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 Quality Living, Inc. during CMS and state inspections, most recent first.
Facility staff failed to follow hand hygiene protocols during meal preparation, as observed with a dietary assistant who did not wash hands between glove changes. Additionally, staff with full beards did not wear beard restraints while preparing food, violating the facility's hygiene policy. These deficiencies affected residents in the Summit area and House 4.
The facility failed to follow proper infection control and medication handling procedures. An LPN did not perform hand hygiene between glove changes during wound care for a resident with multiple sclerosis. Additionally, a urinary drainage bag for another resident was found on the floor, and medications were handled without gloves for two residents. These actions were confirmed by staff and the DON.
A resident with multiple sclerosis and severe cognitive impairment developed a stage 3 pressure ulcer on the coccyx, but the facility failed to notify the medical provider of this significant change. The facility's policy required prompt reporting of such changes, but this was not followed, as confirmed by the DON.
A facility failed to re-evaluate a protective device as a potential restraint for a resident with severe cognitive impairment. The resident was observed with a trunk restraint, and the facility did not update or re-evaluate the interventions since 2022. Despite a physician's order for a floor alarm, seat belt, and video monitoring, these interventions were not fully implemented, as confirmed by observations and an interview with the administrator.
A resident with intact cognitive function developed an abrasion on the right heel, which was not properly documented or treated by the facility. The nurse failed to record the wound's condition when it was found, and treatment orders for Mepilex dressing and triple antibiotic ointment were not transcribed to the MAR/TAR, leading to a lack of treatment monitoring.
A resident with multiple sclerosis and severe cognitive impairment developed a stage 3 pressure ulcer due to the facility's failure to conduct weekly skin evaluations and adhere to treatment orders. The LPN applied incorrect treatment, and the DON confirmed the lack of proper documentation and adherence to orders, leading to a decline in the resident's skin condition.
A resident dependent on staff for all care and movements did not receive adequate Range of Motion (ROM) exercises as per their care plan. The resident's care plan required passive ROM exercises three times a week for the upper extremities and neck, but documentation showed inconsistent performance of these exercises. ROM for the lower extremities was not included in the care plan, and therapy staff failed to document the exercises. The facility's policy emphasizes the importance of ROM exercises, but the care plan was not updated, and documentation was lacking, leading to a deficiency in care.
A facility failed to evaluate a G-tube for drainage or migration before administering tube feeding to a resident with aphasia, quadriplegia, and traumatic brain disorder. Despite the resident's abdominal pain, an LPN did not inspect the G-tube site, contrary to facility policy. The resident's care plan required nutrition via G-tube, and the facility's policy mandated physician notification if drainage or migration was suspected.
A facility failed to identify and monitor specific target behaviors for a resident's as-needed antianxiety medications. Despite the resident having intact cognition and a diagnosis of anxiety disorder, the Comprehensive Care Plan lacked specific target behaviors for the use of hydroxyzine and clonazepam. The facility's policy required monitoring of psychotropic medication use, but this was not adhered to, as confirmed by a Registered Nurse Coordinator.
The facility's QAPIP failed to identify and address deficiencies found during an annual survey, including issues with physician notification, skin and pressure ulcer treatments, range of motion services, tube feeding, anxiety medication use, and hand hygiene. Staff interviews revealed a lack of awareness of the QAPIP, and the DON confirmed the absence of effective Performance Improvement Programs, affecting all 95 residents.
Failure in Hand Hygiene and Beard Restraint Compliance
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols during meal preparation, as observed on multiple occasions. Dietary Assistant (DA)-R was seen putting on gloves without washing hands, handling various food items, and changing gloves without performing hand hygiene. This occurred during the preparation of pureed fish and corn, where DA-R used the same gloves to handle different food items and equipment, and placed soiled gloves on a spice table before donning a new pair without washing hands. An interview with DA-R confirmed the failure to wash hands after glove removal, which is against the facility's hand hygiene policy. Additionally, the facility staff did not comply with the policy requiring beard restraints in the food preparation area. Observations revealed that House Supervisor (HS)-H and Physical Therapist (PT)-I, both with full beards, prepared food without wearing beard nets. This was confirmed by interviews with the facility Compliance Coordinator and the House Coordinator for House 4, where 10 residents were affected by the food prepared in the house kitchen. The lack of beard restraints during food preparation is a violation of the facility's hygiene policy, which mandates hair and beard restraints to prevent contamination.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care, urinary drainage bag handling, and medication administration. For Resident 39, who has multiple sclerosis and severe cognitive impairment, an LPN did not perform hand hygiene between glove changes while providing wound care. This was confirmed by both the LPN and the Director of Nursing (DON). Additionally, a Medication Aid (MA) administered medications to Resident 39 without wearing gloves, directly handling omeprazole and potassium chloride capsules, which was also acknowledged as improper by the MA and the DON. For Resident 47, who also has severe cognitive impairment and requires total assistance, the external urinary catheter drainage bag was observed lying on the floor on two separate occasions. This was confirmed by a Nurse Aid (NA) and a Campus Leader (CL), who acknowledged that the bag should have been placed in a designated basin to prevent infection. Furthermore, another incident involved an LPN opening a Dantrolene capsule without gloves for Resident 5, which was confirmed as a breach of protocol by both the LPN and the DON.
Failure to Notify Physician of Resident's Pressure Ulcer
Penalty
Summary
The facility failed to notify the medical practitioner of a change in wound condition for a resident with multiple sclerosis. The resident, who had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 4, required extensive assistance with daily activities and had a pressure ulcer. On a specific date, a stage 3 pressure ulcer was identified on the resident's coccyx, but there was no documentation indicating that the physician had been notified of this significant change in the resident's condition. An interview with the Director of Nursing confirmed that the medical provider was not informed about the stage 3 pressure ulcer. The facility's policy, dated December 2023, emphasized the importance of notifying medical providers of significant changes in a resident's condition to ensure effective medical care. However, in this instance, the facility did not adhere to its policy, resulting in a failure to communicate a critical change in the resident's health status to the medical provider.
Failure to Re-evaluate Protective Device as Potential Restraint
Penalty
Summary
The facility failed to re-evaluate a protective device as a potential restraint for a resident with severe cognitive impairment. The resident, identified as having a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment, was observed with a trunk restraint while in a chair or out of bed. The resident's Minimum Data Set (MDS) dated February 11th, 2025, confirmed the use of a trunk restraint. A Physical/Occupational Therapy Evaluation and Consent for Use of Protective Devices dated April 8th, 2021, indicated the use of a rear buckling lap belt due to falls and decreased awareness. However, the facility did not update or re-evaluate the interventions since 2022, as confirmed by an interview with the facility's administrator. The physician's order for the resident's protective device, dated March 16th, 2021, included interventions such as a floor alarm, seat belt, and video monitoring due to the resident's diffuse weakness, poor balance, and unawareness of deficits. Observations on February 25th and March 3rd, 2025, revealed the resident had a seatbelt across their lap, but no transfer pole or video monitoring was in place as ordered. The facility's policy on restraints/protective devices requires a medical provider order for any type of restraint or protective device, but the facility failed to adhere to this policy by not updating or re-evaluating the interventions for the resident.
Failure to Document and Administer Treatment for Heel Abrasion
Penalty
Summary
The facility failed to properly evaluate and document the condition of an abrasion on a resident's right heel when it was initially discovered. The resident, who had intact cognitive function and was independent in walking and transfers, developed a small abrasion on the right heel due to rubbing against the toenail of the left foot while sleeping. Despite the resident's report that staff checked the area daily, there was no documentation of the wound's condition until a late entry note was made during the annual survey. The nurse who initially found the abrasion did not document any information, measurements, or the condition of the wound at the time it was discovered. Additionally, the facility did not ensure that treatment orders for the resident's heel abrasion were transcribed to the Medication Administration Record (MAR) or Treatment Administration Record (TAR). Orders for Mepilex dressing and triple antibiotic ointment were not recorded, resulting in a lack of monitoring to confirm that the treatments were administered. The Residential Nurse Coordinator confirmed these omissions and acknowledged that the nurse should have documented the wound assessment and condition when it was first identified.
Failure to Monitor and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly evaluate, implement treatment orders, and monitor a pressure ulcer for a resident with multiple sclerosis and severe cognitive impairment. The resident required extensive assistance with daily activities and had a pressure ulcer. The facility's care plan included following physician orders for treatment, monitoring, and documenting the condition of skin injuries. However, the facility did not conduct weekly skin and wound evaluations as ordered, resulting in a decline in the resident's condition, including the development of a stage 3 pressure ulcer on the coccyx. Additionally, the facility did not adhere to treatment orders for the resident's buttocks wounds. Observations revealed that the LPN applied calmoseptine cream to both wounds, contrary to the order to crust the buttocks with calmoseptine and stoma powder. The DON confirmed that the observed treatment was not in line with the current orders, and there were no treatment orders documented for the right buttock. This lack of adherence to treatment protocols contributed to the resident's deteriorating skin condition.
Inadequate Range of Motion Exercises for a Resident
Penalty
Summary
The facility staff failed to provide adequate Range of Motion (ROM) exercises to maintain mobility for a resident, identified as Resident 29, who was dependent on staff for all care and movements. The resident's Minimum Data Set (MDS) indicated impairments on both sides of the body involving upper and lower extremities, and the care plan specified that the resident was to receive passive ROM exercises three times a week for the bilateral upper extremities and neck. However, documentation revealed that ROM exercises were inconsistently performed, with significant gaps in the frequency of exercises provided. For instance, ROM to the neck was performed only six times out of twelve potential visits in December 2024, three times in January 2025, and five times in February 2025. Similarly, ROM for the upper extremities was performed only four times in December 2024, once in January 2025, and once in February 2025. ROM for the lower extremities was performed only twice in December 2024 and not at all in January and February 2025. The facility's policy on exercise and ROM, dated April 25, 2012, outlines the importance of these exercises in maintaining joint mobility and preventing complications such as contractures and muscle atrophy. Despite this, the care plan was not updated to include lower extremities, and therapy staff failed to document the ROM exercises. An interview with the Administrator confirmed these deficiencies, highlighting a lack of adherence to the care plan and documentation requirements. This failure to provide consistent and documented ROM exercises represents a deficiency in the care provided to Resident 29, potentially impacting their mobility and overall health status.
Failure to Evaluate G-Tube Before Feeding
Penalty
Summary
The facility failed to evaluate the gastrostomy tube (G-tube) for drainage or migration prior to administering tube feeding for one resident. The resident, who had diagnoses of aphasia, quadriplegia, and traumatic brain disorder, required tube feeding for nutrition and hydration. The facility's policy stated that if drainage or migration was suspected, the physician should be notified for further assessment. However, during an observation, a Licensed Practical Nurse (LPN) administered tube feeding without checking the G-tube site for drainage or migration, contrary to the facility's policy. The resident's Minimum Data Set (MDS) indicated that the resident was rarely or never understood, and the Comprehensive Care Plan (CCP) highlighted the need for nutrition and hydration via G-tube. Despite the resident experiencing abdominal pain the night before, the LPN did not inspect the G-tube site before proceeding with the feeding. An interview with the LPN revealed that tube placement checks were only performed when ordered by a physician, and a Registered Nurse Coordinator confirmed that without direct inspection, leakage or migration could not be detected.
Failure to Monitor Specific Target Behaviors for Antianxiety Medication Use
Penalty
Summary
The facility failed to identify and monitor specific target behaviors for the continued use of as-needed antianxiety medications for a resident. The interdisciplinary team was responsible for ensuring appropriate use, evaluation, and monitoring of psychotropic medications, as per the facility's undated policy. However, a review of the resident's Comprehensive Care Plan (CCP) revealed no evidence of specific target behaviors, despite the resident receiving antianxiety, antidepressant, and hypnotic medications. The resident had a diagnosis of anxiety disorder and was prescribed hydroxyzine and clonazepam for anxiety. The Minimum Data Set (MDS) indicated that the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14. The Medication Administration Record (MAR) included an order for behavior monitoring for anxiety to be documented every shift, but the lack of specific target behaviors was confirmed during an interview with the Registered Nurse Coordinator. This deficiency highlights the facility's failure to adhere to its policy on monitoring psychotropic medication use, which is crucial for ensuring the appropriate and safe use of such medications.
Ineffective QAPIP and Unaddressed Deficiencies
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement Program (QAPIP) effectively identified and addressed concerns related to deficient practices identified during the annual survey. These deficiencies included issues such as failure to notify physicians of changes in resident conditions, inadequate skin and pressure ulcer treatments, insufficient services for range of motion, improper tube feeding services, inappropriate use of anxiety medication, and repeated issues with hand washing and gloving during care and medication pass. The facility also did not maintain correction for a repeat deficiency related to hand hygiene from a previous survey. Interviews with several staff members, including nurse aides and a registered nurse, revealed a lack of awareness of the QAPIP within the facility. Additionally, the Director of Nursing and the Compliance Coordinator confirmed that the facility did not have Performance Improvement Programs in place to address the new deficiencies identified during the survey. They acknowledged that the QAPIP process had not been effective in identifying and addressing current issues, which had the potential to affect all 95 residents residing in the facility.
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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 Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Omaha | 0.7 mi | ★★★★★ | 24 | 0 |
| Keystone Ridge Post Acute Nursing And Rehabilitati | 1.2 mi | ★★★★★ | 2 | 0 |
| Maple Crest Health Center | 2.2 mi | ★★★★★ | 25 | 0 |
| Emerald Nursing & Rehab Legacy Pointe Llc | 3.2 mi | ★★★★★ | 2 | 0 |
| Florence Home | 3.3 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.