Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
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 Gordon Countryside Care during CMS and state inspections, most recent first.
The facility failed to notify emergency contacts of two residents about significant changes in their medical conditions. One resident required a hospital transfer for intravenous antibiotics due to worsening symptoms, while another experienced a fall and respiratory issues necessitating emergency care. In both cases, the registered nurse confirmed that the emergency contacts were not informed, contrary to the facility's policy.
The facility failed to ensure proper food storage and hand hygiene practices, affecting all 26 residents. Observations revealed expired food items and improper storage, with food not dated or stored six inches off the floor. The CDM demonstrated inadequate hand hygiene during meal prep, not washing hands after contamination and misunderstanding glove use, contrary to the Nebraska Food Code.
The facility failed to disinfect multi-use equipment during medication administration for three residents and did not implement proper infection control practices during wound care for a resident. A Medication Aide used tweezers without disinfecting them between uses, and a Registered Nurse did not follow CDC guidelines for handwashing and glove use during wound care.
A resident's oxygen concentrator was left running unattended while they were out of their room, contrary to the facility's oxygen safety policy. Observations confirmed the concentrator was on during the resident's absence at facility activities, and staff acknowledged it should have been turned off.
A resident was prescribed nitrofurantoin for UTI prevention without a specified duration, continuing for months without reevaluation. Additionally, cephalexin was prescribed based on a urinalysis showing mixed flora, not meeting UTI criteria. The facility failed to follow its Antibiotic Stewardship Program, leading to unnecessary antibiotic use.
The facility exceeded the acceptable medication error rate of less than 5%, with errors involving two residents. A resident received Basaglar insulin earlier than the prescribed time, and another resident was given levothyroxine without observing the instruction to administer it on an empty stomach. These errors were due to staff not adhering to prescribed administration times and instructions.
Failure to Notify Emergency Contacts of Residents' Condition Changes
Penalty
Summary
The facility failed to notify the emergency contacts of two residents regarding significant changes in their medical conditions, as required by their policy. Resident 1 was admitted to the facility on March 21, 2024, and had two emergency contacts listed. On October 16, 2024, a registered nurse documented that Resident 1 showed no improvement in their right lower extremity, with increased redness and swelling, necessitating a hospital transfer for intravenous antibiotics. However, there was no evidence that Resident 1's emergency contact was informed of this change in condition, which was confirmed by the nurse during a telephone interview. Similarly, Resident 2, admitted on September 8, 2023, had an emergency contact listed as a friend. On November 25, 2024, Resident 2 experienced a fall, followed by audible wheezing and low oxygen levels, requiring oxygen administration and a transfer to the Emergency Department for potential respiratory failure. Again, there was no evidence that Resident 2's emergency contact was notified of the change in condition, which was also confirmed by the same registered nurse during an interview. These incidents highlight the facility's failure to adhere to its policy of notifying resident representatives or responsible parties of significant changes in residents' conditions.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, which had the potential to affect all 26 residents. During a kitchen tour, it was observed that several food items were not dated with an open or use-by date, and some were past their best-by dates. These included French-Fried Onions, Whole Oysters, Texas Toast, Deviled Egg Potato Salad, Macaroni Salad, Fat Free Milk, and Strawberry Yogurt. Additionally, a bottle of Strawberry Syrup was found with an expired best-by date. The Certified Dietary Manager (CDM) confirmed that these items should have been dated and consumed or discarded by their use-by dates. The facility also failed to store food at least six inches off the floor as required by their policy. During the kitchen tour, four cardboard boxes of food were found stored on the floor of the freezer. The CDM confirmed that all food should be stored at least six inches above the floor, indicating a lapse in adherence to the facility's food storage policy. Furthermore, the facility did not implement proper hand hygiene practices to prevent cross-contamination and foodborne illness. Continuous observation of the CDM during meal preparation revealed multiple instances of inadequate hand hygiene, such as not washing hands after touching contaminated surfaces, using gloves improperly, and not washing hands for the required 20 seconds. The CDM was observed touching potentially contaminated surfaces and food items without performing hand hygiene, and there was a misunderstanding regarding when gloves should be used. The CDM believed hands should be washed for only 15 seconds, contrary to the 20 seconds required by the Nebraska Food Code.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control practices during medication administration and wound care, as observed in the cases of three residents. During medication administration, a Medication Aide (MA-B) used a pair of tweezers to handle medications for three residents without disinfecting the tweezers before or after each use. This action was contrary to the facility's policy, which requires patient care equipment to be cleaned after each use. MA-B confirmed the need for cleaning or sanitizing the tweezers after each use during an interview. In a separate incident, a Registered Nurse (RN-A) did not follow proper infection control practices during wound care for a resident. The RN washed their hands for only 15 seconds, less than the 20 seconds recommended by the CDC. Additionally, RN-A contaminated their gloves by touching their hair, the trashcan, and a drawer while wearing them. The facility's policy on wound care did not align with CDC guidelines, as it lacked specific instructions on handwashing duration and the necessity of wearing a gown for Enhanced Barrier Precautions. RN-A was unaware of the correct handwashing duration and acknowledged the contamination of gloves during the procedure.
Failure to Turn Off Unattended Oxygen Concentrator
Penalty
Summary
The facility failed to ensure that a resident's oxygen concentrator was turned off when not in use and left unattended, which is a violation of their own policy on oxygen administration. The policy, revised in October 2010, mandates that residents, their families, visitors, and roommates be instructed on oxygen safety precautions, including turning off the oxygen when not in use. Despite this, observations on two separate occasions revealed that the oxygen concentrator for a resident with non-Alzheimer's dementia, pulmonary hypertension, and hypoxia was left running at 3 Liters Per Minute (LPM) while the resident was not in their room. On both occasions, interviews with facility staff confirmed that the resident was attending facility activities and not present in their room, yet the oxygen concentrator remained on. The first observation occurred when the resident had been away since 10:00 AM, and the second when the resident had been out since 2:00 PM. Both the Registered Nurse and the Director of Nursing acknowledged that the concentrator should have been turned off while the resident was not using it, indicating a lapse in adherence to the facility's safety protocols.
Failure to Ensure Drug Regimen Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, the resident was prescribed nitrofurantoin for UTI prevention without a specified duration, and this prescription continued for several months without reevaluation or documentation of its necessity during physician visits. Additionally, the resident was prescribed cephalexin for a suspected UTI based on a urinalysis that did not meet the criteria for a UTI diagnosis, as it showed mixed flora and lacked an antibiotic susceptibility report. The facility's policy required that all antibiotic prescriptions specify dose, duration, and indication, and that resident responses and lab results be monitored to determine the continued need for antibiotics. The resident experienced increased confusion and decreased appetite, prompting a urinalysis that revealed mixed flora, which is typically considered contaminated. Despite this, the resident was started on cephalexin without supporting documentation for its clinical use. The facility's failure to adhere to its Antibiotic Stewardship Program and the McGeer Criteria for infection surveillance resulted in the unnecessary use of antibiotics for the resident. An interview with a registered nurse confirmed that there was no discussion with the primary provider regarding the reduction of unnecessary antibiotic use for the resident.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered at the correct times for two residents, leading to a medication error rate of 5.4%, which exceeds the acceptable threshold of less than 5%. For Resident 15, Basaglar insulin was ordered to be administered at 9:00 AM, but RN-A administered it at 7:29 AM, citing the resident's early wake-up time as the reason for the deviation. This action was confirmed during an interview with RN-A, who acknowledged awareness of the prescribed administration time but chose to override it. For Resident 1, there was an order for levothyroxine to be taken on an empty stomach. However, an observation revealed that Resident 1 was in the dining room with a plate of food, having already consumed about 25% of it, when MA-B attempted to administer the medication. Resident 1 initially refused the medication, but the DON was later able to administer it. An interview with MA-B revealed that they did not notice the instruction to administer the medication on an empty stomach, contributing to the medication error.
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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 Gordon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oglala Sioux Lakota Nursing Home | 14.7 mi | — | 9 | 0 |
| Pioneer Manor Nursing Home | 26.4 mi | — | 4 | 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.