Douglas County Health Center
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm
resident's chest was dated 09-30-2025 and was to be changed on 10-07-2025. Record review of Resident 5's MER dated 10-12-2025 revealed Buprenorphine 10 mcg/hour patch was omitted on 10-07-2025, a new patch was placed on 10-12-2025 and the MAR was updated to reflect the new dates to change the patch going forward. An interview with UM-F on 10-30-2025 at 11:55 AM confirmed Resident 5's Buprenorphine 10mcg/hour patch was not changed on 10-07-2025 and should have been.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Douglas County Health Center
4102 Woolworth Avenue Omaha, NE 68105
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was scheduled to be given at bedtime and was given at 9:00 AM. An interview conducted on 10-30-2025 at 11:55 AM confirmed Resident 5 received temazepam at 9:00 AM in error. Record review of Resident 5's MAR for October 2025 revealed an order for Buprenorphine 10 micrograms (mcg)/hour patch (an opioid medication used to manage severe or chronic pain). Apply topically every 7 days on Sundays for chronic pain. Record review of Resident 5's PN dated 10-12-2025 revealed Resident 5's Buprenorphine 10mcg/hour patch was changed on 10-12-2025. The patch found on the resident's chest was dated 09-30-2025 and was to be changed on 10-07-2025. Record review of Resident 5's MER dated 10-12-2025 revealed Buprenorphine 10 mcg/hour patch was omitted on 10-07-2025, a new patch was placed on 10-12-2025 and the MAR was updated to reflect the new dates to change the patch going forward. An
interview with UM-F on 10-30-2025 at 11:55 AM confirmed Resident 5's Buprenorphine 10mcg/hour patch was not changed on 10-07-2025 and should have been. Record review of Resident 5's PN dated 10-17-2025 revealed Resident 5 received the wrong medications. Record review of Resident 5's MER dated 10-17-2025 revealed Resident 5 had received another resident's medications at 9:00 AM. An
interview with UM-F on 10-30-2025 at 2:55 PM confirmed Resident 5 received the following medications in error:-apixaban 5mg (an anticoagulant medication used to keep blood from clotting),-Hydrochlorothiazide 12.5mg (a thiazide diuretic medication used for high blood pressure and swelling),-Losartan 100mg (a medication to treat high blood pressure), and-Olanzapine 5 mg (an antipsychotic medication used to treat schizophrenia or bipolar disorder). Record review of Resident 5's MAR for October 2025 revealed an order for Entresto Oral Tablet 24-26 mg, give 1 tablet twice a day for Congestive Heart Failure, hold if Systolic Blood Pressure (SBP: the top number of a blood pressure reading) is less than 90. Review of this order also revealed an SBP of 86 on 10-03-2025 and the Entresto was documented as administered, and an SBP of 85 on 10-29-2025 and the Entresto was documented as administered. An interview with UM-F on 10-30-2025 at 2:55 PM confirmed Resident 5 had received Entresto 24-26mg on 10-03-2025 and 10-29-2025 when it should have been held according to the practitioner's orders and was administered in error.
Event ID:
Facility ID:
If continuation sheet
Douglas County Health Center in Omaha, NE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Omaha, NE, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Douglas County Health Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.