Below 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 Broken Bow Health And Rehab during CMS and state inspections, most recent first.
Failure to supervise a resident at high risk for wandering led to an elopement event. The resident had dementia, delirium, and head injury, with moderate cognitive impairment and later documentation showing a high wandering risk. Nursing notes described the resident as confused, pacing, and easily redirected, and the resident exited the facility and was found at a fast food restaurant after crossing a busy four-lane highway.
Care Plan Not Updated for Wandering Risk Increase A resident with dementia, delirium, head injury, and moderate cognitive impairment had a care plan that noted impaired cognition but no wandering interventions. After a wandering risk scale changed from low to high risk and notes documented pacing, confusion, wandering, and an exit from the facility that required staff intervention, the care plan was not updated to include wandering or elopement risk interventions.
A resident’s ordered hemoglobin A1c testing was missed twice in a row, with no documentation that the January and April labs were obtained. An LPN acknowledged the order was not followed, and the DON stated the A1c should have been collected as soon as the missing tests were identified.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist as required.
Surveyors observed three treatment carts left unlocked and unattended in different areas near the nurse's station and front entrance. An LPN was seen leaving a cart unsupervised while retrieving supplies, contrary to facility policy requiring carts to be locked and supervised at all times. Facility leadership confirmed the expectation that carts remain secured.
A resident's care plan was not updated to include a new breast cancer diagnosis or related interventions, despite facility policy requiring care plans to be revised after significant changes in condition. The omission was confirmed by both the ADON and DON during review.
A resident who missed 77 doses of cancer medication was not included in the facility's QAPI activities. Despite policies requiring ongoing quality monitoring, the missed medications and the resident's cancer diagnosis were not discussed in recent QAPI meetings, as confirmed by interviews with the ADON and DON.
The facility failed to accurately complete MDS assessments for two residents. One resident's hospice care was not documented correctly, despite active orders. Another resident's antipsychotic medication administration was inaccurately reported due to a misunderstanding by the MDS coordinator, who was still in training.
A resident with hemiplegia and other conditions did not receive the required assistance with showers and baths as per their care plan, which stipulated assistance three times a week. Despite a paper schedule indicating showers, the electronic health record showed only one shower per month, and the resident reported not having a shower in five days. Staff interviews revealed a lack of proper documentation and adherence to the care plan.
A resident with major depressive disorder was inappropriately administered Risperdal 0.5 mg daily despite a physician's order to discontinue it. The error occurred due to a lapse in communication and oversight by the DON, who was new at the time, resulting in the medication being administered from November to December 2024.
The facility failed to monitor and log dish machine temperature and sanitizer concentration, and improperly stored food items. Observations included a non-functioning paper towel dispenser, missing documentation in the Dish Machine Temperature Log, and improperly labeled and stored food items. The DM confirmed the need for regular checks and proper storage practices.
The facility did not implement a water management plan to prevent water-borne pathogens. Despite having a policy for Legionella surveillance, the administrator could not provide documentation of monitoring activities. The facility had a census of 55.
A facility failed to assess a resident for self-administration of medication, as required by policy. The resident, with chronic conditions and legal blindness, was found with medications at their bedside without a documented assessment. Both the LPN and DON confirmed the lack of assessment, indicating non-compliance with the facility's policy on medication self-administration and secure storage.
A facility failed to document wound care for a resident with pressure ulcers, despite physician's orders for daily treatment. The resident had multiple pressure ulcers upon admission, and the Treatment Administration Record lacked documentation for specific dates. Interviews with staff revealed that wound care was performed but not recorded, violating the facility's documentation policy.
A resident with a seizure disorder did not receive their prescribed phenytoin medication on seven occasions in November 2024. The DON was unable to explain the missed doses, which could lead to seizures.
The facility failed to provide snacks between meals for two residents who expressed a need for them. One resident, with cerebrovascular disease, dysphagia, and aphasia, stated the importance of having snacks available. Another resident, with cerebral infarction, muscle weakness, and diabetes, reported that snacks were only available at night and had to repeatedly ask for a snack during the day. The Dietary Manager confirmed that snacks were only provided at night unless there was a medical need.
Failure to Supervise a Resident at High Risk for Wandering
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for one resident who had a history of wandering and cognitive impairment. Resident #3 had diagnoses including dementia, delirium, and head injury, and an admission assessment showed a BIMS score of 11, indicating moderate cognitive impairment. A wandering risk scale dated 03/23/26 identified the resident as low risk for wandering, with no history of wandering noted at that time and no wandering interventions included in the care plan. Later, a wandering risk scale dated 04/22/26 identified the resident as high risk for wandering, noting a history of wandering and continued cognitive impairment. Nursing notes documented that the resident was pacing, confused, and easily redirected, and on 05/10/26 the resident exited the facility and was found at a fast food restaurant four blocks away after crossing a busy four-lane highway. An incident report stated a witness had seen the resident leave the facility earlier and later observed the resident at the restaurant, then called the facility to report it. A CMA stated the resident was pleasant, confused, and wandered often, but did not show exit-seeking behaviors before the elopement event.
Care Plan Not Updated for Increased Wandering and Elopement Risk
Penalty
Summary
The facility failed to ensure a comprehensive care plan was updated after Resident #3’s wandering risk increased to high risk. The resident’s care plan, dated 03/22/26, identified impaired cognition but did not include interventions for wandering risks. A Wandering Risk Scale dated 03/23/26 showed the resident was at low risk for wandering, with no history of wandering but with cognitive impairment. An admission assessment dated 03/27/26 showed the resident was admitted with diagnoses including dementia, delirium, and head injury, and had a BIMS score of 11, indicating moderate cognitive impairment. A later Wandering Risk Scale dated 04/22/26 showed the resident was at high risk for wandering and had a history of wandering while continuing to have cognitive impairment. Nurse progress notes documented the resident ambulating and pacing the halls while confused but easily redirected on 04/26/26, and on 05/10/26 a family member was notified after the resident exited the facility and was safely brought back inside by a CNA. On 05/19/26, a CMA described the resident as pleasant, confused, and wandering often, and stated the resident had not shown exit-seeking behavior prior to 05/10/26. The MDS coordinator stated the care plan should have included interventions for wandering and elopement risk when dementia, confusion, and disorientation were documented.
Failure to Obtain Ordered Hemoglobin A1c Testing
Penalty
Summary
The facility failed to obtain hemoglobin A1c laboratory testing as ordered for one resident who had an order dated 01/02/17 for hemoglobin A1c testing due in January, April, July, and October. Review of the resident’s laboratory results for January and April 2026 showed no documentation that the tests were obtained. A physician’s progress note dated 05/18/26 stated that an A1C was needed with the patient’s labs every 90 days and that it had been missed twice in a row. During interviews on 05/21/26, an LPN stated that lab requisitions were normally completed and labs collected on Tuesdays and Thursdays, acknowledged that the hemoglobin A1c test was not collected in January and April 2026, and stated that the physician’s order was not followed. The LPN later stated the hemoglobin A1c test was collected at 8:00 a.m. that day, and the DON stated the test should have been collected as soon as possible when the physician noticed the tests were missing.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Unlocked and Unsupervised Treatment Carts
Penalty
Summary
The facility failed to ensure that three treatment carts were locked and supervised in accordance with facility policy and professional standards. On multiple occasions, surveyors observed treatment carts left unlocked and unattended in various locations near the nurse's station and the front entrance. One LPN was seen walking away from an unlocked cart to retrieve medication cups, leaving the cart unsupervised and accessible. The facility's policy requires medication carts to be locked at all times when not in use or out of the nurse's view, and this was confirmed by both the ADON and the LPN during interviews. The DON reported that there were no wanderers in the facility at the time.
Failure to Update Care Plan Following New Cancer Diagnosis
Penalty
Summary
The facility failed to update the care plan for one of three sampled residents, specifically neglecting to include a diagnosis and interventions for breast cancer after a physician consultation identified this condition. The facility's policy requires that comprehensive, person-centered care plans be developed and revised as residents' conditions change, including after significant changes such as a new diagnosis. Despite this, the most recent care plan for the resident did not reflect the cancer diagnosis or any related interventions. Both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed during interviews that the care plan lacked the necessary updates, in contradiction to facility policy.
Failure to Include Missed Cancer Medications in QAPI Activities
Penalty
Summary
The facility failed to include a resident who missed 77 cancer medication doses in its Quality Assurance and Performance Improvement (QAPI) activities. Record review and staff interviews revealed that, despite the facility's policy requiring an ongoing, data-driven QAPI program focused on care outcomes, the resident's missed medications and cancer diagnosis were not discussed or addressed in recent QAPI meetings. The Assistant Director of Nursing (ADON) indicated that the QAPI process was not initiated for the missed cancer medications because the issue was not known at the time. The Director of Nursing (DON) confirmed that the resident's cancer diagnosis and related interventions were not included in the QAPI meetings held during the relevant period.
Inaccurate MDS Assessments for Hospice and Medication Administration
Penalty
Summary
The facility failed to ensure accurate completion of MDS assessments for two residents. For one resident, there was a discrepancy in the documentation regarding hospice services. Despite having an active physician's order indicating the resident was under hospice care, both the significant change and quarterly MDS assessments inaccurately documented that the resident did not receive hospice services. The MDS coordinator and the Director of Nursing (DON) acknowledged the inaccuracies, noting that the assessments were incorrect as the resident was indeed receiving hospice services during the assessment periods. For another resident, there was an error in documenting the administration of an antipsychotic medication. The resident was prescribed Risperdal, with records showing administration of both 0.5 mg and 1 mg doses daily throughout November. However, the quarterly MDS assessment inaccurately reported that the resident had not been administered any antipsychotic medication during the look-back period. The MDS coordinator misunderstood the assessment question, thinking it referred to the initiation of the medication rather than its administration. The DON confirmed the error, attributing it to the MDS coordinator's inexperience and ongoing training.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL), specifically showers and baths, for a resident diagnosed with hemiplegia, hemiparesis, aphasia, and dysphagia following a cerebral infarction. The resident's care plan, dated March 1, 2022, required staff to assist with a bath at least three times a week and as requested by the resident, with a two-person assist for shower transfers. However, the electronic health records for November and December 2024 documented that the resident received only one shower or bath each month, indicating a failure to meet the care plan requirements. Interviews with the resident and staff revealed discrepancies in the documentation and reporting process. The resident reported not having a shower in five days, contrary to the care plan's stipulations. A CNA mentioned a paper shower schedule signed by staff and reviewed by the DON or ADON, but the DON confirmed that the electronic health record lacked documentation of the showers or baths provided. This lack of documentation and adherence to the care plan led to the identified deficiency in providing necessary ADL assistance.
Failure to Discontinue Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident did not receive an antipsychotic medication that had been discontinued by a physician. Resident #12, who had a diagnosis of major depressive disorder with psychotic features, was prescribed Risperdal 0.5 mg once daily. A Pharmaceutical Consultant Report recommended a dose reduction of several psychotropic medications, including Risperdal, and documented a physician's order to stop the use of Risperdal 0.5 mg once daily. Despite this order, the Medication Administration Record (MAR) for November and December 2024 showed that the resident continued to receive the medication daily from November 1 through December 11, 2024. The Licensed Practical Nurse (LPN) confirmed that the physician's order to discontinue Risperdal was included in the pharmaceutical report, but the order remained active in the electronic health record, resulting in the resident receiving the medication daily. The Director of Nursing (DON) acknowledged that the process for handling pharmaceutical reports involved communicating with the appropriate nurse to make any necessary changes. However, the DON, who was new at the time, admitted to missing the order to discontinue the medication, leading to the continued administration of Risperdal to the resident.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to ensure proper monitoring and logging of dish machine temperature and sanitizer concentration, as well as appropriate storage of food items. During an initial kitchen tour, it was observed that the paper towel dispenser at the handwashing sink was not functioning. The Dish Machine Temperature Log for December 2024 lacked documentation for several days, indicating a failure to record the temperature and sanitizer concentration. Additionally, several food items, including prune juice, ranch dressing, whole eggs, pudding, brown sugar, flour, rice, canned pears, and turnip greens, were found without proper labeling of received or opened dates, and some were stored improperly, such as being uncovered or placed on the floor. The Dietary Manager (DM) confirmed that the dish machine's temperature and sanitizer concentration should be checked three times daily and acknowledged the need for repairs to the paper towel machine. The DM also stated that dry goods should be stored off the floor in closed containers, and all food items should be dated upon receipt and opening.
Failure to Implement Water Management Plan
Penalty
Summary
The facility failed to implement a water management plan to prevent the spread of water-borne pathogens. The facility had a policy titled 'Legionella Surveillance and Detection,' which stated a commitment to the prevention, detection, and control of water-borne contaminants, including Legionella. However, during an interview on December 12, 2024, the administrator reported they were unable to locate any documentation of monitoring for water-borne pathogens. The facility had a census of 55 at the time of the report.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, which is a requirement when a resident is allowed to self-administer drugs. The policy of the facility states that residents have the right to self-administer medications if the interdisciplinary team determines it is clinically appropriate and safe. This determination should be documented in the medical record and care plan, and medications should be stored securely. However, for the resident in question, there was no documentation of an assessment for self-administration of medication in the care plan or medical record. The resident, who had diagnoses including chronic obstructive pulmonary disease, reflux disease, and legal blindness, was observed with medications at their bedside, including an inhaler, cold medicine, and Cortisone cream. The LPN and DON both confirmed that no assessment had been completed for the resident's self-administration of medication, and the DON was unaware of the medications at the bedside. This oversight indicates a failure to adhere to the facility's policy on medication self-administration and secure storage.
Failure to Document Wound Care for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure accurate medical records for a resident with pressure ulcers. The resident, diagnosed with congestive heart failure and urinary incontinence, had one stage II and two stage III pressure ulcers upon admission. Physician's orders required daily wound care for the resident's left ankle, left heel, and coccyx. However, the Treatment Administration Record (TAR) did not document wound care on several specific dates. Interviews with the Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) revealed that wound care was performed but not documented, contrary to the facility's policy that mandates documentation of all treatments and services in the resident's medical record.
Failure to Administer Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. A resident with a history of epileptic seizures, cerebral infarction, and cognitive communication deficit was prescribed phenytoin, an anticonvulsant medication, to be administered daily via a PEG tube. However, the Medication Administration Record (MAR) for November 2024 indicated that the resident did not receive the prescribed phenytoin medication on seven out of 25 occasions. During an interview, the Director of Nursing (DON) reviewed the MAR and was unable to explain why the medication was not administered, acknowledging that the omission could lead to seizures.
Failure to Provide Snacks Between Meals
Penalty
Summary
The facility failed to provide snacks between meal times for two residents, both of whom were cognitively intact and had expressed a desire for snacks between meals. Resident #2, diagnosed with cerebrovascular disease, dysphagia, and aphasia, stated that having snacks available between meals was very important. Despite this, the resident reported that they would like to have a snack if they were hungry between meals, indicating that snacks were not being provided as needed. Resident #4, with diagnoses including cerebral infarction, muscle weakness, and diabetes, also expressed a need for snacks between meals. The resident reported that snacks were only available at night and recounted an instance where they had to repeatedly ask for a snack during the day, eventually receiving only a package of crackers. The resident decided to stop asking for snacks during the day due to this experience. During a facility tour, no snacks were observed being offered between meals, and the Dietary Manager confirmed that snacks were only provided at night unless there was a medical need, such as diabetes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Broken Bow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Heights Nursing Center | 9.7 mi | ★★★★★ | 10 | 0 |
| Hill Nursing Home, Inc. | 9.9 mi | ★★★★★ | 0 | 0 |
| Bear Creek Healthcare Llc | 23.1 mi | ★★★★★ | 3 | 0 |
| Clarksville Nursing Home | 33.7 mi | ★★★★★ | 14 | 0 |
| Focused Care At Clarksville | 34.1 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Broken Bow Health And Rehab.
100% money-back within 48 hours.
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.