Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Monument Healthcare And Nursing Center during CMS and state inspections, most recent first.
A resident who required pain management did not receive safe and appropriate care to address their pain, resulting in a deficiency related to pain management services.
A resident with metabolic encephalopathy experienced an unwitnessed fall resulting in a fractured nasal bone and lacerations requiring hospital treatment. While the State Agency was notified within 2 hours of the injury, the facility did not submit the required follow-up investigative report within 5 business days, as confirmed by the DON.
A resident with multiple medical conditions was administered both antipsychotic and opioid medications without adequate monitoring, documentation, or evaluation of necessity. The medications were given frequently, sometimes together, despite warnings about drug interactions, and there was no evidence of non-pharmacological interventions or timely provider review. The resident experienced cognitive and physical decline, and concerns raised by staff and the resident’s representative were not addressed, resulting in a deficiency related to unnecessary drug use.
A resident with mild cognitive impairment and multiple medical conditions was prescribed a PRN antipsychotic for behavioral symptoms without timely notification to their representative. Facility staff confirmed that notification of such medication changes is expected, but there was no documentation or evidence that the representative was informed, leading to a deficiency.
A resident with dementia, Alzheimer's, and depression exhibited ongoing aggressive and agitated behaviors, including altercations with a roommate and staff. Despite documented incidents and staff concerns about room assignments and behavioral triggers, the care plan contained only generic interventions and was not individualized. Staff reported poor communication from management and uncertainty about behavioral interventions, while the administrator confirmed the care plan was not tailored to the resident.
A resident with a chronic surgical wound did not consistently receive daily wound care as ordered by the physician. Documentation showed that dressing changes were missed on multiple days, and both the resident and an LPN confirmed that dressings were sometimes left unchanged for up to three days. The DON verified that the facility's expectation was for daily dressing changes, but this was not consistently followed.
A resident with dementia and a history of aggression was involved in multiple altercations with others, including a physical incident with a roommate and aggression during meals. Staff concerns about room assignments and behavioral triggers were not addressed by management, and recommendations from healthcare providers were not effectively implemented. The lack of a dedicated unit manager and insufficient oversight contributed to the facility's failure to provide adequate supervision and prevent accidents.
A resident with an open shoulder wound did not receive wound care according to the physician's order. The RN failed to apply the No-Sting barrier film and did not establish a clean field during the procedure. The RN confirmed the omission during an interview.
A facility failed to prevent cross-contamination during wound care for a resident with an open shoulder wound. A nurse did not establish a clean field or perform hand hygiene as required by facility policy. Additionally, the nurse did not follow the physician's order to use a no-sting barrier film, and used non-sterile gloves, compromising the sterile environment.
The facility failed to follow advance directives for CPR/DNR for three residents, leading to discrepancies in code status documentation. A resident listed as DNR in the code listing report had a signed directive for CPR, while two other residents with DNR orders were inaccurately listed as Full Code in the facility's code book. These inconsistencies resulted in an immediate jeopardy finding, later reduced after corrective actions.
The facility's dishwashing machine failed to reach the required temperatures for effective cleaning, posing a risk of foodborne illness to all residents. Observations showed the wash and rinse cycles were below the necessary minimums, and staff interviews revealed a lack of awareness about temperature requirements and the meaning of a blinking light indicating low detergent levels.
The facility failed to review pre-employment health screens for five staff members, risking the transmission of contagious diseases. Multi-use equipment like a Hoyer lift was not sanitized between uses, and the facility lacked a water management plan to prevent Legionella. The Infection Control Coordinator and Maintenance Director confirmed these deficiencies.
The facility failed to provide a clean and homelike environment, with missing baseboard trim, scuffed floors, and rough handrails in the 200 wing. In the 400 wing, a cracked television, stained carpets, peeling wallpaper, and exposed electrical panels were observed. These deficiencies were confirmed by the Maintenance Director, indicating an unsafe environment.
The facility failed to provide and document baseline care plans for four residents within 48 hours of admission, as required. These residents, with various medical conditions such as Hemiplegia, Encephalopathy, and Chronic Respiratory Failure, did not receive the necessary written summaries of their care plans. The Director of Nursing Trainer confirmed the absence of these documents and the lack of evidence that they were provided to the residents or their representatives.
The facility failed to ensure proper blood glucose testing procedures for several residents with diabetes. Staff did not adhere to the protocol of wiping away the first drop of blood before testing, potentially leading to inaccurate readings. Interviews confirmed a lack of awareness or adherence to this procedure among staff.
A long-term care facility failed to maintain a medication error rate below 5%, with observed errors involving insulin and eye drop administration. Errors included incorrect priming of insulin pens and improper application of eye drops, as confirmed by the DON. These procedural lapses contributed to a 16% medication error rate.
The facility failed to ensure staff competency in blood glucose testing and insulin pen use, as observed in three staff members. Staff did not follow procedures for wiping away the first drop of blood during glucose testing, potentially leading to inaccurate readings. Additionally, insulin pens were not primed correctly, risking incorrect insulin doses. The facility lacked adequate training and competency documentation for the staff involved.
A resident with no cognitive impairment repeatedly requested a bed bath instead of a shower, but the facility staff denied this preference, insisting on showers. The resident's care plan lacked documentation of bathing preferences, and despite the facility's policy to accommodate such preferences, the staff did not adhere to it, leading to multiple refusals by the resident.
A resident with severe cognitive impairment and multiple diagnoses experienced several unwitnessed falls due to the facility's failure to implement prescribed fall prevention measures. Despite recommendations for a scoop mattress, observations revealed the use of a regular flat mattress, and staff interviews indicated a lack of awareness about specific interventions. This led to the resident sustaining injuries requiring emergency treatment.
A facility failed to perform monthly medication reviews for a resident with complex medical needs, including diabetes and major depressive disorder, from September 2023 to February 2024. The resident was on multiple medications, and the absence of these reviews could have led to unaddressed medication irregularities. The Infection Control Coordinator confirmed the oversight in the required monthly reviews.
A facility failed to limit PRN antipsychotic medication to 14 days and did not inform a resident or their representative of the medication's risks and benefits. The resident, with multiple diagnoses including dementia, was receiving antipsychotic medications without a gradual dose reduction or psychiatric evaluation, and the PRN order for Haloperidol lacked a discontinuation date.
Medication aides in an LTC facility failed to follow proper insulin administration procedures, leading to significant medication errors for three residents with diabetes. The aides did not prime insulin pens correctly, as they held the pen with the needle tip downward instead of upward, which is necessary to remove air and ensure the correct dose. The Director of Nursing confirmed the facility's procedure was not followed.
The facility failed to maintain a pest-free environment, affecting all 75 residents. Flying insects were observed in the courtyard, where a resident was sitting. A wasp nest was found in a window frame, with multiple wasps present. A nurse confirmed residents use the courtyard but was unaware of insect issues. The Maintenance Director acknowledged the nest's presence for a week and had not exterminated it, despite monthly exterminator visits.
A facility failed to complete required background checks before allowing a Medication Aide to work with residents, violating their policy on abuse prevention. The employee worked several shifts before the Nebraska Central Registry Check was completed, exposing residents to potential risks.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate pain management for a resident who required such services. The report indicates that the facility failed to ensure that a resident in need of pain management received care that met professional standards and addressed their pain appropriately. Specific details about the number of residents sampled or cited, as well as the resident's medical history or condition at the time of the deficiency, are not provided in the report.
Failure to Submit Timely Investigative Report After Resident Injury
Penalty
Summary
The facility failed to submit a required investigative report to the State Agency within 5 working days following a significant injury sustained by a resident. According to the facility's policy, any incident resulting in serious bodily injury must be followed by a detailed investigative report submitted to the state within the specified timeframe. In this case, a resident with a diagnosis of metabolic encephalopathy was admitted to the facility and subsequently experienced an unwitnessed fall, resulting in a fractured nasal bone and lacerations requiring stitches. The incident was documented, and the resident was transported to the hospital for treatment. Although the facility notified the State Agency within 2 hours of becoming aware of the resident's significant injury, there was no evidence that a follow-up investigative report was submitted within 5 business days as required. The Director of Nursing confirmed that the follow-up report was not sent, despite the policy and regulatory requirements. This omission constituted a failure to comply with state regulations regarding timely reporting of incidents involving serious injury.
Failure to Prevent Unnecessary Drug Use and Monitor Medication Interactions
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs, as evidenced by the administration of multiple psychotropic and opioid medications without adequate monitoring or documented justification. The resident, who had a history of vertebral fracture, scoliosis, osteoarthritis, and depression, was prescribed risperidone (an antipsychotic) on an as-needed basis for behaviors, as well as multiple opioid medications for pain management. There was no documented stop date or duration for the risperidone, and the order included instructions to follow up with the primary health care provider, but there was no evidence of such follow-up or of regular evaluation of the continued need for the medication. The resident’s medical records showed frequent administration of both antipsychotic and opioid medications, sometimes concurrently, despite a black box warning regarding the risks of combining these drug classes. Documentation was lacking regarding the specific behaviors that prompted the use of the antipsychotic, and there was no evidence of non-pharmacological interventions for pain. Progress notes indicated a decline in the resident’s cognition and physical abilities, with concerns raised by both staff and the resident’s representative. Despite these concerns and requests for medication review, there was no documented evidence that the need for continued use of the antipsychotic or the potential drug interactions were addressed by providers. Interviews with staff and the resident’s representative confirmed that the resident experienced periods of significant cognitive and physical decline, which improved after changes to the medication regimen. The representative was not informed about the initiation of the antipsychotic and expressed concern about the resident’s decline. Staff acknowledged missed opportunities to evaluate for over-medication and potential drug interactions. The facility’s failure to monitor and evaluate the resident’s medication regimen, document the rationale for continued use, and communicate with the resident’s representative contributed to the deficiency.
Failure to Notify Resident Representative of New Antipsychotic Medication
Penalty
Summary
The facility failed to notify a resident and their representative of a newly prescribed medication, specifically an antipsychotic, as required by policy and regulation. Record review showed that a resident with multiple diagnoses, including vertebral fracture, scoliosis, osteoarthritis, and depression, was admitted from a hospital and had mild cognitive impairment. The resident exhibited behavioral symptoms that disrupted care and required significant assistance with daily activities. On a specific date, the resident began yelling out in pain despite receiving pain medication and other interventions. The on-call provider was notified and prescribed Risperidone 0.25 mg every 12 hours as needed for behaviors, with instructions to follow up with the primary care provider. The medication was administered, and the resident's behavior calmed after about 30 minutes. However, there was no documented evidence that the resident or their representative was notified of the new antipsychotic medication. Interviews with the resident's representative confirmed they were not informed of the medication change until much later and would not have agreed to its use if notified. Facility staff, including an LPN and a unit manager, confirmed that the expectation is to notify representatives of such changes and acknowledged that this notification did not occur or was not documented.
Failure to Individualize Care Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to implement resident-specific interventions to address or minimize the behaviors of a resident with dementia, Alzheimer's disease, and depression. The resident had a history of moderate to severe cognitive impairment and minimal symptoms of depression, as documented in their assessments. Despite a care plan noting the potential for physical aggression related to dementia, the interventions listed were generic and not tailored to the resident's specific triggers or behaviors. Multiple incident and behavior notes documented ongoing aggressive and agitated behaviors, including verbal and physical altercations with a roommate and other residents, as well as aggression toward staff. Staff interviews revealed that concerns about placing two residents with histories of aggression in the same room were raised with the Social Services Director, but these concerns were dismissed, and staff felt their input was not sought or valued. Staff also reported a lack of communication from management regarding behavioral interventions and were unsure where to find documentation of such interventions for the resident. The Nursing Home Administrator confirmed a lack of awareness regarding staff concerns and acknowledged that the care plan was not individualized for the resident. Oversight of the unit was fragmented, with no dedicated unit manager, contributing to the lack of individualized care planning and communication among staff. The deficiency was identified through observation, record review, and staff interviews, highlighting the facility's failure to develop and implement a comprehensive, resident-specific care plan as required.
Failure to Perform Wound Care as Ordered
Penalty
Summary
The facility failed to perform wound care as ordered for one resident with a chronic surgical wound to the right shoulder. The resident's care plan and physician orders specified daily dressing changes, including cleansing with normal saline, application of a no sting barrier film, and covering with a silicon border dressing. However, documentation in the Treatment Administration Record (TAR) for March showed that dressing changes were completed only 20 out of 31 days. Interviews with the resident and an LPN confirmed that dressing changes were sometimes missed for up to three days, and dressings were occasionally found undated or dated from previous days. The resident involved had no cognitive impairment and required partial to moderate assistance with activities of daily living. The resident reported that the wound dressing was not always changed daily as ordered. The DON confirmed the discrepancy in the TAR and acknowledged that the facility expectation was for dressing changes to be completed as ordered, with missed treatments to be passed on to the next shift. The failure to follow the wound care orders as prescribed led to the identified deficiency.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision and Response to Behavioral Risks
Penalty
Summary
The facility failed to protect residents from accident hazards and did not provide adequate supervision to prevent accidents involving a resident with a history of adverse behaviors. The resident in question had diagnoses including dementia, Alzheimer's disease, and depression, and was assessed as having moderate to severe cognitive impairment. Despite a care plan identifying the potential for physical aggression and interventions such as analyzing triggers and seeking psychiatric consultation, the resident was involved in multiple incidents of aggression toward others, including a physical altercation with a roommate and striking another resident during lunch. Staff interviews revealed that concerns were raised about placing two residents with histories of aggression in the same room, but these concerns were not addressed by facility management. Staff reported that their input regarding behavioral triggers and interventions was not solicited by the management team, and that the Social Services Director communicated that corporate priorities were focused on bed occupancy rather than resident safety. The memory support unit where the incidents occurred lacked a dedicated unit manager, and oversight was split between other managers, leading to staff feeling unsupported and overlooked. Documentation showed repeated behavioral incidents, including verbal and physical aggression, and recommendations from healthcare providers to change the resident's room assignment to reduce irritability. Despite these documented behaviors and provider recommendations, the facility did not implement effective interventions or adjust supervision to prevent further incidents, resulting in continued altercations and a failure to ensure a safe environment for all residents.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to perform wound care according to the provider's order for a resident with an open wound on their right shoulder. The resident was admitted with this condition, and the physician's order specified a detailed wound care regimen, including cleansing with normal saline or wound cleanser, applying a No-Sting barrier film, and covering with a silicone border dressing. This care was to be performed daily on the day shift and as needed for drainage or dislodgement. During an observation, a registered nurse (RN) did not follow the prescribed wound care procedure. The RN prepared the wound dressing without establishing a clean field and omitted the application of the No-Sting barrier film as ordered. Additionally, the RN had to retrieve forgotten supplies during the procedure, which interrupted the process. An interview with the RN confirmed the omission of the No-Sting barrier film, indicating a failure to adhere to the physician's order for wound care.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to prevent potential cross-contamination during wound care for a resident with an open wound on their right shoulder. The facility's policy required staff to establish a clean field using a disposable cloth on the resident's overbed table and to perform hand hygiene at specific points during the procedure. However, during an observation, a registered nurse (RN) did not follow these protocols. The RN placed the wound dressing directly on the overbed table without establishing a clean field and did not perform hand hygiene after placing supplies on the table, after removing the soiled dressing, or after completing the wound care. Additionally, the RN did not adhere to the physician's order for the wound care procedure. The order specified the use of a no-sting barrier film, which the RN failed to apply. The RN also used non-sterile gloves obtained from the resident's bathroom and did not maintain a sterile environment throughout the procedure. These actions and inactions led to a deficiency in the facility's infection prevention and control program, as they increased the risk of cross-contamination during wound care.
Failure to Follow Advance Directives for CPR/DNR
Penalty
Summary
The facility failed to adhere to the advance directives for cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR) orders for three residents, leading to a deficiency. Resident 40 was listed as a DNR in the facility's code listing report, but their medical record and a signed advance directive indicated a preference for CPR and full treatment. This discrepancy was confirmed through interviews with the Unit Manager and the resident, who verified their choice for CPR. Resident 32's records showed a preference for DNR, as indicated in their resuscitation orders and care plan. However, the facility's code book inaccurately listed them as a Full Code, contradicting their documented wishes. Similarly, Resident 46 had a DNR order signed by their physician, but the facility's code book also incorrectly listed them as a Full Code, not reflecting their choice for no CPR. These discrepancies in code status documentation and the failure to follow residents' advance directives were identified during a survey, resulting in an immediate jeopardy finding. The facility's failure to ensure accurate and consistent documentation of residents' code statuses in their records and emergency crash carts led to the deficiency being cited at the immediate jeopardy level, which was later lowered after corrective actions were verified.
Removal Plan
- All residents' signed code status forms will be audited to ensure physician orders match resident preferences.
- Code status spreadsheet will be updated to reflect accurate and current code statuses for each resident.
- Social Services will contact residents without current code status preferences and discuss resident or representative wishes related to code status.
- The Admissions Department will verify and obtain code statuses prior to admission with responsible party.
- Current code status forms will be placed in the code status binder and placed inside crash cart.
- Director of Nursing (DON) will start in-services regarding: Code status policy, Code status spreadsheet, Code status form: DNR/Full Code/Do Not Hospitalize (DNH), Identifying a resident's code status, Education will be provided to all staff currently on duty and prior to any staff coming off duty.
- Resident profile and code status icon on PCC will be audited and updated with current resident wishes related to code status by Unit Managers or designee weekly or upon admission or re-admit.
- Social Services will audit code status book weekly to ensure code statuses for residents are accurate.
- Admissions Department will audit code status forms received and obtained from hospital records weekly for new residents.
- New admissions will be reviewed during clinical meetings to discuss and determine resident code statuses.
- Auditing results will be submitted to Quality Assurance and Performance Improvement (QAPI) and addressed as appropriate.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility staff failed to ensure that the dishwashing machine reached the required temperatures necessary to prevent potential foodborne illness, affecting all residents who consumed food from the kitchen. Observations revealed that the dishwasher's wash cycle temperature was 145 degrees Fahrenheit, and the rinse cycle was 163 degrees Fahrenheit, both below the required minimums of 160 and 180 degrees Fahrenheit, respectively. Interviews with dietary aides and maintenance personnel indicated a lack of knowledge regarding the dishwasher's temperature requirements and the significance of a blinking light on the dishwashing monitor, which signaled low detergent levels. The facility had a census of 75 residents at the time of the observation.
Deficiencies in Infection Control and Water Management
Penalty
Summary
The facility failed to ensure that pre-employment health history screens were reviewed to prevent the potential transmission of contagious diseases for five staff members. The records for Medication Aide-E, Maintenance Worker-H, Nurse Aide-F, Transportation Driver, and Medication Aide-G all showed that their Employee Health Screening forms were not reviewed or signed by a Registered Nurse, as required. The Human Resources department confirmed that these forms were placed in employee files without being reviewed by nursing staff to assess for potential communicable diseases. Additionally, the facility did not ensure that multi-use equipment, such as a Hoyer lift, was sanitized between uses. Observations revealed that Medication Assistants did not sanitize the Hoyer lift after using it with different residents. The Infection Control Coordinator stated that cleaning multi-use equipment should be done between uses by the nursing department. Furthermore, the facility lacked a water management plan to prevent waterborne illnesses, such as Legionella. The Maintenance Director confirmed that there were no measures or monitoring processes in place to prevent the growth of Legionella, and there was no documentation or communication regarding a water management plan.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, as evidenced by several deficiencies observed during a survey. In the 200 wing, the baseboard trim was missing, exposing unfinished and flaking drywall, and there was a visible buildup of gray-black substance in the cracks where the trim was absent. The tile floor was scuffed and stained, with yellow-brown buildup along the edges. Additionally, the wooden handrail was rough and porous due to the varnish wearing off, changing its color from light tan to white-gray. In the 400 wing, the commons sitting area had a television with a splintering crack, rendering part of the screen non-functional. The floor trim was missing, exposing soiled underlayment. The hallway carpet had multiple large stains, and the wallpaper was peeling. An electrical panel had crumbling spackling and warped wallpaper, while the dining room ceiling had reddish-brown stains and a loose electrical outlet. The window was obstructed by a white-gray film and old tape. These issues were confirmed by the facility's Maintenance Director, indicating an unsafe and un-homelike environment.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was reviewed with the resident or their representative and that a copy was provided to them within 48 hours of admission. This deficiency was identified for four residents during the review. The baseline care plan is crucial as it includes instructions needed to provide effective, person-centered care for residents until a comprehensive care plan is developed. For Resident 22, who was admitted with diagnoses including Hemiplegia following a stroke, Pneumonia, and Parkinson's Disease, there was no baseline care plan identified in the medical record. Additionally, there was no documentation that the resident or their representative received a written summary of the baseline care plan. The Director of Nursing Trainer (DONT) confirmed the absence of these documents and the lack of evidence that the required information was provided to the resident or their representative. Similar deficiencies were found for Residents 127, 23, and 13, each with their own set of medical conditions. Resident 127, admitted with Encephalopathy, Severe Malnutrition, and Acute Kidney Failure, also lacked a baseline care plan and documentation of its provision to the resident or representative. Resident 23, with Chronic Respiratory Failure and Severe Obesity, and Resident 13, with Malnutrition and Transient Ischemic Attacks, similarly had no baseline care plans or documentation of their provision. In each case, the DONT confirmed the absence of these critical documents and the failure to provide them to the residents or their representatives.
Improper Blood Glucose Testing Procedures
Penalty
Summary
The facility failed to ensure that staff performed blood glucose testing in accordance with current professional standards for five residents diagnosed with diabetes. The deficiency was identified through observations, record reviews, and interviews, revealing that staff did not follow the proper procedure for blood glucose testing. Specifically, the staff did not wipe away the first drop of blood and obtain a second drop for testing, as required by the facility's procedure. For Resident 47, the medication aide did not follow the procedure of wiping away the first drop of blood before testing, resulting in a blood sugar reading of 130. This was documented in the Medication Administration Record (MAR) for the resident, who had an order for sliding scale insulin. Similar observations were made for Residents 40, 48, 21, and 1, where the staff failed to wipe away the first drop of blood before applying it to the glucometer test strip, leading to potentially inaccurate blood sugar readings. Interviews with the Director of Nursing and the medication aides confirmed that the staff were either unaware or did not adhere to the procedure of using the second drop of blood for testing. The Director of Nursing acknowledged that not following this procedure could result in inaccurate blood sugar readings, which are critical for residents with diabetes who require precise insulin dosing.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 16%. This was identified through multiple observations of medication administration errors involving insulin pens and eye drops. The errors were primarily due to incorrect procedures followed by medication aides during insulin administration, such as not priming the insulin pen correctly by holding the needle tip upward and failing to apply the needle before priming. Additionally, there was an error in administering eye drops, where the medication was not placed in the lower eyelid as required. One specific incident involved a resident with diabetes who was supposed to receive 6 units of Lispro insulin. The medication aide did not prime the insulin pen correctly and failed to apply the needle before priming, leading to a medication error. Another resident with diabetes was observed receiving 2 units of Lispro insulin, but the medication aide again did not prime the pen correctly by holding the needle tip downward instead of upward. These procedural errors were confirmed by the Director of Nursing, who reiterated the correct steps for insulin administration. In another case, a medication aide incorrectly administered Systane eye drops to a resident by placing the drops on the top of the eyelid instead of pulling down the lower eyelid and placing the drop in the lower eyelid pocket. This resulted in the eye drop not being administered correctly, as confirmed by the Director of Nursing. These errors highlight the facility's failure to adhere to established procedures for medication administration, contributing to the high medication error rate.
Deficiency in Staff Training and Competency for Blood Glucose and Insulin Administration
Penalty
Summary
The facility failed to ensure that staff received adequate training and competency assessments for obtaining resident blood glucose levels and using insulin pens, as observed in three staff members. This deficiency was identified through observations, record reviews, and interviews. The facility's procedure for measuring blood glucose using a handheld glucometer requires staff to wipe away the first drop of blood and use the second drop for testing to ensure accuracy. However, staff members did not follow this procedure, potentially leading to inaccurate blood sugar readings. In one instance, a medication aide did not wipe away the first drop of blood when checking the blood glucose level of a resident with diabetes, resulting in a documented blood sugar reading of 130. The Director of Nursing confirmed that the expectation is for staff to follow the procedure to ensure accurate readings. Additionally, the facility's competency checklist for insulin administration did not include steps for using an insulin pen, and the medication aide did not prime the pen correctly, which could lead to incorrect insulin doses. Another medication aide also failed to follow the correct procedure for blood glucose testing and insulin pen use. The aide did not wipe away the first drop of blood and did not prime the insulin pen correctly. The facility was unable to provide adequate training or competency documentation for the staff involved, and the Director of Nursing was unsure of the timeframe for competency assessments. This lack of proper training and assessment could result in potential harm to residents with diabetes due to inaccurate blood sugar readings and incorrect insulin administration.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to honor the bathing preferences of a resident, identified as Resident 27, who was cognitively intact with a BIMS score of 15. Despite the resident's request for a bed bath, the facility staff insisted on showers, which the resident consistently refused. The resident's care plan did not document any preferences regarding bathing methods, and the facility's policy required that such preferences be accommodated. Interviews with staff revealed that the resident's request for a bed bath was denied, and the staff believed that bed baths would not adequately clean the residents. Documentation in the Hall Bath Book and the electronic medical record showed multiple instances of the resident refusing scheduled showers, with no evidence of alternative arrangements being made. The facility's policy stated that if a resident refused a bath due to a preference for a different method, such as a bed bath, the preference should be accommodated. However, the facility did not adhere to this policy, resulting in a failure to support the resident's right to self-determination and choice in their care.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to adequately investigate and implement interventions to prevent falls for Resident #24, who was admitted with multiple diagnoses including Multiple Sclerosis, generalized muscle weakness, seizure disorder, and dementia. The resident experienced several unwitnessed falls over a period of time, with documented incidents on specific dates. Despite the resident's severe cognitive impairment and dependence on staff for mobility and toileting, the facility did not consistently apply the prescribed interventions to mitigate fall risks. Observations and interviews revealed discrepancies in the implementation of fall prevention measures. Although a scoop mattress was recommended as an intervention, the resident's bed was found to have a regular flat mattress on multiple occasions. Additionally, staff interviews indicated a lack of awareness regarding the specific interventions required for the resident, such as the use of a scoop mattress. This inconsistency in applying fall prevention strategies contributed to the resident sustaining a hematoma and laceration requiring emergency room treatment after a fall.
Failure to Conduct Monthly Medication Review
Penalty
Summary
The facility failed to ensure a monthly medication review (MRR) was performed for a resident, identified as Resident 37, which is a requirement to minimize or prevent adverse consequences or unnecessary drug administration. The record review revealed that Resident 37, who was admitted with diagnoses including diabetes, hypertension, and major depressive disorder, did not have MRRs completed for several months, specifically from September 2023 to February 2024. This oversight had the potential for significant medication irregularities to go unidentified, as the resident was on multiple medications, including insulin, antipsychotic, antianxiety, antidepressant, and antiplatelet medications. The care plan for Resident 37 indicated the use of diuretic therapy, which could cause dizziness, hypotension, fatigue, and increased risk for falls. The resident's care plan also noted an increase in antipsychotic medication due to increased anxiety. Despite these complexities in the resident's medication regimen, the facility did not conduct the required monthly reviews for several months, as confirmed by the facility's Infection Control Coordinator, who is responsible for following up on MRRs. This lapse in protocol could have led to unaddressed medication issues, as previous MRRs had noted recommendations for medication adjustments.
Failure to Limit PRN Antipsychotic Use and Inform Resident
Penalty
Summary
The facility failed to ensure that as-needed antipsychotic medications were limited to 14 days of use and that residents or their representatives were informed of the risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use. This deficiency affected one resident, who was admitted with multiple diagnoses including Multiple Sclerosis, generalized muscle weakness, seizure disorder, and dementia. The resident was severely cognitively impaired, requiring assistance with daily activities, and was receiving antipsychotic medications without a gradual dose reduction being attempted or documented as clinically contraindicated. The resident's care plan indicated a potential for verbal and physical aggression, wandering, and care rejection, with interventions including medication administration, offering choices, and psychiatric evaluation. However, there was no documentation of behaviors in July 2024, and the resident's as-needed Haloperidol order lacked a 14-day discontinuation date. The Assistant Director of Nursing confirmed the indefinite use of Haloperidol and acknowledged that the resident had not been seen by a psychiatric provider as planned, nor were the resident or their representative informed about the antipsychotic medication's risks and benefits.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that staff administered insulin correctly, leading to significant medication errors for three residents with diabetes. The errors were observed during insulin administration by medication aides who did not follow the proper procedure for priming insulin pens. Specifically, the aides did not hold the insulin pen with the needle tip upward while priming, which is necessary to remove air and ensure the correct dose is administered. For Resident 40, the medication aide did not apply the needle before priming the pen and attempted to administer insulin without proper priming, resulting in a failed injection attempt. The aide then replaced the needle but did not prime the new needle before administering the insulin. Similarly, for Resident 48, the medication aide primed the pen with the needle tip downward, contrary to the required procedure, before administering the insulin. Resident 16 also experienced a similar error, where the medication aide primed the pen incorrectly by holding the tip downward. The Director of Nursing confirmed that the facility's procedure requires the needle to be applied before priming and the pen to be held with the needle tip upward during priming. These observations indicate a failure to adhere to the established insulin administration protocol, resulting in significant medication errors for the residents involved.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, which had the potential to affect all 75 residents residing in the facility. During an observation, flying insects were seen gathering in the corner of a window in the courtyard, across from two rooms. A resident was observed sitting in their wheelchair in the gazebo in the courtyard area. A wasp nest, approximately the size of a softball, was present in the upper right-hand corner of the window frame, with multiple wasps visibly crawling on the nest and flying to and from it. In an interview, a registered nurse confirmed that residents frequently use the courtyard to enjoy the flowers and weather but denied awareness of any issues with flying insects. The Maintenance Director confirmed the presence of the active wasp nest, which had been observed about a week prior, and admitted not having had the time to exterminate the wasps. The Maintenance Director also stated that the exterminator visits monthly for pest and insect control and acknowledged that the active wasp nest posed a potential hazard to residents wishing to use the courtyard.
Failure to Complete Background Checks Before Employment
Penalty
Summary
The facility failed to ensure that background checks were completed prior to staff working in the facility, which is a violation of their policy on abuse, neglect, exploitation, and misappropriation prevention. The policy mandates that the facility conduct employee background checks and not employ individuals with findings of abuse, neglect, exploitation, or related offenses. However, a review of the employee file for a Medication Aide (MA-E) revealed that the Nebraska Central Registry Check was completed 13 days after the hire date, during which time the employee had already worked with residents. The facility's hiring process checklist requires a Nebraska state-specific APS/CPS Registry Check to be completed, but this was not done before MA-E began working. The timecard report showed that MA-E attended orientation and worked several shifts before the background check was completed. An interview with the facility's Human Resources confirmed that the Central Registry check was not completed before MA-E started working with residents, exposing the facility to potential risks of abuse and neglect.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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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
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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 Scottsbluff
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northfield Retirement Communities Care Center | 1.1 mi | — | 2 | 0 |
| Heritage Estates | 4.4 mi | — | 0 | 0 |
| Mitchell Care Center | 8.2 mi | — | 10 | 0 |
| Chimney Rock Villa | 19.3 mi | — | 1 | 0 |
| Goshen Healthcare Community | 30.6 mi | — | 1 | 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.