to maintain cleanliness and proper storage of oxygen equipment. Nasal cannulas for two residents were found improperly stored, with one on the floor and another between blankets, instead of being bagged as per policy. Additionally, oxygen concentrators for these residents were observed with thick layers of dust and debris, indicating they were not cleaned as needed. These deficiencies were acknowledged by the facility's staff during interviews.
Failure to Follow Wound Care Protocols
Penalty
Summary
The facility failed to ensure that wound care was completed as ordered for a resident, leading to a deficiency. The resident, who was admitted to the facility in August 2022, had multiple medical diagnoses including diabetes mellitus with diabetic neuropathy, lymphedema, chronic heart failure, COPD, and was on long-term anticoagulant therapy. The resident was severely cognitively impaired and required varying levels of assistance with personal care. The care plan indicated a potential impairment to skin integrity, with specific interventions for a right great toe wound and right leg edema, but lacked an intervention for a left lower leg skin tear. Observations revealed that the facility's contracted wound care APRN did not follow proper wound care procedures. During a wound care session, the APRN used contaminated gloves to handle dressing materials and did not perform hand hygiene or change gloves when moving from a contaminated site to a clean site. The APRN also failed to wash the resident's wounds with soap and water before applying new dressings, as ordered. These actions were confirmed by the Director of Nursing, who acknowledged that the APRN should have adhered to proper hand hygiene and wound care protocols. The facility's Wound Treatment Management policy required that wound treatments be provided in accordance with physician's orders, including specific cleansing methods and dressing applications. However, the APRN's actions during the wound care session did not align with these requirements, resulting in a failure to provide appropriate treatment and care as ordered. This deficiency was identified through observation, interview, and record review, highlighting a lapse in adherence to established wound care procedures.
Failure to Implement Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility staff failed to implement non-pharmacological interventions before administering a PRN psychotropic medication to a resident. The facility's policy requires that PRN medications be documented with a rationale in the resident's medical record, and that non-pharmacological approaches be considered based on the resident's underlying condition, symptoms, and treatment goals. However, for one resident with a history of Parkinson's Disease, Major Depressive Disorder, and Generalized Anxiety Disorder, there was no documentation of anxiety symptoms or non-pharmacological interventions prior to the administration of Alprazolam on three separate occasions. The resident, who had a Brief Interview of Mental Status (BIMS) score indicating moderately impaired cognition, received Alprazolam as needed on specific dates without documented evidence of anxiety symptoms or attempts at non-pharmacological interventions. The Director of Nursing confirmed the administration of the medication without the required documentation or interventions, which is a violation of the facility's policy on the use of psychotropic medications.
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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) |
|---|---|---|---|---|
| Nye Legacy Health & Rehabilitation Center | 1 mi | ★★★★★ | 0 | 0 |
| Dunklau Gardens | 1.1 mi | ★★★★★ | 0 | 0 |
| Arbor Care Center-valhaven, Llc | 12 mi | ★★★★★ | 29 | 0 |
| Life Care Center Of Elkhorn | 17 mi | ★★★★★ | 27 | 0 |
| Crowell Memorial Home | 17.9 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.