Douglas County Health Center

In the surveyor’s words

From the most serious findings on record at Douglas County Health Center, in the surveyor’s own words.

• Actual harm, isolatedF760Oct 30, 2025

  Licensure Reference Number 175 NAC 12-006.10(D). Based on interview and record review the facility failed to ensure residents were free of significant medication errors for 3 (Resident 1, 4 and 5) of 5 residents sampled. The facility census was 233. The findings are:Record review of the facility's policy dated 02-22-2022 titled Medication Administration revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Staff are to obtain and record vital signs, when applicable or per physician orders. […]

• Actual harm, isolatedF686Feb 1, 2022

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D2b Based on observation, record review and interview; the facility staff failed to monitor and evaluate causal factors for the development of pressure ulcers for 1 (Resident 177) of 3 resident sampled. The facility staff identified a census of 188. Findings are: Record review of Resident 177's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 12-29-21 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was assessed as a 3. […]

• No harm, potential for more than minimal, widespreadF812May 13, 2025

  Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review the facility failed to utilize beard restraints while preparing food in facility kitchen. This had the potential to affect 231 of the 235 residents in the facility. The facility census was 240. The findings are: Record review of the Nebraska Food Code 2-402.11 revealed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service items. […]

• No harm, potential for more than minimal, widespreadF812May 16, 2023

  Licensure reference: 175 NAC 12-006.11E Based on observation and interview, the facility failed to ensure glove changes were completed during food preparation and service to prevent potential food borne illness. This has the potential to affect 208 residents who eat meals prepared in the kitchen. The facility had a total census of 216 residents. Findings are: Observations of tray line on 5/15/23 between 11:45 AM-12:03 PM revealed Cook-F wearing gloves to open freezer door to obtain pizza then with same gloves used hands to place sausage on pizza. Cook-F continued with food preparation without changing gloves including handling precook hamburgers and tomato and lettuce for hamburgers. […]

• No harm, potential for more than minimal, widespreadF880Feb 1, 2022

  Licensure Reference Number 175 NAC 12-006.17A(2) Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review; the facility failed to ensure all staff and visitors were screened for COVID-19 prior to entrance into the facility. This had the potential to affect all residents that resided in the facility. The staff failed to change gloves during [CONDITION(S)] [([CONDITION(S)]) a tube inserted in a person's throat to allow free airflow] care to prevent cross-contamination (bacteria moving from one source to another) for Resident 106, and failed to utilize hand washing and gloving techniques to prevent cross contamination and failed to clean scizzors before and after treatments for Resident 177. Total census was 188. Findings are: A. […]