Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Sarah Ann Hester Memorial Home during CMS and state inspections, most recent first.
A facility failed to submit a thorough investigation to the state agency after a resident experienced an unwitnessed fall while attempting a self-transfer, later being found to have a left femoral neck fracture, low Hgb, low BP, and pneumonia. The resident had multiple diagnoses, including dementia, COPD, ataxic gait, osteoarthritis, and weakness, was care-planned for wheelchair use at all times, and had a history of multiple falls and recent illness with fever and low O2 saturation. Although the DON identified weakness and low Hgb as possible causes of the fall, the investigation report submitted by the ADM did not include weakness as a cause and omitted key information such as the resident’s diagnoses, documented symptoms, BP findings, and whether medications had been reviewed.
The facility failed to keep food items within date, maintain resident refrigerators, ensure sanitizer was at the required ppm, and prevent bare-hand contact with ready-to-eat food. Surveyors found expired Caesar dressing, Jello, and maple syrup packets, an undated container of tomatoes, incorrect sanitizer strength at the 3-compartment sink, no routine food temp checks during meal service, and a CDM preparing a chicken salad sandwich with bare hands. Staff also confirmed resident room refrigerator temps were not being logged or cleaned as required.
A facility failed to maintain the dignity of 3 residents by leaving urinary catheter bags visible to others while the residents were in their rooms. One resident’s catheter bag was hanging from a walker and visible from the hallway, another resident with a catheter for wound healing was repeatedly observed with the bag hanging from the bedframe and visible from the hallway, and a third resident’s catheter bag was repeatedly seen uncovered, visible from the hallway, and touching the floor. The DON confirmed one resident’s bag should have been concealed in a dignity bag.
A resident was discharged to a family member's home, but the facility did not complete a recapitulation of stay and did not notify the Ombudsman of the discharge. The DON confirmed the recapitulation was not completed, and the SSD confirmed the Ombudsman was only notified for emergency transfers, not other discharge types.
Failure to Complete Required Pre-Employment Screening: The facility did not complete a criminal background check for a Dietary Aide and did not complete a nurse aide registry check or sex offender registry check for a Housekeeper before they began work. The Administrator confirmed the missing checks during interview, and record review showed no documentation that the required screenings were completed.
Two residents who experienced falls did not have their care plans updated with new fall prevention interventions as required by facility policy. Despite staff and MDS Coordinator confirming that care plans should be revised promptly after incidents, no new interventions were documented for these residents, both of whom had cognitive deficits and were at high risk for falls.
The facility failed to sanitize food preparation surfaces after handling raw chicken, affecting all residents. Cook-I was observed transferring raw chicken, with liquid dripping onto the table, and later mixed a sanitation solution incorrectly. The table was used during meal service without proper cleaning, as confirmed by the Dietary Manager.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing specific needs. One resident's plan lacked interventions for behaviors, another's omitted critical aspects like restraint use and guardian changes, and a third's did not reflect antibiotic use accurately. These issues were confirmed by staff, indicating a lack of individualized care planning.
The facility failed to ensure proper antibiotic stewardship for three residents, as antibiotics were prescribed without specified stop dates, contrary to facility policy and CDC guidelines. Interviews confirmed the absence of stop dates, leading to unnecessary antibiotic exposure.
The facility failed to document clinical rationale for declining gradual dose reductions (GDRs) of psychotropic medications for several residents. Despite federal regulations requiring such documentation, physicians marked that no changes were needed without providing written justification. This affected residents with varying cognitive and behavioral conditions, who were on multiple psychotropic medications. Interviews confirmed the absence of required documentation, indicating a systemic issue in medication management.
The facility failed to ensure that three nurse aides completed the required 12 hours of ongoing training annually, as mandated by policy. Record reviews revealed duplicate courses in the training records, resulting in NA-F completing only 3.5 hours, NA-E 9.25 hours, and NA-D 10 hours of training. The DON confirmed the discrepancies and acknowledged the potential impact on all 30 residents.
A facility failed to notify a resident's guardian about the use of a wheelchair lap tray as a restraint, its purpose, duration, and alternatives, despite the resident's severe cognitive impairment and the facility's policy requiring such communication. The resident had multiple diagnoses affecting movement and cognition, and the absence of documentation confirming guardian notification was confirmed by staff interviews.
Facility staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a wound infection. Despite policy requirements, staff did not don gowns or gloves during high-risk care activities, such as changing briefs and transferring the resident. Interviews revealed a misunderstanding of EBP requirements, with staff believing PPE was only needed for direct wound care. The Infection Preventionist was unaware of the PPE requirements during these activities.
A facility failed to conduct a nurse aide registry check for a newly hired NA before allowing unsupervised contact with residents. Despite a policy requiring licensure verification before job responsibilities, the check was delayed until months after the NA's hire and orientation. The DON confirmed the oversight.
Failure to Submit Thorough Investigation After Resident Fall With Injury
Penalty
Summary
The deficiency involves the facility’s failure to complete and submit a thorough investigation to the state agency following a resident’s unwitnessed fall that resulted in serious injury and subsequent death. The resident had multiple significant medical diagnoses, including weakness, dementia, COPD, ataxic gait, and osteoarthritis, and had a history of multiple falls and a care plan requiring wheelchair use at all times. Prior to the fall, nursing notes documented elevated temperatures and low oxygen saturation, and after the fall, the resident’s blood pressure readings were low, with documentation that the resident’s blood pressure was chronically low. The fall occurred when the resident attempted a self-transfer without calling for staff assistance, and staff later transported the resident to the emergency room, where a left femoral neck fracture and low hemoglobin were identified. The resident was also found to have pneumonia upon hospital admission. The DON reported that the cause of the fall was weakness, possibly related to low hemoglobin, and that the resident had been sick for two days one week prior to the fall. However, the investigation report submitted to the state agency did not include weakness as a cause of the fall and omitted other relevant clinical information, including the resident’s diagnoses of dementia, COPD, ataxic gait, osteoarthritis, the symptoms documented on the date of the fall, whether medications had been reviewed, and the resident’s low blood pressure. The Administrator confirmed these omissions during interview, acknowledging that the investigation report lacked these details despite their relevance to the incident.
Food Storage, Sanitizer, Temperature, and Hand Hygiene Failures
Penalty
Summary
The facility failed to ensure food was used or discarded before expiration dates, failed to maintain and clean resident refrigerators as required, and failed to keep sanitizing solutions at the strength directed by the manufacturer. During kitchen observations, surveyors found 3 bottles of Caesar dressing with an expiration date of November 2025, 2 basins of Jello boxes with expiration dates of 3/8/2026 and 6/2024, and a basin of individual maple syrup packets that the CDM removed after confirming they were expired. Surveyors also observed a container of tomatoes in the kitchen refrigerator with no label or date; the CDM confirmed the missing date and relabeled the tomatoes for use that night. Surveyors observed the DC-C preparing the 3-compartment sink with an unmeasured amount of water in each sink, no water temperatures taken, and an unmeasured amount of dish soap in the washing sink. The sanitizer test strip did not show the required 200 ppm, and the DC-C confirmed the sanitizer level was incorrect and that the tablets were still dissolving, without retesting the solution. Surveyors also observed the DC-C use water from the washing sink to wet a cloth and clean the meal prep counter. During lunch preparation, the DC-C did not take temperatures during or after meal service, and later recorded temperatures for some foods while leaving others unchecked. The DC-C also prepared a ready-to-eat chicken salad sandwich with bare hands, despite the facility policy and FDA food code prohibiting bare hand contact with ready-to-eat foods. In addition, staff confirmed resident room refrigerators were not being temperature-logged or cleaned as required.
Catheter bags left visible, affecting resident dignity
Penalty
Summary
The facility failed to maintain the dignity of 3 residents by allowing urinary catheter bags to remain visible to others while the residents were in their rooms. The facility policy Nursing/Catheter Usage stated catheter tubing and bags were to be kept off the floor and that the catheter bag was to be encased in a catheter bag pouch or cover anytime the resident was up and about in the facility. The facility also had a Resident Rights document stating all residents are to be afforded a dignified existence. Resident 8 had an indwelling urinary catheter, and on 3/30/2026 at 11:19 AM was observed sitting in a recliner with the catheter bag hanging from the front wheeled walker, not concealed in a dignity bag, and visible from the hallway. Resident 37 had a urinary catheter in place to promote healing of a coccyx wound, and was repeatedly observed with the catheter bag hanging from the bedframe and visible from the hallway on 3/30/2026, 3/31/2026, 4/1/2026, and 4/2/2026; the DON confirmed on 4/1/2026 that the bag was not concealed in a dignity bag and was visible from the hallway. Resident 2 was observed multiple times on 3/31/2026 and again on 4/1/2026 with the urinary catheter bag visible from the hallway, not covered, and touching the floor.
Failure to Complete Recapitulation of Stay and Notify Ombudsman of Discharge
Penalty
Summary
The facility failed to complete a recapitulation of stay and failed to notify the Ombudsman upon discharge for Resident 35. Resident 35 was admitted to the facility and was later discharged to a family member's home on 1/28/2026. A review of the resident's medical records found no evidence that a recapitulation of stay was completed. During interview on 4/01/2026, the DON confirmed the recapitulation of stay had not been completed and stated the facility knew it was supposed to have been completed. A review of facility documents and the resident's medical record also found no evidence that the Ombudsman was notified of the discharge. During interview on 3/31/2026, the SSD stated the facility's practice was to notify the Ombudsman only of emergency transfers and not other transfer or discharge types, and confirmed the Ombudsman had not been notified of Resident 35's discharge.
Failure to Complete Required Pre-Employment Background and Registry Checks
Penalty
Summary
The facility failed to complete required pre-employment screening for 2 employees. Record review showed Dietary Aide-A had a hire date of 3/2/26, and no documentation was found that a criminal background check was performed. In interview, the Administrator stated the facility sent a background check request to the Nebraska State Patrol, but the criminal background check was not performed and no further attempt was made before the employee began work. Record review also showed Housekeeper-B had a hire date of 2/24/26, and no documentation was found that a nurse aide registry check or sex offender registry check was performed before employment. The Administrator confirmed that the facility did not complete the pre-employment nurse aide registry check or sex offender registry check before Housekeeper-B began work in the facility.
Failure to Update Care Plans with Fall Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that Comprehensive Care Plans (CCPs) were updated with fall interventions for two of four sampled residents following documented fall incidents. Facility policy requires that CCPs be developed and revised by a team of health professionals within seven days of a comprehensive assessment, and that interventions, including those for fall prevention, be promptly updated and communicated to relevant staff. For both residents, record reviews showed that after experiencing falls, there were no new interventions identified or documented in their care plans to address fall prevention, despite the facility's own policies mandating such updates. Resident 2, who was cognitively impaired and at high risk for falls, experienced a fall but had no new fall prevention interventions added to their care plan. Similarly, Resident 4, who had moderate cognitive deficits and multiple diagnoses including non-Alzheimer's dementia and weakness, also experienced a fall without subsequent updates to their care plan for fall prevention. Interviews with LPNs and the MDS Coordinator confirmed that care plans should be updated the same day or the following day after such incidents, but this was not done for either resident.
Improper Sanitization of Food Preparation Surfaces
Penalty
Summary
The facility failed to properly clean and sanitize food preparation surfaces after handling raw chicken, affecting all 30 residents. During an observation of meal preparation, Cook-I was seen transferring raw chicken breasts from a tote to a metal pan, with pink-tinged liquid dripping onto the preparation table. After placing the chicken in the oven, Cook-I mixed a sanitation solution incorrectly, not following the posted instructions, which required 2 1/2 ounces of sanitizer per full sink of water. Later, during meal service, the preparation table still had drops of pink-tinged fluid from the earlier chicken preparation. The table was used for spicing foods and placing various kitchen items during meal service. The Dietary Manager confirmed that the sanitation solution was not mixed according to instructions and acknowledged that food preparation surfaces should have been sanitized after preparation and before food service, which was not done.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. For Resident 6, the care plan did not include specific interventions for behaviors such as rejection of care and wandering, despite the resident's known anxiety and behavioral triggers. The care plan was identified as a template rather than tailored to the resident's individual needs, as confirmed by the MDS Coordinator. Resident 1's care plan was incomplete and did not reflect several critical aspects of the resident's condition. The care plan failed to address the use of a restraint tray for positioning, did not update the change in the resident's guardian, and omitted concerns related to the resident's poor vision and aphasia. These omissions were confirmed by both the LPN and the MDS Coordinator, indicating a lack of comprehensive planning for the resident's complex needs. For Resident 20, the care plan did not accurately reflect the use of a prophylactic antibiotic, as there was no stop date for the medication. This oversight was confirmed by both the LPN and the MDS Coordinator, highlighting a gap in the medication management aspect of the care plan. These deficiencies indicate a failure to provide individualized and comprehensive care planning for the residents involved.
Failure to Ensure Antibiotic Stewardship in Resident Care
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary antibiotics, as required by their own policy and regulatory standards. Specifically, the facility's policy on Antibiotic Stewardship mandates that all antibiotic prescriptions must specify dose, duration, and indications for use. However, record reviews revealed that Residents 2, 17, and 20 were prescribed antibiotics without a specified duration or stop date. Resident 17 had been receiving Macrobid daily for over a year without an end date, despite not being treated for a current infection. Similarly, Resident 2 was prescribed Trimethoprim for UTI prophylaxis since January 2022, and Resident 20 since September 2024, both without a stop date. Interviews with facility staff, including the Director of Nursing and a Licensed Practical Nurse, confirmed the absence of stop dates for these antibiotics. The CDC's guidelines on antibiotic stewardship highlight the risks associated with prolonged antibiotic use, particularly for UTI prophylaxis in older adults, which can lead to side effects and resistant organisms. The facility's failure to adhere to its own policy and CDC guidelines resulted in unnecessary antibiotic exposure for these residents, potentially compromising their health outcomes.
Lack of Clinical Rationale for Declined GDRs in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that physicians provided a written clinical rationale for declining gradual dose reductions (GDRs) of psychotropic medications for six residents. This deficiency was identified through record reviews and interviews, revealing that the facility did not comply with federal regulations requiring documentation of clinical rationale when GDRs are deemed clinically contraindicated. The facility's policy on psychotropic medications, dated December 14, 2022, indicated that GDRs should be conducted in accordance with federal regulations, yet this was not adhered to in practice. Resident 13, who had no cognitive impairment or symptoms of depression, was taking multiple psychotropic medications, including Buspar, Abilify, and Duloxetine. Despite the absence of behaviors or depression symptoms, the physician marked that no changes were needed, and the benefits outweighed the risks, but failed to provide a written clinical rationale for not reducing the doses. Similarly, Resident 31, with severe cognitive impairment and worsening behaviors, was on a regimen of antipsychotic, antianxiety, and antidepressant medications. The physician repeatedly marked that no changes were needed without providing a clinical rationale, despite the resident's significant behavioral issues. Other residents, including Residents 20, 23, 16, and 17, were also affected by the lack of documented clinical rationale for not pursuing GDRs. These residents were on various psychotropic medications for conditions such as depression, anxiety, and insomnia. The consulting pharmacist had requested GDRs for these medications, but the physicians did not adjust the dosages or provide the necessary clinical rationale. Interviews with the Director of Nursing confirmed the absence of required documentation, highlighting a systemic issue within the facility's medication management practices.
Deficiency in Nurse Aide Training Hours
Penalty
Summary
The facility failed to ensure that three out of five sampled nurse aides completed the required 12 hours of ongoing training annually, as mandated by the facility's policy. This deficiency was identified through record reviews and interviews, which revealed that the training records for the nurse aides contained duplicate courses, leading to an inaccurate total of training hours. Specifically, NA-F had completed only 3.5 hours of training after removing duplicate courses, NA-E had completed 9.25 hours, and NA-D had completed 10 hours of training for the year. The Director of Nursing (DON) acknowledged awareness of the 12-hour training requirement and confirmed the discrepancies in the training hours for the nurse aides. The DON is responsible for tracking the training on a January-to-January basis and confirmed the completion of duplicate courses by NA-F and NA-E, as well as the insufficient training hours for NA-D. This oversight had the potential to affect all 30 residents residing within the facility, as the nurse aides may not have been adequately trained in essential areas such as dementia care and abuse prevention.
Failure to Notify Resident's Guardian of Restraint Use
Penalty
Summary
The facility failed to ensure that a resident's representative was notified of the use of physical restraints, specifically a wheelchair lap tray, as well as the duration and alternatives to its use. The facility's Restraint Policy mandates that residents' care plans should be updated to include interventions addressing risks related to restraint use, and that residents or their representatives should be informed about the potential risks and benefits of using or not using a restraint, along with alternatives. However, a review of the resident's records revealed no evidence of such notification to the resident's guardian, who was responsible for making decisions on behalf of the resident. The resident in question had multiple diagnoses, including cerebral palsy, stroke, non-traumatic brain dysfunction, and impaired cognition, which severely affected their cognitive patterns. The resident's care plan indicated the presence of a guardian to be notified of all medical decisions. Despite this, interviews with facility staff, including an LPN and the DON, confirmed the absence of signed consent or any documentation showing that the guardian was informed about the restraint's purpose, duration, or alternatives. This oversight represents a failure to comply with the facility's own policies and regulatory requirements regarding restraint use and communication with residents' representatives.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to adhere to the Enhanced Barrier Precautions (EBP) policy during high-risk care activities for a resident with a wound infection. The policy, implemented on February 5, 2024, mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms (MDRO). Despite the presence of a sign indicating EBP on the resident's door and a caddy with gowns and gloves, staff members did not don the required personal protective equipment (PPE) while assisting the resident with activities such as changing briefs, dressing, and transferring. Observations revealed that Nurse Aide (NA) - D and NA - H did not wear gowns or gloves during these activities, even though the resident had an active diagnosis of a wound infection. Interviews with the aides indicated a misunderstanding of the EBP requirements, as they believed PPE was only necessary when providing direct wound or catheter care. The Infection Preventionist (IP) was also unaware of the PPE requirements during high-risk care activities, indicating a gap in the facility's implementation and understanding of the EBP policy.
Failure to Complete Nurse Aide Registry Check
Penalty
Summary
The facility failed to complete a nurse aide registry check for one of the three sampled employees before allowing the staff member to have unsupervised contact with residents. The facility's policy, dated December 19, 2023, required checking the licensing website for proof of current licensure before an applicant assumes job responsibilities. However, a review of the personnel file for a nurse aide hired on August 12, 2024, revealed that the registry check was not conducted until January 13, 2025. The Director of Nursing confirmed that the nurse aide began orientation on August 25, 2024, without the necessary registry check being completed, leading to unsupervised contact with residents.
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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 Benkelman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cheyenne County Village Inc | 23.8 mi | ★★★★★ | 5 | 0 |
| Wauneta Care And Therapy Center | 26.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Atwood | 31 mi | ★★★★★ | 0 | 0 |
| Imperial Manor Nursing Home | 33.1 mi | ★★★★★ | 7 | 0 |
| Hillcrest Care Center | 36 mi | ★★★★★ | 0 | 0 |
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