Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Clara's Rehab & Senior Care during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a high risk for falls was not properly secured during van transport by an LPN, who only locked the wheelchair wheels and did not use the required securement systems. This lapse led to the resident falling and sustaining a subdural hematoma and scapular fracture.
The facility did not provide prescribed skin treatments for two residents, missing multiple applications of ointments and dressings as ordered by physicians. Additionally, blood glucose monitoring was not performed as ordered for a resident with diabetes on two occasions. These deficiencies were confirmed by the DON through review of treatment and medication administration records.
A resident with Type II Diabetes Mellitus did not receive prescribed doses of Insulin Aspart and Humalog at multiple scheduled times, including missed sliding scale doses when indicated by blood glucose readings. The DON and physician confirmed these omissions as medication errors, in violation of facility policy.
A resident developed a stage four pressure ulcer due to the facility's failure to implement specific pressure-relieving interventions. Despite being identified as at risk for pressure ulcers, the facility did not complete the required Braden Scale assessments or provide individualized care to prevent ulcers on the resident's heels. Observations showed the resident's heels were not consistently offloaded, and the pressure-relieving boot was not used as required, leading to the ulcer's deterioration.
The facility failed to ensure proper sanitation and food safety practices, affecting all 96 residents. The dishwashing machine used temperature testing strips that only indicated 160°F, below the required 180°F, and were used weekly instead of daily. Additionally, the facility did not log the cooling of meals containing meat, such as goulash and lasagna, as per their policy, risking foodborne illnesses.
The facility failed to provide appropriate indications for antipsychotic medication use in four residents with dementia and did not attempt a gradual dose reduction (GDR) for one resident. Despite facility policy requiring non-pharmacological interventions first, residents were prescribed Seroquel without documented behaviors justifying its use. Observations showed residents were calm and in no distress, questioning the necessity of the medication. The Director of Nursing confirmed the lack of appropriate diagnoses and the failure to attempt a GDR.
A facility failed to follow proper infection control protocols, including hand hygiene and glove changes during medication administration by an LPN. Additionally, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds or indwelling medical devices. A CNA performed catheter care without a gown, and the Infection Control Preventionist acknowledged missing EBP implementation for certain residents.
A facility failed to follow proper hand hygiene and glove-changing protocols during catheter care for a resident with an indwelling urinary catheter. The CNA did not wash hands or change gloves before providing care, violating the facility's policy and infection control standards. This was confirmed by the DON, highlighting a deficiency in care procedures.
A resident with a history of hypertension and diabetes was not weighed daily as ordered by the physician, missing five days within a two-week period. The resident experienced a significant weight increase of 15.6 pounds in one day, but the physician was not notified, as confirmed by the DON.
The facility failed to follow its Oxygen Administration policy by not placing an oxygen sign on a resident's door and administering oxygen to another resident without a physician's order. One resident with COPD and acute respiratory failure had a physician's order for continuous oxygen, but no sign was placed on their door. Another resident was receiving oxygen without a physician's order, which was confirmed by the DON.
The facility failed to notify the Ombudsman in writing of resident transfers, as confirmed by the Assistant Administrator. While the Ombudsman was notified of admissions and discharges out of the building, transfers to the hospital were not communicated. This oversight has the potential to affect all 94 residents in the facility.
An LPN failed to ensure proper pressure ulcer wound treatment for a resident, leading to potential cross-contamination by allowing the cleansed wound to touch a soiled incontinence brief.
The facility failed to identify target behaviors for antipsychotic medication use and did not ensure a resident received the lowest effective dose. Additionally, another resident's PRN psychotropic medication order lacked the required 14-day stop date.
Failure to Properly Secure Resident During Transport Resulting in Serious Injury
Penalty
Summary
The facility failed to follow its established procedures for the safe transportation and supervision of a resident, resulting in a significant accident. Specifically, a Licensed Practical Nurse (LPN) who was newly trained and licensed to drive the facility van transported a resident from the emergency room back to the facility. The LPN did not properly secure the resident in the van, only locking the wheelchair wheels and neglecting to use the required securement systems. The LPN admitted to this lapse, stating that he believed the short distance justified the omission. As a result, when the van accelerated from a stop, the resident rolled backward and fell, striking his head on the rear door of the van. The resident involved had a complex medical history, including a left above-knee amputation, hemiplegia, diabetes, dementia, and a history of falls, and was identified as being at high risk for falls and injury. Following the incident, the resident was diagnosed with a left subdural hematoma and a minimally displaced left scapular fracture. Documentation and interviews confirmed that the LPN had received training on securing residents but failed to implement these procedures during the transport, directly leading to the resident's injuries.
Failure to Provide Physician-Ordered Skin Treatments and Blood Glucose Monitoring
Penalty
Summary
The facility failed to provide skin treatments as ordered by the physician for two residents who were being monitored for skin alterations. For one resident, the treatment administration records showed that emollient ointment was not applied to the bilateral upper extremities on five occasions, and barrier cream was not applied to the buttocks on three occasions, despite physician orders. For the second resident, skin preparation to the left heel was missed on two occasions, triple antibiotic ointment and dressings to the left forearm were missed once, and petroleum dressing and related wound care to the left arm were missed on three occasions. These omissions were verified by the Director of Nursing through review of the treatment administration records. Additionally, the facility failed to obtain blood glucose levels as ordered by the physician for one resident with a diagnosis of Type II Diabetes Mellitus. The medication administration records indicated that blood glucose testing was not performed as ordered before meals and at bedtime on two specific occasions. The Director of Nursing confirmed these omissions during record review. These failures represent non-compliance with the facility's own policies for wound care and blood glucose monitoring.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer insulin as ordered for a resident with Type II Diabetes Mellitus. According to the Medication Administration Records (MARs) and physician orders, the resident was prescribed both Insulin Aspart and Humalog insulin to be given subcutaneously before meals, with additional sliding scale dosing based on blood glucose levels. The MARs documented multiple instances where the resident did not receive the prescribed doses of Insulin Aspart and Humalog at the specified times. Additionally, on at least one occasion, the sliding scale dose of Insulin Aspart was not administered when the resident's blood sugar reading indicated it was required. Interviews with the resident's physician and the Director of Nursing confirmed that the insulin doses were missed and that this constituted a medication error. The facility's own policy requires medications to be administered accurately and according to physician orders, but this was not followed in the resident's case, as evidenced by the documented omissions in the MARs.
Failure to Implement Pressure Ulcer Prevention Leads to Stage Four Ulcer
Penalty
Summary
The facility failed to develop and implement specific pressure-relieving interventions for a resident, leading to the development and worsening of a pressure ulcer. The resident, who was admitted with no pressure ulcers, was identified as being at risk for pressure ulcers based on the Braden Scale assessments conducted shortly after admission. Despite this, the facility did not complete the required weekly Braden Scale assessments for four weeks post-admission, as per their Wound and Ulcer Policy. Additionally, the care plan lacked individualized interventions to prevent pressure ulcers on the resident's heels, despite the noted risk. The resident's condition deteriorated from a blister to a stage four pressure ulcer on the right heel, requiring surgical debridement. Observations revealed that the resident's heels were not consistently offloaded while in bed, and the pressure-relieving boot was not used as required when the resident was out of bed. The resident reported pain and expressed that staff did not promptly address complaints of discomfort, leading to a delay in identifying the pressure ulcer. Interviews with facility staff, including the Registered Nurse/Infection Preventionist and the Wound Physician, confirmed that the necessary interventions to relieve pressure on the resident's heels were not implemented. The pressure-relieving boot was misplaced for at least two days, and the resident's heels were observed resting directly on the floor and mattress, contrary to the physician's recommendations. These failures contributed to the worsening of the resident's pressure ulcer, highlighting a significant deficiency in the facility's pressure ulcer prevention and management practices.
Deficiencies in Dishwashing and Food Cooling Practices
Penalty
Summary
The facility failed to ensure proper sanitation and food safety practices in their dietary department, which could potentially affect all 96 residents. The facility used a high-temperature dishwashing machine that requires a rinse cycle temperature of at least 180 degrees Fahrenheit for proper sanitation. However, the dietary manager, V4, admitted to using temperature testing strips that only indicate a temperature of 160 degrees Fahrenheit, which is below the required temperature. Furthermore, these strips were only used once a week instead of daily, as the facility relied on the machine's digital thermometer for daily checks. This practice does not ensure that the dishes are sanitized at the required temperature. Additionally, the facility did not adhere to its own policy for cooling hot foods to prevent foodborne illnesses. The policy requires that food be cooled from 135 degrees to 70 degrees Fahrenheit within two hours and then to 41 degrees Fahrenheit within an additional four hours, with temperatures recorded on a log. However, the facility's logs for January and February 2025 only documented the cooling of pork loin, while other prepared meals containing meat, such as goulash and lasagna, were not monitored or logged for proper cooling. The dietary manager confirmed the absence of cool down logs for these meals, indicating a failure to ensure food safety standards were met.
Inappropriate Use of Antipsychotic Medications and Lack of GDR in Residents with Dementia
Penalty
Summary
The facility failed to provide appropriate indications for the use of antipsychotic medications for four residents diagnosed with dementia and did not attempt a gradual dose reduction (GDR) for one resident. The facility's policy on psychotropic medication requires that these medications be used only when necessary and that non-pharmacological interventions be attempted first unless contraindicated. However, the facility did not adhere to these guidelines, as evidenced by the lack of appropriate diagnoses for the use of Seroquel/Quetiapine in residents R2, R5, R54, and R82. Resident R2 was admitted with severe dementia and other conditions, and was prescribed Seroquel for unspecified dementia without behavioral disturbance. Observations showed R2 was calm and in no distress, indicating a lack of justification for the antipsychotic use. Similarly, Resident R5, with a diagnosis of unspecified dementia and other disorders, was on Seroquel despite no documented behaviors warranting its use. Observations of R5 showed calmness and no distress, further questioning the necessity of the medication. Resident R54, diagnosed with Parkinson's disease and dementia, was on Seroquel without documented behaviors justifying its use, and a GDR was not attempted despite policy requirements. The physician rejected a GDR request without providing clinical rationale. Resident R82, with severe cognitive impairment, was also on Seroquel for unspecified dementia without behavioral disturbance. Observations showed R82 was pleasant and in no distress, indicating the medication might not be necessary. The Director of Nursing confirmed the lack of appropriate diagnoses and the failure to attempt a GDR for R54.
Infection Control Deficiencies in Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in hand hygiene and glove usage during medication administration. An LPN was observed applying gloves and then touching various surfaces, including medication cart keys and a medication drawer, before administering eye drops and an intramuscular injection to residents without changing gloves or performing hand hygiene. The LPN acknowledged the potential for germ transmission due to this practice. The Infection Control Preventionist confirmed that gloves should be changed and hand hygiene performed before administering invasive medications. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. One resident with a stage two pressure wound did not have EBP signage or PPE available in or outside their room. Another resident with an indwelling urinary catheter also lacked EBP signage and PPE. A CNA performed catheter care without using a gown, and the CNA was unaware of the EBP requirements. The Infection Control Preventionist confirmed the oversight and acknowledged the need for EBP for residents with catheters and wounds. The deficiencies highlight lapses in the facility's infection control practices, particularly in the use of PPE and adherence to EBP protocols. The Infection Control Preventionist admitted to missing the implementation of EBP for certain residents, which should have been in place due to their medical conditions. These oversights were identified during the survey, indicating a need for improved infection control measures and staff education on EBP requirements.
Failure in Hand Hygiene and Glove Protocol During Catheter Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove-changing protocols during urinary catheter care for a resident with an indwelling urinary catheter. The resident, who was admitted with a diagnosis of Neuromuscular Dysfunction of Bladder and had a care plan indicating the use of a urinary catheter due to Benign Prostatic Hyperplasia, Obstructive Uropathy, and Neurogenic Bladder, was supposed to receive catheter care every shift as per the physician's order. However, during an observation, a Certified Nursing Assistant (CNA) did not wash her hands or change gloves before providing catheter care, which is a violation of the facility's Catheter Care/Incontinent Care policy and the Infection Prevention and Control Standard. The CNA entered the resident's room with personal protective equipment and necessary supplies, placed them on the overbed table, and proceeded to perform catheter care without changing gloves or washing hands from the time of entry until leaving the room. This action was verified by the Director of Nursing, who confirmed that the CNA should have performed hand hygiene and changed gloves before providing care. This oversight in following standard precautions and facility policy led to the deficiency noted in the report.
Failure to Monitor and Report Significant Weight Changes
Penalty
Summary
The facility failed to adhere to a physician's order for daily weights for a resident, identified as R347, who was part of a sample of 33 residents reviewed for daily weights. The resident had a medical history that included essential hypertension, benign prostatic hyperplasia, atherosclerosis of the aorta, and type 2 diabetes mellitus. The physician's order, dated 2/4/25, required daily weights with a directive to notify the provider if there was a weight increase of more than three pounds in 24 hours or five pounds in one week. However, the facility did not weigh the resident on five separate days within a two-week period, specifically on 1/22, 1/24, 1/26, 1/27, and 1/28/2025. On 1/31/25, the resident's weight was recorded as 233.7 pounds, and on 2/1/25, it was documented as 249.4 pounds, indicating a significant increase of 15.6 pounds. Despite this substantial weight gain, there was no evidence that the physician was notified, as confirmed by the Director of Nursing (V3) during an interview on 2/4/25. This oversight in communication and failure to follow the physician's order for daily weights and notification of significant weight changes constituted a deficiency in the facility's care for the resident.
Failure to Follow Oxygen Administration Policy
Penalty
Summary
The facility failed to adhere to its Oxygen Administration policy by not placing an oxygen sign on the door of a resident with COPD and acute respiratory failure. The resident, who was admitted with these diagnoses, had a physician's order for continuous oxygen to maintain oxygen saturation above 92%. However, during an observation, it was noted that there was no oxygen sign on the resident's door, which was later confirmed by the Director of Nursing. Additionally, another resident was found to be receiving oxygen at two liters per nasal cannula without a physician's order, as required by the facility's policy. The Director of Nursing verified that there was no current physician order for this resident's oxygen use, acknowledging that the facility should have obtained an order prior to administering oxygen.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify in writing, and maintain a copy in the medical record, notification to the Ombudsman of residents that were reviewed for notices before transfers. This deficiency was identified during an interview and record review, where it was found that multiple residents had been discharged or transferred without the Ombudsman being notified. The Assistant Administrator confirmed that while the Ombudsman was notified of resident admissions and discharges out of the building, they were not notified of transfers to the hospital. This failure has the potential to affect all 94 residents residing in the facility.
Improper Pressure Ulcer Wound Treatment
Penalty
Summary
The facility failed to ensure proper pressure ulcer wound treatment for one resident, leading to potential cross-contamination. During an observation, an LPN provided wound care for a resident with a stage II pressure ulcer on the coccyx area. The LPN cleansed the wound but allowed the resident to roll back onto an incontinence brief, causing the cleansed wound to touch the soiled brief. The LPN then prepared medication and dressing, rolled the resident back onto their side, applied the treatment, and repositioned the resident back onto the incontinence brief. The LPN confirmed that the resident should not have been allowed to roll back onto the brief after cleansing the wound.
Failure to Justify Antipsychotic Medication Use and Ensure PRN Stop Date
Penalty
Summary
The facility failed to identify target behaviors to warrant the use of an antipsychotic medication and did not ensure a resident received the lowest effective dose of psychotropic medication. Specifically, a resident with diagnoses including unspecified dementia with psychotic disturbance, anxiety disorder, and depression was prescribed Seroquel. Despite a pharmacy recommendation to reduce the dose from 50 mg to 25 mg, the dose was increased back to 50 mg due to the resident and their power of attorney's refusal, without any documented behaviors justifying the increase. Observations and interviews confirmed that the resident did not exhibit behaviors warranting the use of the antipsychotic medication, and behavior tracking logs did not document any behaviors to justify the medication's use. The facility's staff, including the Regional Director of Operations and the Assistant Administrator, verified the lack of documented behaviors and acknowledged that psychotropic medications cannot be increased based on family preference alone. Additionally, the facility failed to ensure that PRN psychotropic medication had a 14-day stop date for another resident diagnosed with unspecified dementia, gastro-esophageal reflux disease, anxiety disorder, hallucinations, and hypertension. The resident's electronic medical record documented a physician's order for Lorazepam to be given as needed for anxiety, but the order was indefinite and did not include the required 14-day stop date. This was confirmed by the Regional Nurse Consultant, who acknowledged the oversight.
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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 Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Village Healthcare | 2.7 mi | — | 8 | 0 |
| H & J Vonderlieth Lvg Ctr, The | 10.9 mi | — | 8 | 0 |
| Mason City Area Nursing Home | 15.6 mi | — | 1 | 0 |
| Villa Health Care East | 21.1 mi | — | 6 | 1 |
| Goldwater Care Clinton | 22.2 mi | — | 52 | 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 August 2026) and official state health department websites.