Sarah Ann Hester Memorial Home: Fall Death Unreported - NE
When Sarah Ann Hester Memorial Home submitted the required incident report to Nebraska state regulators, the document left out nearly everything that mattered.
The fall happened early on a morning that inspectors, in keeping with standard practice, redacted from the report. The resident, identified only as Resident 2, had been care-planned to use a wheelchair at all times. She had dementia, meaning she could not reliably judge when she needed help or remember to call for it. She had ataxic gait, a neurological condition that makes walking unstable even under the best circumstances. She had osteoarthritis and chronic obstructive pulmonary disease. She had a history of multiple falls at the facility before this one. Her blood pressure was chronically low.
None of that appeared in the report the facility sent to the state.
Inspectors reviewed the investigation document the facility had submitted following the fall. The facility's administrator confirmed, in an interview on the day of the inspection, that the report did not include the resident's weakness as a contributing cause. It did not include her dementia, her COPD, her ataxic gait, or her osteoarthritis. It did not address whether her medications had been reviewed. It did not mention her chronically low blood pressure. It did not include her symptoms from the days before she fell.
The administrator confirmed all of this. The omissions were not in dispute.
What the nursing notes did contain was a picture of a resident who had been struggling for days. A week before the fall, she had been sick for two days. In the hours around the fall, her vital signs told a grim story: at 12:05 in the morning, her temperature was 100.8 degrees Fahrenheit and her oxygen saturation was 84 percent on room air, a level low enough to indicate serious respiratory distress. A minute later, with supplemental oxygen running at three liters per minute, it climbed to 95 percent. By 3:00 in the morning, her temperature was still elevated at 100.4 degrees. After the fall itself, her blood pressure lying down was 95 over 49. Sitting up, it was 105 over 42. The nursing note described her blood pressure as chronically low.
The Director of Nursing, interviewed on the day of the inspection, said the cause of the fall was weakness. One possible cause of that weakness, the DON said, was the resident's low hemoglobin, a condition that reduces the blood's ability to carry oxygen through the body. The resident had previously declined treatment for the low hemoglobin.
She was transported to the emergency room at 11:00 that morning. She had fractured her left femoral neck, the section of bone at the top of the thigh that connects to the hip joint. The hospital admission confirmed she had pneumonia.
She was placed on comfort care. She died.
The administrator confirmed to inspectors that the investigation report submitted to the state was the document that had been filed following the fall. The administrator confirmed it was incomplete.
The facility had 30 residents at the time of the inspection.
What regulators found was not a facility that had failed to file a report. The report existed. It had been submitted. The problem was what the report contained, or more precisely, what it did not. An investigation is supposed to capture the full picture of what happened to a resident and why, so that regulators can assess whether the care was appropriate and whether the fall could have been prevented or responded to differently. The investigation Nebraska regulators received after this resident broke her hip and died contained no mention of the constellation of conditions that made her vulnerable, no accounting of her vital signs in the hours before the fall, no review of whether her medications played a role, and no documentation of the pneumonia that was diagnosed when she reached the hospital.
The facility's investigation report was undated.
The safety alarms in the resident's room were functioning at the time of the fall. She had attempted a self-transfer without calling for staff. Her mental status before the fall was described as confused. She had been sick the week before. Her oxygen levels in the middle of the night were critically low. Her blood pressure, both before and after the fall, was dangerously depressed. All of that existed in the nursing notes. None of it made it into the report that went to the state.
The inspection, conducted as a complaint investigation and completed on April 30, 2026, cited the facility under Nebraska licensure reference 175 NAC 12-006.02(G) for failing to complete and submit a thorough investigation for a reportable incident. The level of harm was assessed as minimal harm or potential for actual harm. The deficiency affected one of three residents whose reportable incidents were reviewed.
That regulatory language, minimal harm or potential for actual harm, applies to the deficiency itself, the incomplete paperwork. It does not describe what happened to the resident. She fell, broke her hip, was found to have pneumonia, was placed on comfort care, and died. The report the facility filed with the state left out the details that would have allowed anyone reading it to understand how sick she already was, how many risk factors had converged in that room in the early morning hours, and whether anything in her care in the days before the fall might have changed what happened next.
The administrator did not dispute that the report was incomplete. The director of nursing identified weakness as the cause of the fall and named low hemoglobin as a possible source of that weakness. Neither the weakness nor the hemoglobin appeared in the investigation the facility submitted.
She had multiple falls before this one. She had been care-planned to stay in a wheelchair. She had a lung disease, a gait disorder, dementia, and blood that could not carry enough oxygen. At 6:35 in the morning, she was on the floor.
The state received a document that did not say any of that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sarah Ann Hester Memorial Home 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
Sarah Ann Hester Memorial Home in Benkelman, NE was cited for violations during a health inspection on April 30, 2026.
When Sarah Ann Hester Memorial Home submitted the required incident report to Nebraska state regulators, the document left out nearly everything that mattered.
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.