Maple Crest Health Center
Maple Crest Health Center in Omaha, NE — inspection on April 30, 2026.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review the facility
sampled.
The facility census was 151.
The findings are:A.
Record review of the facility policy titled Change in Condition dated 05-21-2023 revealed it is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate.
The resident and/or their representatives will be educated about treatment options and supported to make an informed choice about care preferences when there are multiple care options available.
All pertinent information will be made available to the provider by the facility staff.
Requirements for notification of resident, the resident representative and their physician:-an accident involving the resident, which results in injury and has the potential for requiring physician intervention. -a significant change in the resident's physical, mental, or psychosocial status.-a need to alter treatment significantly such as the need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. B.
Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 01-26-2026 revealed the facility staff assessed the following about the resident:-admitted to the facility on [DATE].-had a diagnosis of Cerebral Vascular Accident (stroke) affecting the right side of the body.-Brief Interview of Mental Status (BIMS) was scored as a 5.
According to the MDS Manual a score of 0-7 indicates a person has severe cognitive impairment. -required total assistance with toileting, hygiene, dressing, bed mobility, transfers and bathing.-was frequently incontinent of bladder.-was always incontinent of bowel. -did not have a pressure ulcer.
Record review of Resident 1's Tissue Analytics Document (TAD) dated 03-03-2026 revealed Resident 1 had developed a new wound on the right ankle and a new Deep Tissue Injury to the left heel.
Record review of Resident 1's Progress Notes revealed no indication Resident 1's representative was informed of the new wounds on the right ankle or left heel. An interview conducted with Licensed Practical Nurse (LPN) C on 04-30-2026 at 3:41 PM confirmed Resident 1's representative was not updated of the new wounds to the right ankle and left heel and should Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
establish a grievance policy and make prompt efforts to resolve grievances.
failed to resolve grievances and provide grievance resolution response for 1 (Resident 10) of 2
facility policy entitled Grievances dated reviewed/revised 08/25/2026 revealed: - 9.
Upon receipt of a written grievance/complaint, Social Services and Department Managers will investigate the allegations and submit a written report of such findings to the administrator.
The investigation and report will include, as each may apply: -a.
The date and time of the alleged incident; -b.
The circumstances surrounding the alleged incident; -c.
The location of the alleged incident; -d.
The names of any witnesses and their account of the alleged incident; -e.
The resident's account of the alleged incident; -f.
The employee's account of the alleged incident; -g.
Accounts of any other individuals involved (i.e., employee's supervisor, etc.); and -h.
Recommendations for corrective action. -9.
The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. -10.
The resident or person filing the grievance and/or complaint in behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems in a timely manner. A written summary of the report will also be provided to the resident if requested, and a copy will be filed in the Social Services office.B.
Record review of Resident or Family Concern/Grievance Report Form (grievance form) received from Social Worker (SW)-A on 04/28/2026 at 10:46 AM revealed Resident 10's family member had submitted a grievance on 03/02/2026 regarding a staff member's attitude towards Resident 10 and the family member.
The rest of the grievance form including the resolution and administrator review were incomplete.
Record review of a grievance form received on 04/28/2026 at 2:18 PM from the Social Services Supervisor (SSS) detailed the grievance received by the facility on 03/02/2026 revealed the grievance of a staff member's attitude towards Resident 10 and their family member.
The form was completed to include resolution and follow up with Resident 10 and their family member via a one-to-one discussion dated 03/10/2026.Interview on 04/28/2026 at 10:45 AM with the SSS revealed the facility was in receipt of a grievance regarding a concern with a staff member's attitude. SSS further revealed the grievance was written and was being processed.Interview on 04/28/2026 at 10:46 AM with SW-A revealed the grievance form was incomplete because SW-A was awaiting the permanent interventions from the Director of Nursing or Assistant Director of Nursing.Interview on 04/28/2026 at 10:59 AM with the Assistant Director of Nursing (ADON) revealed the ADON spoke with the staff member in question regarding the grievance.
The staff member denied the allegation.
The ADON reported the staff member was removed from Resident 10's care and education was provided.Interview on 04/28/2026 at 11:05 AM with the facility Administrator (ADM) revealed the ADM was unaware of the grievance until 04/28/2026 due to the ADM was not at the facility at the time of the grievance.Interview on 04/28/2026 at 3:33 PM with SSS revealed the facility provided grievance resolution on 03/10/2026 to Resident 10 and their family member.Phone interview 04/29/2026 at 10:47 AM with Resident 10's family member revealed the grievance filed was related to a staff member's attitude. Resident 10's family member further revealed that [gender] had not been notified of the resolution of the grievance filed.Interview on 04/29/2026 at 11:50 AM with the ADM revealed a reasonable time frame for grievance resolution was within 10-14 days, which included the form completion and review.During a follow up interview on 04/30/2026 at 11:45 AM, SW-A confirmed the grievance form was not complete when originally provided to surveyors on 04/28/2026 because the permanent grievance resolution was unknown.
SW-A reported they informed Resident 10 and the family member of resolution the facility would normally implement in these types of grievances, not the permanent and grievance-specific resolution provided for Resident 10. SW-A further confirmed the grievance was not completed until 04/28/2026.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
distal bruise measure 0.5 cm x 0.5 cm; and antecubital fossa (the fold in the elbow) measured 7 cm x
abuse.Interview on 04/29/2026 at 11:50 AM with the facility Administrator (ADM) confirmed law
not report bruising to the Police Department.Interview on 04/29/2026 at 12:36 PM with the SSS confirmed the allegation of physical abuse was not reported to law enforcement and should have been.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
reviewed, and revised by a team of health professionals.
record review and interview, the facility failed to update the comprehensive care plan (CCP, a
and mental and psychosocial needs that are identified in the comprehensive assessment) to reflect the current resuscitation status for 1 (Resident 10) of 15 sampled residents.
The facility staff identified a census of 151.Findings are:A.
Record review of facility policy entitled Comprehensive Care Plans dated reviewed/revised 09/02/2025 revealed the CCP would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set ((MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) assessment.B.
Record review of Resident 10's MDS dated [DATE] revealed the facility admitted Resident 10 on 09/23/2024.
Further review of the MDS revealed Resident 10 had a condition or chronic disease that may result in a life expectancy of less than six months, and Resident 10 was receiving hospice services.
Record review of Resident 10's Do-Not-Resuscitate Order (DNR) dated 04/03/2026 revealed Resident 10's representative requested a DNR resuscitation status.
Record review of Resident 10's Order Listing Report identified an order Do Not Resuscitate dated 04/22/2026.
Record review of Resident 10's CCP printed 04/28/2026 at 9:18 AM revealed Resident 10 had a full code, do not resuscitate status dated 10/02/2024.Interview on 04/28/2026 at 3:33 PM with the Social Services Supervisor (SSS) revealed the facility had updated the care plan on 04/28/2026.
The SSS further confirmed the code status should have been updated at the time of the code status change.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
According to the MDS Manual a score of 12 indicates moderate cognitive impairment.-required set up and clean up assistance with eating.-required total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers.-was receiving dialysis services.
Record review of Resident 5's Order Listing Report (OLR) printed on 04-28-2026 revealed an order for wound care for the buttocks and coccyx (tailbone) area as follows:-cleanse with foam soap and water and pat dry-apply preventative ointment up to 4 times a day and as needed for soiling-secure with a sacral mepilex dressing (according to the manufacturer Molnlycke Health Care, mepilex sacral dressing is a self-adherent, 5-layer, silicone foam dressing specifically shaped for the sacral area to treat and prevent pressure injuries).
Record review of Resident 5's Nurse Administration Record (NAR) for April 2026 revealed no order for wound care to the buttocks and coccyx area. An observation conducted on 04-30-2026 at 10:40 AM during the provision of incontinence care for Resident 5 revealed pink skin discoloration to the sacral area and the absence of a mepilex dressing to the sacral and coccyx area.An interview conducted on 04-30-2026 at 2:30 PM with Licensed Practical Nurse (LPN) C confirmed Resident 5 was to receive wound care to the sacral and coccyx area, confirmed the treatment had not been provided and there must have been a glitch in the electronic medical record program because the order was not on the NAR to cue the staff to provide the treatment.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. -required total assistance with toileting, bathing, dressing, personal hygiene, bed mobility and transfers.-was always incontinent of bowel and bladder.-was at risk of developing a pressure ulcer.-had a stage 2 pressure ulcer. An observation conducted on 04-27-2026 at 1:30 PM revealed Resident 7 was lying in bed on a DermaFloat air mattress set at the firmest setting.An observation conducted on 04-28-2026 at 8:00 AM revealed Resident 7 was lying in bed on a DermaFloat air mattress set at the firmest setting.An observation conducted on 04-29-2026 at 4:50 AM revealed Resident 7 was lying in bed on a DermaFloat air mattress set at the firmest setting. An interview conducted with the Director of Nursing (DON) on 04-30-2026 at 3:30 PM confirmed the facility had not followed the DermaFloat air mattress manual for the set up of Resident 7's air mattress and could not confirm if the mattress was at the correct setting to prevent bottoming out as described in the manual.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
ml at the lunch meal. C.
Record review of Resident 5's MAR for April 2026 revealed on 04-24-2026 a 3
am.-Fluticasone nasal spray 1 spray both nares at 9 am.-linagliptin (a medication used to treat Type 2
tartrate (a medication that lowers the resting heart rate, reduces the hearts workload and lowers blood pressure) 25 mg tablet at 9 am.-mucinex extended release (a medication used for chest congestion) 600 mg at 9 am.-carboxymethycellulose sodium ophthalmic solution 0.5% (used for dry eyes) 1 drop in both eyes at 9 am.-ipratropium-albuteral inhalation solution (a medication used to open airways for COPD) 3 mg/ml 3ml inhaled at 9 am. An interview conducted with the Director of Nursing on 04-30-2026 at 3:00 PM confirmed the medications were omitted due to being out of the facility at dialysis and did not know the provision of medications should be scheduled around dialysis services.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
Based on interview and record review the facility failed to
minutes for 3 (Residents 4, 5 and 7) of 15 sampled residents.
The facility census was 151.
The findings are:A. An interview conducted with Resident 4 on 04-29-2026 at 9:00 AM revealed Resident 4 had been left on the toilet for a very long time in mid-January of this year.
The interview further revealed on 04-26-2026 Resident 4 was left on the toilet for a long time, but not as long as in January.
Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 1/15/2026 revealed the facility staff assessed Resident 4's Brief interview for Mental Status (BIMS) as a 13.
According to the MDS [NAME] a score of 13 to 15 indicates a person is cognitively intact.
Record review of Resident 4's Alarm Average Response Time Report (AARTR) for 01-10-2026 to 01-17-2026 revealed on January 13, 2026 Resident 4's call light was on for 167 minutes and 51 seconds.
Record review of Resident 4's AARTR for 04-17-2026 to 04-30-2026 revealed on April 26, 2026 at 8:59 AM Resident 4's call light was on for 46 minutes and 32 seconds, and at 1:05 PM Resident 4's call light was on for 73 minutes and 34 seconds. B.
Record review of Resident 5's MDS dated [DATE] the facility staff assessed Resident 5's BOMS as a 12.
According to the MDS [NAME] a score of 8 to 12 indicates a persons cognition is moderately impaired.An interview conducted on 4-28-2026 at 8:00 AM with Resident 5's family member revealed Resident 5 has had to wait an hour to be laid down after dialysis.
Record review of Resident 5's AARTR for 04-17-2026 to 04-30-2026 revealed on 04-26-2026 at 1:13 AM Resident 5's call light was on for 61 minutes and 38 seconds, and on 04-26-2026 at 6:26 AM Resident 5's call light was on for 76 minutes and 33 seconds. C. An interview conducted on 04-28-2026 at 10:00 AM with Resident 7 revealed Resident 7 had waited as long as 2 hours for someone to answer the call light.
Record review of Resident 7's MDS dated [DATE] revealed the facility staff assessed the residents BIMS as a 15.
Record review of Resident 7's AARTR for 04-17-2026 to 04-30-2026 revealed on 04-25-2026 at 2:44 PM Resident 7's call light was on for 65 minutes and 18 seconds and at 8:01 PM Resident 7's call light was on for 63 minutes.An interview conducted with the Director of Nursing (DON) on 04-30-2026 revealed the goal for call light response was 7 minutes and confirmed call light times over 30 minutes were not timely.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
According to the MDS Manual a score of 12 indicates moderate cognitive impairment.-required set up and clean up assistance with eating.-required total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers.-was receiving dialysis services.
Record review of Resident 5's Comprehensive Care Plan (CCP) revised 04-13-2026 revealed Resident 5 needs dialysis related to ESRD and had dialysis appointments on Monday, Wednesday and Friday.
Record review of Resident 5's Medication Administration Record (MAR) for April 2026 revealed on 04-24-2026 a 3 indicating Resident 5 did not receive the following medication due to being away from the facility without medications:-metoprolol tartrate (a medication that lowers the resting heart rate, reduces the hearts workload and lowers blood pressure) 25 milligram (mg) tablet at 9 AM.
Record review of Resident 5's Progress Note dated 04-24-2026 revealed morning medications were not given due to being at dialysis that morning and the physician wrote an order to give metoprolol tartrate 25mg now due to Resident 5's heart rate was 116. An interview conducted with the Director of Nursing (DON) on 04-30-2026 at 3:00 PM confirmed Resident 5 did not receive the metoprolol and linagliptin on 04-24-2026 and a medication omission was an error.
285149 04/30/2026
Maple Crest Health Center 2824 North 66th Avenue Omaha, NE 68104
worn while changing Resident 5's brief and wasn't because I forgot.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.