Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 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 Omaha Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, total dependence for ADLs, and a documented fall risk with prior falls had a care plan that included Dycem on the wheelchair cushion as a fall-prevention intervention. Policy required staff to ensure appropriate and immediate interventions were implemented after incidents. On multiple observations, including while the resident was in the therapy gym, the wheelchair lacked the care-planned Dycem on or under the cushion. The ADON confirmed the absence of Dycem, resulting in a deficiency for not implementing a prescribed fall intervention.
A resident with a stage four pressure ulcer and chronic pain received a wound dressing change without appropriate pain management, despite exhibiting clear signs of severe pain such as crying, yelling, and verbalizing distress. Staff did not pause the procedure to assess or address the pain, and interviews confirmed that additional pain medication should have been administered prior to the treatment but was not.
An LPN did not perform hand hygiene between glove changes while providing wound care to a resident, contrary to facility policy. The LPN changed gloves multiple times during the procedure without using hand sanitizer or washing hands in between, and later confirmed this omission.
The facility did not follow individualized care plan interventions for two residents: one with a history of falls did not have required fall-prevention measures in place, and another dependent on staff for transfers was assisted by only one staff member instead of two, resulting in a significant leg injury. Staff interviews confirmed a lack of awareness and adherence to care plan requirements.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with multiple chronic conditions and significant pain did not receive several scheduled doses of prescribed medications, including pain management and other treatments, due to delays in pharmacy delivery and the absence of a facility policy for handling unavailable medications. Facility staff confirmed the missed doses and the lack of a system to ensure medication availability.
Two residents with documented medication allergies were prescribed and administered drugs to which they had known or potential allergies. In both cases, alerts for allergies were either overridden or not followed up, and there was no evidence of provider consultation or evaluation. The DON confirmed that the facility lacked a policy for addressing medication allergies.
A resident with multiple chronic conditions and moderate cognitive impairment had conflicting documentation regarding CPR preferences, with both DNR and full code forms present in the record. The facility did not consistently update or confirm the resident's code status in the electronic health record, and staff interviews revealed inconsistent processes for verifying advance directives, leading to a failure to ensure the resident's wishes were clearly documented and communicated.
A resident with multiple medical conditions and a vegetarian diet experienced significant unaddressed weight loss. Staff did not complete a requested re-weigh, failed to assess the weight loss, and did not implement new interventions. Dietary staff were unaware of the resident's nutritional needs, and the resident was observed receiving inadequate meals.
Staff did not follow ordered interventions to prevent pressure ulcers for two residents at risk. One resident was observed in bed without the required Prevalon boot, and another was repeatedly found without heel elevation or use of heel protection boots, despite care plans and practitioner orders. Both staff and residents confirmed these interventions were not consistently implemented.
A resident with multiple diagnoses and a high risk for falls experienced two falls during care due to staff not implementing additional interventions beyond those already in place. The care plan required two staff for bed mobility and proper positioning, but these measures were not consistently followed, and no new interventions were added after the incidents, as confirmed by the DON.
Facility staff did not complete all required background and registry checks for two housekeeping staff members prior to hire, as confirmed by the facility administrator. Facility policy mandates screening for abuse, neglect, exploitation, or misappropriation history before employment, but documentation was missing or incomplete for these employees.
A resident with hypertension, severe sepsis, and diabetes had specific wound care orders for their left foot's second toe, which were not followed by an LPN. Instead of using mild soap and water as ordered, the LPN used saline to cleanse the toe. The LPN acknowledged the deviation from the practitioner's orders during an interview.
The facility failed to maintain a safe and clean environment in nine resident rooms, affecting 14 residents. Observations included unsanitary conditions, structural issues, and non-functional equipment, confirmed by the Maintenance Director and Administrator.
The facility failed to maintain functional ambulation for a resident post-toe amputation surgery, as therapy services were discontinued without a follow-up mobility program, leading to a decline in ambulation. Additionally, another resident did not receive follow-up audiology services for hearing aids, despite a prior recommendation, due to the facility's inaction.
A resident with multiple medical conditions, including post-traumatic seizures, did not receive a complete dose of Dilantin as ordered due to improper medication administration via a gastric tube. The LPN responsible failed to ensure all medication particles were fully dispersed in water, leaving remnants in the cup. This resulted in a significant medication error, as confirmed by the DON.
The facility failed to follow Enhanced Barrier Precautions (EBP) for several residents, including not wearing gowns during high-contact care activities and improper handling of medical equipment. A nursing assistant did not wear a gown while performing catheter care for a resident, and an RN failed to wear a gown while flushing a feeding tube. Additionally, an oxygen nasal cannula was used on a resident after being on the floor, and a stethoscope was not sanitized after use on a resident under EBP.
Failure to Implement Care-Planned Fall Intervention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall intervention for a resident identified as being at risk for falls. The facility’s incident and accident policy dated 12-2023 states that staff are to report, investigate, and review accidents or incidents and ensure appropriate and immediate interventions are implemented to prevent recurrences and improve resident care management. Record review showed that the resident had severe cognitive impairment with a BIMS score of 2 and required total assistance with bed mobility, toileting, dressing, personal hygiene, transfers, and bathing. The resident’s comprehensive care plan identified them as at risk for falls related to incontinence, weakness, osteoarthritis of both hips, and a history of falls at home, and documented multiple fall-related interventions, including the use of Dycem on the wheelchair cushion starting on 11-09-2025 following a fall. The facility incident log showed the resident had falls on 11-09-2025 and 03-15-2026, and the care plan included Dycem to the wheelchair cushion as a fall intervention. However, during observations on 04-01-2026 at 5:50 AM and again at 11:15 AM, the resident’s wheelchair did not have Dycem on or underneath the wheelchair cushion, including while the resident was in the therapy gym working with therapy. In an interview later that day, the Assistant Director of Nursing confirmed that there was no Dycem in place on the resident’s wheelchair cushion. This lack of implementation of the care-planned Dycem intervention for a resident with a known fall risk and prior falls constituted the cited deficiency in ensuring the area was free from accident hazards and that adequate supervision and interventions were provided to prevent accidents.
Failure to Provide Adequate Pain Management During Wound Care
Penalty
Summary
Facility staff failed to implement appropriate pain management interventions during wound care for a resident with a stage four pressure ulcer. The resident, who had diagnoses including depression, osteoarthritis, and chronic pain, was admitted with a significant sacral wound and had a history of almost constant pain, frequently rated as severe. The resident's care plan included both scheduled and as-needed pain medications, specifically acetaminophen and oxycodone, and the facility's policy required staff to anticipate, evaluate, and manage pain in accordance with the resident's assessment and plan of care. On the day of the observed incident, the resident received scheduled acetaminophen and a PRN dose of oxycodone several hours before a negative pressure wound therapy (NPWT) dressing change. During the procedure, the resident exhibited clear signs of pain, including yelling, crying, facial grimacing, and verbalizing distress. Despite these indications, the staff performing the wound care did not pause the procedure to assess the resident's pain or offer additional pain relief. Instead, they continued the treatment while providing only verbal encouragement and distraction techniques. Interviews with staff confirmed that the procedure was known to be painful and that the resident was in significant distress during the dressing change. The Assistant Director of Nursing acknowledged that a PRN dose of oxycodone should have been administered prior to the treatment but was not. The resident later reported experiencing pain at the highest level during the procedure and stated that staff did not offer the option to stop the treatment or address the pain further.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
During wound care treatment for one resident, an LPN failed to perform hand hygiene between glove changes as required by facility policy. The facility's hand hygiene policy, revised in October 2022, specifies that staff must use an alcohol-based hand rub or soap and water before handling clean or soiled dressings, before moving from a contaminated to a clean body site, after handling used dressings and contaminated equipment, and after removing gloves. Observation revealed that the LPN washed hands and donned gloves and a gown at the start of the procedure, but subsequently removed gloves and donned new ones multiple times without performing hand hygiene in between. This sequence occurred while providing wound care to the resident's posterior thighs and right posterior heel. The LPN confirmed in an interview that hand hygiene was not performed between glove changes and acknowledged that it should have been done.
Failure to Implement Care Plan Interventions for Transfers and Fall Prevention
Penalty
Summary
The facility failed to implement and follow individualized care plan interventions for two residents, resulting in a significant injury for one and failure to prevent potential falls for another. For one resident with moderate cognitive impairment and a history of repeated falls, the care plan included specific interventions such as pinning the top blankets to the fitted sheet to prevent entanglement and offering bathroom assistance at designated times. Multiple observations revealed that the top covers were not pinned as required, and staff interviews confirmed a lack of awareness regarding this intervention. This failure to implement the care plan intervention was directly observed on several occasions and acknowledged by both nursing assistants and an LPN. For another resident with cirrhosis, muscle weakness, generalized edema, and diabetes, the care plan specified that transfers from bed to wheelchair required two staff members and the use of a slide board or Hoyer lift. Despite this, the resident was transferred by only one staff member, a Certified Medication Aide, without the use of a gait belt or slide board. The aide reported that the resident claimed to transfer independently and instructed the aide on how to position the wheelchair. During the transfer, the resident sustained a laceration to the left lower leg after hitting the wheelchair pedal bracket, requiring hospital transport and stitches. Interviews with staff and the resident confirmed that only one staff member was present during the transfer, contrary to the care plan requirements. Facility policies reviewed indicated that individualized care plans are to be developed and interventions provided according to professional standards and the resident's needs. The failure to follow these care plans and ensure staff awareness of required interventions led to a significant injury and the lack of fall prevention measures for the residents involved. The deficiencies were identified through observation, record review, and staff interviews.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were consistently available and administered as ordered for a resident with multiple chronic conditions, including pneumonia, chronic inflammatory demyelinating polyneuritis, neuropathy, chronic pain, and osteoarthritis. Record reviews showed that the resident was admitted with significant pain and required scheduled and PRN pain medications, among other treatments. Despite these needs, the Medication Administration Records (MARs) revealed multiple instances where prescribed medications, including buprenorphine for pain, fish oil, polyethylene glycol, lubiprostone, Bactrim DS, and Metamucil, were not administered on several dates across multiple months. Notably, there were 11 consecutive missed doses of buprenorphine and several other missed doses of various medications. Interviews with facility staff, including the Unit Manager and DON, confirmed that the resident did not receive all scheduled medications on the identified dates. The DON further confirmed that some missed doses were due to waiting for pharmacy delivery, and acknowledged that the facility did not have a policy regarding unavailable medications. The lack of a system or policy to ensure timely medication availability and administration directly contributed to the resident not receiving necessary medications as ordered.
Failure to Evaluate and Address Medication Allergies
Penalty
Summary
The facility failed to properly evaluate and address medication allergies for two residents. For one resident with a history of respiratory failure, COPD, pneumonia, and chronic inflammatory demyelinating polyneuritis, records showed an allergy to Bactrim with a previously observed mild adverse reaction resulting in increased serum creatinine. Despite this documented allergy, the resident was prescribed and administered Bactrim DS on multiple occasions, and the provider overrode the allergy alert without documented consultation or follow-up in the electronic health record. The Director of Nursing confirmed that the allergy was not addressed at the time of order entry and that there was no facility policy regarding medication allergies. Another resident with acute respiratory failure and documented allergies to aspirin, codeine, penicillin, and zaleplon was prescribed Diclofenac sodium gel, a nonsteroidal anti-inflammatory drug. An alert for a possible drug allergy was generated in the electronic medical record, but there was no evidence of evaluation or follow-up regarding the potential allergy to Diclofenac. The Director of Nursing confirmed that no follow-up was completed and that the facility lacked a policy for addressing potential drug allergies when alerts were triggered.
Failure to Ensure Accurate and Updated Advance Directive Documentation for Code Status
Penalty
Summary
The facility failed to ensure that a signed Advance Directive Code Status Form was properly completed and updated to confirm a resident's directives for Cardiopulmonary Resuscitation (CPR). The resident in question had multiple diagnoses, including Type 2 Diabetes Mellitus, congestive heart failure, and chronic obstructive pulmonary disease, and was assessed as having moderate cognitive impairment. Upon admission, the resident's care plan indicated full code status, and interventions required quarterly review of code status during care plan conferences. However, there were inconsistencies in the documentation of the resident's code status. The medical record contained both a form signed by the resident's representative indicating Do Not Resuscitate (DNR) and a form signed by the resident indicating full code. Hospital discharge orders also indicated DNR status, but the facility's electronic health record did not reflect an updated Advance Directive Code Status form confirming the DNR status. Multiple orders and practitioner notes alternated between DNR and full code, and the process for updating and confirming code status was not consistently followed as outlined in facility policy. Interviews with facility staff revealed that code status was typically determined at admission and entered into the medical record, but there was no consistent process for verifying or updating this information, especially on readmission or during care plan reviews. The facility's policy required that advance directives be reviewed, validated, and communicated to the care team, but this was not consistently documented or implemented for the resident. As a result, there was a failure to ensure the resident's wishes regarding CPR were clearly documented and communicated prior to an emergency event.
Failure to Address Significant Weight Loss and Dietary Needs
Penalty
Summary
Facility staff failed to evaluate and implement interventions to prevent significant weight loss for a resident with multiple medical conditions, including hyperlipidemia, hypokalemia, muscle weakness, dysphagia, and protein calorie malnutrition. The resident, who followed a lacto-ovo-vegetarian diet, experienced a weight loss of 20.4 lbs (11.11%) over 90 days. Despite this significant weight loss, there was no documented assessment or follow-up by the registered dietitian (RD) or other staff after a re-weigh was requested. The care plan did not include specific interventions to address the resident's vegetarian diet or food preferences, and the dietary staff were unaware of how to meet the resident's nutritional needs. Observations showed the resident was served inadequate meals, such as a salad without protein or dressing and a small drink, which the resident expressed dissatisfaction with. Interviews with the dietary supervisor and RD revealed a lack of awareness regarding the resident's significant weight loss and dietary needs. The director of nursing confirmed that the re-weigh requested by the RD was not completed and that no new interventions were implemented despite the resident's ongoing weight loss.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
Facility staff failed to implement ordered interventions to prevent pressure ulcer development for two residents identified as at risk. For one resident with multiple diagnoses including malnutrition, muscle weakness, and impaired cognition, the care plan and practitioner orders required the use of a Prevalon boot on the left foot while in bed. Observations on multiple occasions revealed the resident was in bed without the Prevalon boot, and the device was found on the chest of drawers instead of being used as ordered. A nursing assistant confirmed the boot was not in place during an interview. For another resident with diagnoses including schizoaffective disorder, depression, and obesity, the care plan and practitioner orders required the resident's heels to be elevated while in bed to prevent skin breakdown. Multiple observations showed the resident in bed without their feet elevated, and heel protection boots were found on top of the dresser rather than in use. The resident reported that staff did not elevate their feet or use the heel boots, and a nursing assistant confirmed the resident's feet were not elevated during an interview.
Failure to Implement Additional Fall Prevention Interventions
Penalty
Summary
Facility staff failed to implement additional interventions to prevent falls for a resident who was identified as being at risk for falls. The resident, who had diagnoses including schizoaffective disorder, depression, obesity, and required assistance with personal care, was assessed as cognitively intact and dependent on staff for transfers and bed mobility. The resident's care plan included interventions such as keeping the bed in the lowest position, ensuring appropriate footwear, and requiring two staff members for bed mobility. Despite these interventions, the resident experienced two falls during care provision, one in which the resident's legs hung over the bed and they were lowered to the floor, and another where the resident slid off the bed. After the first fall, the only intervention added was to ensure the resident was positioned in the middle of the bed. Following the second fall, the intervention was updated to require two staff for bed mobility. The Director of Nursing confirmed that two staff should have been assisting during both incidents and that the resident should have been positioned in the middle of the bed, but no new interventions were implemented after these falls.
Failure to Complete Required Employee Background and Registry Checks
Penalty
Summary
Facility staff failed to complete required background and registry checks for two of five employee files reviewed. Specifically, one housekeeping staff member was hired without documentation of a Nurse Aide registry check, and another housekeeping staff member was hired with only Adult/Child Protection Services background checks completed, lacking other required screenings. The facility administrator confirmed during interview that the necessary background checks had not been completed for these two staff members. Facility policy requires screening of potential employees for history of abuse, neglect, exploitation, or misappropriation prior to hire, including documentation from licensing or registration boards and other registries.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility staff failed to follow the practitioner's orders for wound care for a resident with a history of hypertension, severe sepsis with septic shock, and diabetes. The resident was admitted with a specific treatment order for the left foot's second toe, which included cleaning with mild soap and water, applying betadine, and covering with a non-adherent dressing. However, during an observation, an LPN was seen using saline instead of mild soap and water to cleanse the toe, which was not in accordance with the practitioner's orders. The LPN confirmed during an interview that the correct procedure was not followed.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed in nine rooms on the second-floor north hallway. These deficiencies included unsanitary conditions such as a dark brown smeared substance resembling bowel movement on a toilet riser and seat, and a ventilation cover in a resident bathroom covered with a gray fuzzy substance resembling dust. Structural issues were also noted, such as an open and exposed floor radiator cover, missing and damaged drawer components in dressers, gouged and broken floor tiles, and protruding sharp edges from vent covers and baseboards. Additional observations included a continuously running shared toilet, a non-functional bathroom vent, and various holes and cracks in the drywall. The environmental tour conducted with the Maintenance Director and Administrator confirmed these issues, which had the potential to affect all 14 residents utilizing the affected rooms. The facility census at the time was 58, indicating that a significant portion of the resident population was impacted by these environmental deficiencies.
Failure to Maintain Ambulation and Follow Up on Audiology Appointment
Penalty
Summary
The facility staff failed to maintain functional ambulation for a resident who had undergone toe amputation surgery earlier in the year. Despite being cognitively intact and having a history of high blood pressure, peripheral vascular disease, end-stage renal disease, diabetes mellitus type 2, and heart failure, the resident reported not receiving therapy and feeling weaker post-surgery. The resident's last recorded physical and occupational therapy session was in mid-February, and there was no subsequent functional mobility program implemented. The Director of Rehabilitation confirmed the resident had not received therapy services since then, leading to a decline in the resident's ability to ambulate. Additionally, the facility staff did not follow up on an audiology appointment for another resident who was supposed to be fitted for hearing aids. This resident, also cognitively intact, had a history of diabetes mellitus, Parkinson's disease, heart failure, and high blood pressure. The resident had an audiology appointment in March of the previous year, with a recommendation to be fitted for hearing aids within 1-3 months. However, there were no further audiology appointments recorded, and the Director of Nursing confirmed the facility did not assist the resident in obtaining the hearing aids.
Incomplete Medication Administration via G-Tube
Penalty
Summary
The facility failed to ensure that a resident received a complete dose of seizure medication as ordered, resulting in a significant medication error. Resident 34, who was admitted with multiple diagnoses including cerebral infarction, hydrocephalus, and post-traumatic seizures, was dependent on staff for all activities of daily living and received all nutrition and medications through a gastric tube. The resident had a physician's order for Dilantin 100 mg every 8 hours via the g-tube. During an observation, it was noted that the LPN responsible for administering the medication crushed the Dilantin tablet and mixed it with water, but visible remnants of the medication remained in the cup after administration, indicating that the full dose was not delivered to the resident. The facility's policy for medication administration via feeding tube requires that tablets be crushed to a fine consistency and fully dispersed in water before administration. However, the LPN did not ensure that all particles were in solution, leading to the incomplete administration of the medication. The Director of Nursing confirmed that the resident did not receive the complete dose of Dilantin, which constituted a significant medication error. This incident highlights a failure in adhering to the facility's medication administration procedures, resulting in a deficiency in the care provided to Resident 34.
Infection Control Deficiencies in EBP and Equipment Handling
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) during care activities for several residents, as observed by surveyors. For Resident 215, nursing assistants NA-D and NA-E did not wear gowns while performing catheter care, despite the EBP sign on the resident's door indicating the requirement for gown and glove use. Both the nursing assistants and the Director of Nursing (DON) acknowledged the oversight. Similarly, for Resident 53, Registered Nurse (RN) F did not wear a gown while flushing the resident's feeding tube, even though the care plan and EBP signage specified the need for gown and glove use due to the resident's high risk of infection from a multidrug-resistant organism (MDRO). In another instance, the facility failed to maintain proper infection control practices concerning oxygen equipment. An oxygen nasal cannula for Resident 3 was observed lying on the floor, and later, a nursing assistant placed the same cannula into the resident's nose without cleaning it. The facility's policy requires that any nasal cannula that comes into contact with the floor should be replaced, a fact confirmed by both the nursing assistant and the DON. Additionally, the facility did not ensure proper sanitization of medical equipment used on residents under EBP. LPN H used a stethoscope on Resident 34, who was under EBP, and failed to sanitize it before leaving the room. The stethoscope was then carried to another area of the facility, potentially risking cross-contamination. The DON confirmed that the stethoscope should have been cleaned before being taken out of the resident's room.
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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 Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Nursing & Rehab Omaha | 1.2 mi | — | 31 | 0 |
| Douglas County Health Center | 2.5 mi | — | 2 | 0 |
| Emerald Nursing & Rehabilitation Mercy | 2.8 mi | — | 16 | 0 |
| The Cypress At Midtown | 2.9 mi | — | 1 | 0 |
| St. Joseph Villa Nursing Center | 3.7 mi | — | 27 | 0 |
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