Douglas County Health Center: Pain Patch Missed - NE
The patch, delivering 10 micrograms of buprenorphine per hour, had been placed on the resident's chest on September 30, 2025. It was due to be swapped out on October 7. It wasn't. The resident wore the same patch for five additional days before anyone intervened. A new one was finally placed on October 12.
Buprenorphine patches are designed to release a controlled amount of medication steadily through the skin over a fixed period. When a patch is left in place past its scheduled change date, the medication delivery drops off. The resident in this case went without a proper dose during that window.
A unit manager confirmed the lapse during an interview with inspectors on October 30. The patch, she said, was not changed on October 7 and should have been.
What the medication administration record shows is that after the new patch went on October 12, staff updated the chart to reflect the new change schedule going forward. The record of what happened between October 7 and October 12 remained: a single omission notation, and five days of a resident receiving less pain relief than their care plan called for.
The inspection was a complaint survey, meaning someone had flagged a concern at the facility before investigators arrived. Inspectors cited the deficiency under F0697, which covers pain management, and characterized the level of harm as minimal harm or potential for actual harm. A few residents were noted as affected.
That classification reflects the regulatory floor, not necessarily what the resident experienced. A buprenorphine patch at 10 micrograms per hour is not a low-stakes medication. It is prescribed when a person's pain requires around-the-clock management. A gap in coverage is not a paperwork problem.
Douglas County Health Center is a county-run facility on Woolworth Avenue in Omaha. The inspection was completed October 30, 2025.
The resident whose patch was missed is identified in inspection records only as Resident 5. What the record does not say is whether anyone told them why their pain may have felt different that week, or whether anyone told them at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Douglas County Health Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Douglas County Health Center in Omaha, NE was cited for violations during a health inspection on October 30, 2025.
The patch, delivering 10 micrograms of buprenorphine per hour, had been placed on the resident's chest on September 30, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.