Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Omaha Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, total dependence for ADLs, and a documented fall risk with prior falls had a care plan that included Dycem on the wheelchair cushion as a fall-prevention intervention. Policy required staff to ensure appropriate and immediate interventions were implemented after incidents. On multiple observations, including while the resident was in the therapy gym, the wheelchair lacked the care-planned Dycem on or under the cushion. The ADON confirmed the absence of Dycem, resulting in a deficiency for not implementing a prescribed fall intervention.
A resident with a stage four pressure ulcer and chronic pain received a wound dressing change without appropriate pain management, despite exhibiting clear signs of severe pain such as crying, yelling, and verbalizing distress. Staff did not pause the procedure to assess or address the pain, and interviews confirmed that additional pain medication should have been administered prior to the treatment but was not.
An LPN did not perform hand hygiene between glove changes while providing wound care to a resident, contrary to facility policy. The LPN changed gloves multiple times during the procedure without using hand sanitizer or washing hands in between, and later confirmed this omission.
The facility did not follow individualized care plan interventions for two residents: one with a history of falls did not have required fall-prevention measures in place, and another dependent on staff for transfers was assisted by only one staff member instead of two, resulting in a significant leg injury. Staff interviews confirmed a lack of awareness and adherence to care plan requirements.
Significant medication error with carvedilol: A resident with a hx of subarachnoid hemorrhage and moderate cognitive impairment received carvedilol outside ordered BP hold parameters on multiple occasions. The MAR showed doses given when SBP was below the hold threshold, including after a recent hypotensive episode that required ER evaluation and overnight observation, and an LPN confirmed the medication was administered outside parameters.
Broken Refrigerator Door Seal Caused Inconsistent Food Temps: A kitchen refrigerator had a broken middle door seal and did not close completely, and staff observed inconsistent temperatures behind the damaged seal, including 32 degrees and 41 degrees. The DM confirmed the temperature was not consistent and could affect the safety of the food stored inside.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with a hx of subarachnoid hemorrhage and moderate cognitive impairment was receiving multiple psychotropic meds, including 2 antipsychotics, 2 antianxiety meds, and antidepressants, without documented indication for sertraline or rationale for duplicate therapy. The MAR also showed PRN trazodone for insomnia without a stop date or documented rationale to continue beyond 14 days, and the pharmacy AMRR noting the need for diagnosis support, monitoring, and review of duplicate therapy was not acted upon by the DON.
Failure to complete a significant change MDS assessment for a resident with malnutrition, dehydration, hypokalemia, dysphagia, and a new esophageal cancer diagnosis. The resident was transferred to the hospital, returned with NPO status and G-tube enteral feeds, and had a BIMS score of 10 indicating moderate cognitive impairment. The MDSC confirmed the assessment should have been completed as a significant change assessment, and the DON stated the facility relied on the RAI manual rather than having an MDS completion policy.
Missing BiPAP Care Plan for a Resident: The facility failed to include a resident’s BiPAP use in the CCP. The resident had COPD, HF, a-fib, anxiety, and tobacco use, and progress notes documented nightly BiPAP use. However, the EHR lacked any BiPAP entry in the orders, MAR, TAR, CCP, or scanned documents. Staff later confirmed the resident used BiPAP and that it should have been listed in the CCP.
Failure to apply ordered left arm splint: A resident with a hx of chronic subdural hemorrhage, TBI, and OA had limited ROM in one upper extremity and an order for a left arm brace at night to prevent contractures. OT documented fitting and caregiver training, but staff notes did not show the brace being applied or refused. Surveyors observed the resident without the splint in bed, with the splint left on a table out of reach, and the resident had contractures in the left hand digits.
Catheter Care and Continued Use Assessment Deficiencies: The facility failed to provide catheter care in a way that prevented cross contamination for one resident with moderate cognitive impairment and total care needs, as an NA used the same wipe in a back-and-forth motion during catheter care while an LPN observed. The facility also failed to assess the continued need for an indwelling catheter for another resident with a history of brain injury and moderate cognitive impairment; the catheter order and urology documentation lacked a diagnosis supporting ongoing use, and the DON stated the facility does not perform this assessment.
Failure to Obtain and Follow BiPAP Orders: A resident with a-fib, anxiety, HF, COPD, and tobacco use had progress notes stating BiPAP use at night, but the EHR lacked any physician's order, care plan entry, or documentation for the BiPAP device. Surveyors observed the BiPAP machine, mask, and tubing at the bedside with the mask left out without a bag or barrier, and the mask seal appeared dirty and oily. An LPN confirmed there were no orders for BiPAP use or cleaning, and the DON stated orders were expected for both use and cleaning.
Failure to act on the pharmacist AMRR findings for a resident with moderate cognitive impairment and a subarachnoid hemorrhage. The resident was receiving multiple psychotropics, including Seroquel, haloperidol, sertraline, trazodone, buspirone, and clonazepam, and the pharmacist identified concerns about diagnosis support, monitoring, PRN trazodone use, duplicate therapy, and insomnia assessment. The EHR showed no evidence the recommendations were addressed, and the DON confirmed the AMRR was not acted upon by staff.
A resident with a subarachnoid hemorrhage and moderate cognitive impairment received Carvedilol despite hold parameters requiring the dose to be withheld when SBP was 120 or less. The MAR showed multiple administrations when SBP was below or at the hold threshold, and the DON confirmed the medication was given when the BP was too low and that the AMRR was not acted upon.
A resident with cirrhosis, muscle weakness, generalized edema, and type 2 DM had a care plan directing two-staff transfers, but an RN progress note inaccurately documented that two staff assisted during a transfer that actually involved only one staff member. During the transfer, the resident struck the left lower leg on the wheelchair and sustained a laceration with heavy bleeding, requiring pressure dressing and hospital transport.
Failure to Use PPE During EBP Cares: Staff failed to use required PPE during EBP cares for two residents. CNAs provided incontinent care without gowns and with inconsistent hand hygiene and glove changes, despite knowing the resident was on EBP. An LPN also performed G-tube care without a gown and without hand hygiene, even though EBP signage was posted and PPE was available.
A resident with multiple chronic conditions and significant pain did not receive several scheduled doses of prescribed medications, including pain management and other treatments, due to delays in pharmacy delivery and the absence of a facility policy for handling unavailable medications. Facility staff confirmed the missed doses and the lack of a system to ensure medication availability.
Two residents with documented medication allergies were prescribed and administered drugs to which they had known or potential allergies. In both cases, alerts for allergies were either overridden or not followed up, and there was no evidence of provider consultation or evaluation. The DON confirmed that the facility lacked a policy for addressing medication allergies.
A resident with multiple chronic conditions and moderate cognitive impairment had conflicting documentation regarding CPR preferences, with both DNR and full code forms present in the record. The facility did not consistently update or confirm the resident's code status in the electronic health record, and staff interviews revealed inconsistent processes for verifying advance directives, leading to a failure to ensure the resident's wishes were clearly documented and communicated.
A resident with multiple medical conditions and a vegetarian diet experienced significant unaddressed weight loss. Staff did not complete a requested re-weigh, failed to assess the weight loss, and did not implement new interventions. Dietary staff were unaware of the resident's nutritional needs, and the resident was observed receiving inadequate meals.
Staff did not follow ordered interventions to prevent pressure ulcers for two residents at risk. One resident was observed in bed without the required Prevalon boot, and another was repeatedly found without heel elevation or use of heel protection boots, despite care plans and practitioner orders. Both staff and residents confirmed these interventions were not consistently implemented.
A resident with multiple diagnoses and a high risk for falls experienced two falls during care due to staff not implementing additional interventions beyond those already in place. The care plan required two staff for bed mobility and proper positioning, but these measures were not consistently followed, and no new interventions were added after the incidents, as confirmed by the DON.
Facility staff did not complete all required background and registry checks for two housekeeping staff members prior to hire, as confirmed by the facility administrator. Facility policy mandates screening for abuse, neglect, exploitation, or misappropriation history before employment, but documentation was missing or incomplete for these employees.
A resident with hypertension, severe sepsis, and diabetes had specific wound care orders for their left foot's second toe, which were not followed by an LPN. Instead of using mild soap and water as ordered, the LPN used saline to cleanse the toe. The LPN acknowledged the deviation from the practitioner's orders during an interview.
The facility failed to maintain a safe and clean environment in nine resident rooms, affecting 14 residents. Observations included unsanitary conditions, structural issues, and non-functional equipment, confirmed by the Maintenance Director and Administrator.
The facility failed to maintain functional ambulation for a resident post-toe amputation surgery, as therapy services were discontinued without a follow-up mobility program, leading to a decline in ambulation. Additionally, another resident did not receive follow-up audiology services for hearing aids, despite a prior recommendation, due to the facility's inaction.
A resident with multiple medical conditions, including post-traumatic seizures, did not receive a complete dose of Dilantin as ordered due to improper medication administration via a gastric tube. The LPN responsible failed to ensure all medication particles were fully dispersed in water, leaving remnants in the cup. This resulted in a significant medication error, as confirmed by the DON.
The facility failed to follow Enhanced Barrier Precautions (EBP) for several residents, including not wearing gowns during high-contact care activities and improper handling of medical equipment. A nursing assistant did not wear a gown while performing catheter care for a resident, and an RN failed to wear a gown while flushing a feeding tube. Additionally, an oxygen nasal cannula was used on a resident after being on the floor, and a stethoscope was not sanitized after use on a resident under EBP.
Failure to Implement Care-Planned Fall Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as being at risk for falls. The facility’s incident and accident policy dated 12-2023 states that staff are to report, investigate, and review accidents or incidents and ensure appropriate and immediate interventions are implemented to prevent recurrences and improve resident care management. Record review showed that the resident had severe cognitive impairment with a BIMS score of 2 and required total assistance with bed mobility, toileting, dressing, personal hygiene, transfers, and bathing. The resident’s comprehensive care plan identified them as at risk for falls related to incontinence, weakness, osteoarthritis of both hips, and a history of falls at home, and documented multiple fall-related interventions, including the use of Dycem on the wheelchair cushion starting on 11-09-2025 following a fall. The facility incident log showed the resident had falls on 11-09-2025 and 03-15-2026, and the care plan included Dycem to the wheelchair cushion as a fall intervention. However, during observations on 04-01-2026 at 5:50 AM and again at 11:15 AM, the resident’s wheelchair did not have Dycem on or underneath the wheelchair cushion, including while the resident was in the therapy gym working with therapy. In an interview later that day, the Assistant Director of Nursing confirmed that there was no Dycem in place on the resident’s wheelchair cushion. This lack of implementation of the care-planned Dycem intervention for a resident with a known fall risk and prior falls constituted the cited deficiency in ensuring the area was free from accident hazards and that adequate supervision and interventions were provided to prevent accidents.
Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
Facility staff failed to implement appropriate pain management interventions during wound care for a resident with a stage four pressure ulcer. The resident, who had diagnoses including depression, osteoarthritis, and chronic pain, was admitted with a significant sacral wound and had a history of almost constant pain, frequently rated as severe. The resident's care plan included both scheduled and as-needed pain medications, specifically acetaminophen and oxycodone, and the facility's policy required staff to anticipate, evaluate, and manage pain in accordance with the resident's assessment and plan of care. On the day of the observed incident, the resident received scheduled acetaminophen and a PRN dose of oxycodone several hours before a negative pressure wound therapy (NPWT) dressing change. During the procedure, the resident exhibited clear signs of pain, including yelling, crying, facial grimacing, and verbalizing distress. Despite these indications, the staff performing the wound care did not pause the procedure to assess the resident's pain or offer additional pain relief. Instead, they continued the treatment while providing only verbal encouragement and distraction techniques. Interviews with staff confirmed that the procedure was known to be painful and that the resident was in significant distress during the dressing change. The Assistant Director of Nursing acknowledged that a PRN dose of oxycodone should have been administered prior to the treatment but was not. The resident later reported experiencing pain at the highest level during the procedure and stated that staff did not offer the option to stop the treatment or address the pain further.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During wound care treatment for one resident, an LPN failed to perform hand hygiene between glove changes as required by facility policy. The facility's hand hygiene policy, revised in October 2022, specifies that staff must use an alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after handling used dressings and contaminated equipment, and after removing gloves. Observation revealed that the LPN washed hands and donned gloves and a gown at the start of the procedure, but subsequently removed gloves and donned new ones multiple times without performing hand hygiene in between. This sequence occurred while providing wound care to the resident's posterior thighs and right posterior heel. The LPN confirmed in an interview that hand hygiene was not performed between glove changes and acknowledged that it should have been done.
Failure to Implement Care Plan Interventions for Transfers and Fall Prevention
Penalty
Summary
The facility failed to implement and follow individualized care plan interventions for two residents, resulting in a significant injury for one and failure to prevent potential falls for another. For one resident with moderate cognitive impairment and a history of repeated falls, the care plan included specific interventions such as pinning the top blankets to the fitted sheet to prevent entanglement and offering bathroom assistance at designated times. Multiple observations revealed that the top covers were not pinned as required, and staff interviews confirmed a lack of awareness regarding this intervention. This failure to implement the care plan intervention was directly observed on several occasions and acknowledged by both nursing assistants and an LPN. For another resident with cirrhosis, muscle weakness, generalized edema, and diabetes, the care plan specified that transfers from bed to wheelchair required two staff members and the use of a slide board or Hoyer lift. Despite this, the resident was transferred by only one staff member, a Certified Medication Aide, without the use of a gait belt or slide board. The aide reported that the resident claimed to transfer independently and instructed the aide on how to position the wheelchair. During the transfer, the resident sustained a laceration to the left lower leg after hitting the wheelchair pedal bracket, requiring hospital transport and stitches. Interviews with staff and the resident confirmed that only one staff member was present during the transfer, contrary to the care plan requirements. Facility policies reviewed indicated that individualized care plans are to be developed and interventions provided according to professional standards and the resident's needs. The failure to follow these care plans and ensure staff awareness of required interventions led to a significant injury and the lack of fall prevention measures for the residents involved. The deficiencies were identified through observation, record review, and staff interviews.
Significant Medication Error With Carvedilol
Penalty
Summary
Resident 47, who had a history of subarachnoid hemorrhage and moderate cognitive impairment, was assessed by the facility as requiring extensive assistance with several activities of daily living and was receiving multiple high-risk medications. The resident had an order for carvedilol 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or pulse was less than 50. On 07-14-2025, the resident’s systolic blood pressure was 99 at 8:00 AM, and carvedilol was administered despite the hold parameter. After the resident returned from a doctor’s appointment and overnight hospital observation for a hypotensive episode, the carvedilol order was changed to 6.25 mg by mouth twice daily with instructions to hold if systolic blood pressure was 120 or less. The MAR showed multiple administrations outside the ordered blood pressure parameters, including when systolic blood pressures were 118, 117, 104, 120, 106, 99, and 101. An LPN confirmed that carvedilol was given outside the blood pressure parameters and stated it was a significant medication error considering the recent hospitalization for hypotension.
Broken Refrigerator Door Seal Caused Inconsistent Food Temperatures
Penalty
Summary
The facility failed to ensure an intact door seal was present on a refrigerator in the kitchen, resulting in inconsistent food temperatures. On 7/25/2025, an observation found the middle refrigerator door in the kitchen had a broken seal and did not close completely. On 7/30/2025 at 6:15 AM, Dietary Aide C confirmed the portable temperature gauge behind the broken seal read 32 degrees, and at 6:45 AM the Dietary Manager observed the same refrigerator and confirmed the temperature behind the broken seal was 41 degrees. The Dietary Manager also stated the refrigerator temperature was not consistent behind the broken seal and could affect the safety of the food in the refrigerator.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Unnecessary Psychotropic Medication Use and Lack of Supporting Documentation
Penalty
Summary
The facility failed to ensure one resident was free from chemical restraints. Resident 47 had a history of subarachnoid hemorrhage and, on the MDS, was assessed as having moderate cognitive impairment with total assistance needed for toileting and moderate assistance needed for bed mobility, toilet transfers, and lower body dressing. The resident was receiving multiple psychotropic medications, including Seroquel 12.5 mg at 5 AM, Seroquel 50 mg at 1 PM, Seroquel 100 mg at bedtime, haloperidol 1 mg twice daily, sertraline 50 mg daily, trazodone 100 mg at bedtime for insomnia, trazodone 100 mg as needed for insomnia, buspirone HCL 5 mg twice daily, and clonazepam 0.5 mg twice daily. Record review showed no indication for sertraline, no stop date or rationale to continue the as-needed trazodone beyond 14 days, and no rationale for the use of more than one antipsychotic medication or more than one antianxiety medication. The pharmacy AMRR dated 07-08-2025 noted the resident was receiving psychotropic medications and requested proper diagnosis, behavior and side effect monitoring, antipsychotic monitoring for tardive dyskinesia, review of duplicate therapy with trazodone and sertraline and with Seroquel and haloperidol, and a sleep assessment for the insomnia medication. The DON confirmed on 07-30-2025 that the AMRR had not been acted upon by facility staff.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to perform a significant change assessment for one resident after a major change in condition. The resident was admitted with unspecified severe protein-calorie malnutrition, dehydration, hypokalemia, and dysphagia, and later had a new diagnosis of malignant neoplasm of the esophagus. The resident was transferred to the hospital and then re-entered the facility, with orders for NPO status and enteral tube feeding via G-tube. Record review showed the resident’s quarterly MDS dated 5/8/2025 included a BIMS score of 10, indicating moderate cognitive impairment. The resident’s MDS record contained an incomplete quarterly and 5-day assessment dated [DATE], and 7/29/2025 was day 15 post significant change in status. The MDS Coordinator confirmed the assessment should have been completed as a significant change in status assessment, and the DON stated the facility did not have a policy on MDS completion and staff were to follow the RAI manual.
Missing BiPAP Care Plan for Resident
Penalty
Summary
The facility failed to develop a respiratory care plan for Resident 65 that included the use of a BiPAP non-invasive ventilator. Resident 65 was admitted on 5/29/2025 with diagnoses including atrial fibrillation, anxiety, heart failure, COPD, and tobacco use. The admission MDS dated 6/2/2025 showed a BIMS score of 13, indicating the resident was cognitively intact, and the MDS did not select non-invasive ventilator use. Despite progress notes documenting that the resident wore a BiPAP at night on multiple dates, the EHR, including physician orders, MAR, TAR, comprehensive care plan, and scanned documents, lacked any entry regarding BiPAP use. Observations on 7/28/2025 and 7/29/2025 showed a BiPAP machine, mask, and tubing at the resident’s bedside. During interview on 7/29/2025, an LPN confirmed the resident used BiPAP and stated the CCP did not identify the BiPAP use and should have.
Failure to Apply Ordered Left Arm Splint
Penalty
Summary
The facility failed to implement interventions to prevent a potential decrease in range of motion for one resident with a history of nontraumatic chronic subdural hemorrhage, traumatic brain injury, and osteoarthritis. The resident’s quarterly MDS identified a limitation in ROM to one upper extremity, and an order was in place to apply a left arm brace at night and remove it in the morning to prevent contractures. OT documented that the resident was fitted with a resting hand splint, could wear it all day without pain or discomfort, and that training was provided to the resident and family/caregivers on the splinting schedule and techniques to decrease pain, contracture, and increase ROM in the left upper extremity. Despite the order, care plan intervention, and OT instructions, the resident’s progress notes from 6/1/2025 through 7/30/2025 contained no documentation about the brace, including whether it was refused or removed. During observation, the resident was seen with contractures to the fourth and fifth digits of the left hand, with those digits tucked close to the palm while the remaining digits were freely movable. On two separate early-morning observations, the resident was lying in bed without the splint applied, and the splint was found on a table near the door and out of the resident’s reach. The resident stated the splint was supposed to be applied to the left arm and reported that the brace had never been applied, and an NA confirmed the brace was not in place and said it was the first date a brace had been observed in the room.
Catheter Care and Continued Use Assessment Deficiencies
Penalty
Summary
The facility failed to perform catheter care in a manner to prevent cross contamination for Resident 9. Resident 9’s MDS dated 06-16-2025 showed moderate cognitive impairment with a BIMS score of 12, required total assistance with hygiene, dressing, toileting, bathing, bed mobility, and transfers, and had a urinary catheter. An order dated 06-12-2025 directed indwelling catheter care every shift. During observation on 07-30-2025 at 9:40 AM, an NA provided catheter care by wiping around the insertion site with a disposable wipe, discarding it, then using another wipe to clean from the insertion site down the tubing and back toward the resident without folding or changing the wipe. An LPN present during the observation confirmed the back-and-forth motion should not have been done. The facility policy required cleaning the catheter in a downward motion from the insertion point and using a fresh disposable wipe for one cleansing motion. The facility also failed to assess an indwelling catheter for continued use for Resident 7. Resident 7 was admitted on 1/24/2025 and had diagnoses including nontraumatic chronic subdural hemorrhage, traumatic brain injury, and osteoarthritis. The quarterly MDS dated 4/19/2025 showed a BIMS score of 12 and identified an indwelling urinary catheter. The order summary and TAR printed 7/30/2025 showed an order dated 4/16/2025 for an indwelling catheter #16 Fr with a 10 mL balloon to a closed drainage system, with the diagnosis supporting catheter use left blank. A urology visit form dated 5/8/2025 ordered continuation of the catheter and catheter changes every four weeks, but also lacked a diagnosis for continued use. The DON stated on 7/31/2025 that the facility does not perform an assessment for continued use of indwelling urinary catheters and does not have a policy for that assessment.
Failure to Obtain and Follow BiPAP Orders
Penalty
Summary
The facility failed to obtain and implement physician's orders for the use of a CPAP/BiPAP non-invasive ventilator for one resident. The resident was admitted with diagnoses including a-fib, anxiety, heart failure, COPD, and tobacco use, and had a BIMS score of 13 on the admission MDS, indicating cognitive intactness. Although progress notes documented that the resident wore a BiPAP at night on multiple dates, the resident's EHR, including physician's orders, MAR, TAR, comprehensive care plan, and scanned documents, contained no entry regarding BiPAP use. Surveyors observed a BiPAP machine, mask, and tubing at the resident's bedside on two occasions. The mask was left on the bedside table without a bag or barrier, and the seal appeared shiny and oily with debris inside the facemask. An LPN confirmed there was no bag available for the mask, that the mask and seal appeared dirty, and that there were no orders for the BiPAP machine or for cleaning the equipment. The DON also confirmed the expectation that orders should exist for the use and cleaning of the BiPAP machine.
Failure to Act on Pharmacist Medication Regimen Review Findings
Penalty
Summary
The facility failed to notify the practitioner of irregularities identified in the admission medication regimen review for Resident 47. Resident 47 was admitted with a subarachnoid hemorrhage and had moderate cognitive impairment, requiring total assistance with toileting and moderate assistance with bed mobility, toilet transfers, and lower body dressing. The resident was receiving multiple high-risk medications, including antipsychotics, antidepressants, antianxiety medications, anticoagulants, diuretics, and opioids. The MAR showed orders for Seroquel 12.5 mg at 5 AM, Seroquel 50 mg at 1 PM, Seroquel 100 mg at bedtime, haloperidol 1 mg twice daily, sertraline 50 mg daily, trazodone 100 mg at bedtime, trazodone 100 mg as needed for insomnia without a stop date, buspirone HCL 5 mg twice daily, and clonazepam 0.5 mg twice daily. The Core LTC Pharmacy admission medication regimen review identified multiple irregularities, including the need for a proper diagnosis to support psychotropic use, behavior and side effect monitoring for clonazepam, buspirone HCL, haloperidol, trazodone, sertraline, and Seroquel, antipsychotic monitoring or monitoring for tardive dyskinesia, review of PRN trazodone use beyond 14 days with rationale and duration, review of duplicate therapy with trazodone and sertraline and with Seroquel and haloperidol, and consideration of a 3-day sleep study and sleep assessment for insomnia medication use. The EHR showed no indication that these recommendations were acted upon, and the DON confirmed the AMRR was not acted upon by facility staff.
Unnecessary Medication Administration With Low Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure Resident 47’s drug regimen was free from unnecessary drugs when Carvedilol was administered despite blood pressure parameters that required the medication to be held if systolic blood pressure was 120 or less. Resident 47 was admitted with a subarachnoid hemorrhage, had moderate cognitive impairment, and required assistance with toileting, bed mobility, toilet transfers, lower body dressing, upper body dressing, and hygiene. The resident’s medication profile included multiple high-risk medications, including antipsychotics, antianxiety medications, antidepressants, anticoagulants, diuretics, and opioids. The Core LTC Pharmacy admission Medication Regimen Review recommended routine blood pressure and pulse monitoring due to Carvedilol. Review of the July 2025 MAR showed Carvedilol 6.25 mg twice daily was administered on multiple occasions when the resident’s systolic blood pressure was below or at the hold parameter, including readings of 118, 117, 104, 120, 106, 99, and 101. The DON confirmed that Carvedilol was given when the systolic blood pressure was too low and should not have been, and also confirmed the AMRR was not acted upon by the facility.
Inaccurate Transfer Documentation in Resident Record
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident. The resident was admitted with diagnoses including cirrhosis of the liver, muscle weakness, generalized edema, and type 2 diabetes mellitus. The admission MDS dated 5/11/2025 showed a BIMS score of 15, indicating the resident was cognitively intact, and also indicated the resident was dependent on staff for assistance to transfer from bed to wheelchair. The comprehensive care plan in place as of 5/19/2025 directed that the resident be transferred with two staff members using a slide board or with a Hoyer lift and two staff members. A progress note written by an RN stated that on 7/6/2025 the resident was being transferred from bed to wheelchair with two assist when the resident bumped the left lower leg on the wheelchair leg where the pedals attach, causing a laceration with large bleeding and requiring pressure dressing, 911 notification, and transport to the hospital. However, interviews with the resident, the assigned LPN, and the CMA involved in the transfer established that only one staff member was present during the transfer. The DON and ADM also confirmed that the progress note inaccurately stated the resident was assisted by two staff members.
Failure to Use PPE During EBP Cares
Penalty
Summary
Facility staff failed to use PPE, including gowns, gloves, masks, and face shields, during cares for two residents who were identified as requiring Enhanced Barrier Precautions (EBP). For one resident, a sign on the door indicated EBP and the required PPE, but CNA-A and CNA-B entered the room and performed care without gowns. During the observation, CNA-B turned the resident and performed standard perineal care, removed gloves, used ABHR, put on a new pair of gloves, completed the care, and then continued repositioning and covering the resident without changing gloves or performing hand hygiene. CNA-A and CNA-B both stated they knew the resident was on EBP, and later CNA-C was observed providing incontinent care to the same resident without a gown; CNA-C acknowledged the resident was to have EBP precautions with PPE worn during cares. For the second resident, a sign on the door also indicated EBP precautions. An LPN entered the room, marked the piston syringe without hand hygiene, donned gloves, and continued G-tube feeding without a gown. The DON later verified the resident's PPE was available in the room area, and the LPN stated that no gown was worn and hand hygiene was not performed during the G-tube cares. The facility's infection control policy stated that EBP expands PPE use and includes gown and glove use during high-contact resident care activities.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for a resident with multiple chronic conditions, including pneumonia, chronic inflammatory demyelinating polyneuritis, neuropathy, chronic pain, and osteoarthritis. Record reviews showed that the resident was admitted with significant pain and required scheduled and PRN pain medications, among other treatments. Despite these needs, the Medication Administration Records (MARs) revealed multiple instances where prescribed medications, including buprenorphine for pain, fish oil, polyethylene glycol, lubiprostone, Bactrim DS, and Metamucil, were not administered on several dates across multiple months. Notably, there were 11 consecutive missed doses of buprenorphine and several other missed doses of various medications. Interviews with facility staff, including the Unit Manager and DON, confirmed that the resident did not receive all scheduled medications on the identified dates. The DON further confirmed that some missed doses were due to waiting for pharmacy delivery, and acknowledged that the facility did not have a policy regarding unavailable medications. The lack of a system or policy to ensure timely medication availability and administration directly contributed to the resident not receiving necessary medications as ordered.
Failure to Evaluate and Address Medication Allergies
Penalty
Summary
The facility failed to properly evaluate and address medication allergies for two residents. For one resident with a history of respiratory failure, COPD, pneumonia, and chronic inflammatory demyelinating polyneuritis, records showed an allergy to Bactrim with a previously observed mild adverse reaction resulting in increased serum creatinine. Despite this documented allergy, the resident was prescribed and administered Bactrim DS on multiple occasions, and the provider overrode the allergy alert without documented consultation or follow-up in the electronic health record. The Director of Nursing confirmed that the allergy was not addressed at the time of order entry and that there was no facility policy regarding medication allergies. Another resident with acute respiratory failure and documented allergies to aspirin, codeine, penicillin, and zaleplon was prescribed Diclofenac sodium gel, a nonsteroidal anti-inflammatory drug. An alert for a possible drug allergy was generated in the electronic medical record, but there was no evidence of evaluation or follow-up regarding the potential allergy to Diclofenac. The Director of Nursing confirmed that no follow-up was completed and that the facility lacked a policy for addressing potential drug allergies when alerts were triggered.
Failure to Ensure Accurate and Updated Advance Directive Documentation for Code Status
Penalty
Summary
The facility failed to ensure that a signed Advance Directive Code Status Form was properly completed and updated to confirm a resident's directives for Cardiopulmonary Resuscitation (CPR). The resident in question had multiple diagnoses, including Type 2 Diabetes Mellitus, congestive heart failure, and chronic obstructive pulmonary disease, and was assessed as having moderate cognitive impairment. Upon admission, the resident's care plan indicated full code status, and interventions required quarterly review of code status during care plan conferences. However, there were inconsistencies in the documentation of the resident's code status. The medical record contained both a form signed by the resident's representative indicating Do Not Resuscitate (DNR) and a form signed by the resident indicating full code. Hospital discharge orders also indicated DNR status, but the facility's electronic health record did not reflect an updated Advance Directive Code Status form confirming the DNR status. Multiple orders and practitioner notes alternated between DNR and full code, and the process for updating and confirming code status was not consistently followed as outlined in facility policy. Interviews with facility staff revealed that code status was typically determined at admission and entered into the medical record, but there was no consistent process for verifying or updating this information, especially on readmission or during care plan reviews. The facility's policy required that advance directives be reviewed, validated, and communicated to the care team, but this was not consistently documented or implemented for the resident. As a result, there was a failure to ensure the resident's wishes regarding CPR were clearly documented and communicated prior to an emergency event.
Failure to Address Significant Weight Loss and Dietary Needs
Penalty
Summary
Facility staff failed to evaluate and implement interventions to prevent significant weight loss for a resident with multiple medical conditions, including hyperlipidemia, hypokalemia, muscle weakness, dysphagia, and protein calorie malnutrition. The resident, who followed a lacto-ovo-vegetarian diet, experienced a weight loss of 20.4 lbs (11.11%) over 90 days. Despite this significant weight loss, there was no documented assessment or follow-up by the registered dietitian (RD) or other staff after a re-weigh was requested. The care plan did not include specific interventions to address the resident's vegetarian diet or food preferences, and the dietary staff were unaware of how to meet the resident's nutritional needs. Observations showed the resident was served inadequate meals, such as a salad without protein or dressing and a small drink, which the resident expressed dissatisfaction with. Interviews with the dietary supervisor and RD revealed a lack of awareness regarding the resident's significant weight loss and dietary needs. The director of nursing confirmed that the re-weigh requested by the RD was not completed and that no new interventions were implemented despite the resident's ongoing weight loss.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Facility staff failed to implement ordered interventions to prevent pressure ulcer development for two residents identified as at risk. For one resident with multiple diagnoses including malnutrition, muscle weakness, and impaired cognition, the care plan and practitioner orders required the use of a Prevalon boot on the left foot while in bed. Observations on multiple occasions revealed the resident was in bed without the Prevalon boot, and the device was found on the chest of drawers instead of being used as ordered. A nursing assistant confirmed the boot was not in place during an interview. For another resident with diagnoses including schizoaffective disorder, depression, and obesity, the care plan and practitioner orders required the resident's heels to be elevated while in bed to prevent skin breakdown. Multiple observations showed the resident in bed without their feet elevated, and heel protection boots were found on top of the dresser rather than in use. The resident reported that staff did not elevate their feet or use the heel boots, and a nursing assistant confirmed the resident's feet were not elevated during an interview.
Failure to Implement Additional Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement additional interventions to prevent falls for a resident who was identified as being at risk for falls. The resident, who had diagnoses including schizoaffective disorder, depression, obesity, and required assistance with personal care, was assessed as cognitively intact and dependent on staff for transfers and bed mobility. The resident's care plan included interventions such as keeping the bed in the lowest position, ensuring appropriate footwear, and requiring two staff members for bed mobility. Despite these interventions, the resident experienced two falls during care provision, one in which the resident's legs hung over the bed and they were lowered to the floor, and another where the resident slid off the bed. After the first fall, the only intervention added was to ensure the resident was positioned in the middle of the bed. Following the second fall, the intervention was updated to require two staff for bed mobility. The Director of Nursing confirmed that two staff should have been assisting during both incidents and that the resident should have been positioned in the middle of the bed, but no new interventions were implemented after these falls.
Failure to Complete Required Employee Background and Registry Checks
Penalty
Summary
Facility staff failed to complete required background and registry checks for two of five employee files reviewed. Specifically, one housekeeping staff member was hired without documentation of a Nurse Aide registry check, and another housekeeping staff member was hired with only Adult/Child Protection Services background checks completed, lacking other required screenings. The facility administrator confirmed during interview that the necessary background checks had not been completed for these two staff members. Facility policy requires screening of potential employees for history of abuse, neglect, exploitation, or misappropriation prior to hire, including documentation from licensing or registration boards and other registries.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility staff failed to follow the practitioner's orders for wound care for a resident with a history of hypertension, severe sepsis with septic shock, and diabetes. The resident was admitted with a specific treatment order for the left foot's second toe, which included cleaning with mild soap and water, applying betadine, and covering with a non-adherent dressing. However, during an observation, an LPN was seen using saline instead of mild soap and water to cleanse the toe, which was not in accordance with the practitioner's orders. The LPN confirmed during an interview that the correct procedure was not followed.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed in nine rooms on the second-floor north hallway. These deficiencies included unsanitary conditions such as a dark brown smeared substance resembling bowel movement on a toilet riser and seat, and a ventilation cover in a resident bathroom covered with a gray fuzzy substance resembling dust. Structural issues were also noted, such as an open and exposed floor radiator cover, missing and damaged drawer components in dressers, gouged and broken floor tiles, and protruding sharp edges from vent covers and baseboards. Additional observations included a continuously running shared toilet, a non-functional bathroom vent, and various holes and cracks in the drywall. The environmental tour conducted with the Maintenance Director and Administrator confirmed these issues, which had the potential to affect all 14 residents utilizing the affected rooms. The facility census at the time was 58, indicating that a significant portion of the resident population was impacted by these environmental deficiencies.
Failure to Maintain Ambulation and Follow Up on Audiology Appointment
Penalty
Summary
The facility staff failed to maintain functional ambulation for a resident who had undergone toe amputation surgery earlier in the year. Despite being cognitively intact and having a history of high blood pressure, peripheral vascular disease, end-stage renal disease, diabetes mellitus type 2, and heart failure, the resident reported not receiving therapy and feeling weaker post-surgery. The resident's last recorded physical and occupational therapy session was in mid-February, and there was no subsequent functional mobility program implemented. The Director of Rehabilitation confirmed the resident had not received therapy services since then, leading to a decline in the resident's ability to ambulate. Additionally, the facility staff did not follow up on an audiology appointment for another resident who was supposed to be fitted for hearing aids. This resident, also cognitively intact, had a history of diabetes mellitus, Parkinson's disease, heart failure, and high blood pressure. The resident had an audiology appointment in March of the previous year, with a recommendation to be fitted for hearing aids within 1-3 months. However, there were no further audiology appointments recorded, and the Director of Nursing confirmed the facility did not assist the resident in obtaining the hearing aids.
Incomplete Medication Administration via G-Tube
Penalty
Summary
The facility failed to ensure that a resident received a complete dose of seizure medication as ordered, resulting in a significant medication error. Resident 34, who was admitted with multiple diagnoses including cerebral infarction, hydrocephalus, and post-traumatic seizures, was dependent on staff for all activities of daily living and received all nutrition and medications through a gastric tube. The resident had a physician's order for Dilantin 100 mg every 8 hours via the g-tube. During an observation, it was noted that the LPN responsible for administering the medication crushed the Dilantin tablet and mixed it with water, but visible remnants of the medication remained in the cup after administration, indicating that the full dose was not delivered to the resident. The facility's policy for medication administration via feeding tube requires that tablets be crushed to a fine consistency and fully dispersed in water before administration. However, the LPN did not ensure that all particles were in solution, leading to the incomplete administration of the medication. The Director of Nursing confirmed that the resident did not receive the complete dose of Dilantin, which constituted a significant medication error. This incident highlights a failure in adhering to the facility's medication administration procedures, resulting in a deficiency in the care provided to Resident 34.
Infection Control Deficiencies in EBP and Equipment Handling
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during care activities for several residents, as observed by surveyors. For Resident 215, nursing assistants NA-D and NA-E did not wear gowns while performing catheter care, despite the EBP sign on the resident's door indicating the requirement for gown and glove use. Both the nursing assistants and the Director of Nursing (DON) acknowledged the oversight. Similarly, for Resident 53, Registered Nurse (RN) F did not wear a gown while flushing the resident's feeding tube, even though the care plan and EBP signage specified the need for gown and glove use due to the resident's high risk of infection from a multidrug-resistant organism (MDRO). In another instance, the facility failed to maintain proper infection control practices concerning oxygen equipment. An oxygen nasal cannula for Resident 3 was observed lying on the floor, and later, a nursing assistant placed the same cannula into the resident's nose without cleaning it. The facility's policy requires that any nasal cannula that comes into contact with the floor should be replaced, a fact confirmed by both the nursing assistant and the DON. Additionally, the facility did not ensure proper sanitization of medical equipment used on residents under EBP. LPN H used a stethoscope on Resident 34, who was under EBP, and failed to sanitize it before leaving the room. The stethoscope was then carried to another area of the facility, potentially risking cross-contamination. The DON confirmed that the stethoscope should have been cleaned before being taken out of the resident's room.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 402 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) |
|---|---|---|---|---|
| Emerald Nursing & Rehab Omaha | 1.2 mi | ★★★★★ | 31 | 0 |
| Douglas County Health Center | 2.5 mi | ★★★★★ | 2 | 0 |
| Emerald Nursing & Rehabilitation Mercy | 2.8 mi | ★★★★★ | 22 | 0 |
| The Cypress At Midtown | 2.9 mi | ★★★★★ | 11 | 0 |
| St. Joseph Villa Nursing Center | 3.7 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.