Maple Crest Health Center: Medication Omission Errors - NE
The resident, identified in inspection records only as Resident 5, lives at Maple Crest Health Center on North 66th Avenue. They carry a diagnosis list that leaves little margin for error: end-stage renal disease requiring dialysis three days a week, Type 2 diabetes, atrial fibrillation, chronic obstructive pulmonary disease, and chronic heart failure. They have moderate cognitive impairment and require total staff assistance for bathing, dressing, toileting, and getting in and out of bed.
On April 24, Resident 5 left the facility for a Monday dialysis appointment. The morning medications went with no one.
One of those medications was metoprolol tartrate, 25 milligrams, prescribed for 9 AM. Metoprolol lowers resting heart rate, reduces the heart's workload, and brings down blood pressure. For a patient with atrial fibrillation and chronic heart failure, missing a dose is not a minor inconvenience. The second missed medication was linagliptin, a diabetes drug.
The facility's own medication administration record for April flagged both omissions with a code 3, indicating the resident did not receive the medications because they were away from the facility without them.
A progress note from that same day documents what followed. Morning medications had not been given because the resident was at dialysis. By the time the gap was recognized, Resident 5's heart rate was 116. A physician wrote an order to give the metoprolol immediately.
The Director of Nursing confirmed both omissions during an interview with inspectors on April 30. She said Resident 5 did not receive the metoprolol or the linagliptin that morning, and that a medication omission was an error.
State inspectors cited the facility for failing to ensure residents were free of significant medication errors, a violation rated at minimal harm or potential for actual harm. The inspection, triggered by a complaint, was completed April 30. Maple Crest had 151 residents at the time. Inspectors reviewed one resident for this deficiency. That resident was Resident 5.
The care plan for Resident 5, revised just eleven days before the incident on April 13, documented the Monday, Wednesday, Friday dialysis schedule. The routine was not a surprise. Neither was the 9 AM medication window. The two facts sat in the same record, and the morning of April 24 they failed to connect.
What the inspection does not explain is who was responsible for sending medications with the resident to dialysis, whether a policy existed for doing so, and whether anyone reviewed the care plan before the transport. The record shows only that the medications stayed behind, that the resident came back with a heart rate of 116, and that a doctor had to intervene with an unscheduled dose.
Resident 5 has moderate cognitive impairment. They could not have flagged the omission themselves. They needed total assistance for nearly every physical task that morning, and they needed someone to make sure their heart medication made the trip to dialysis. Neither happened.
The physician's order to give metoprolol after the fact addressed the immediate problem. What it could not undo was the window between the missed 9 AM dose and the moment someone measured a heart rate of 116 and reached for the phone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Maple Crest Health Center from 2026-04-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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
Maple Crest Health Center in Omaha, NE was cited for violations during a health inspection on April 30, 2026.
The resident, identified in inspection records only as Resident 5, lives at Maple Crest Health Center on North 66th Avenue.
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.