Heritage Of Webster County
Inspection Findings
F-Tag F0605
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-14.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0607
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0607 during a standard health inspection conducted on 2025-08-14.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Licensure Reference Number 175NAC 12-00.02(H)Based on record review and interview, the facility failed to submit a written investigation of a possible instance of abuse or neglect to the state agency within 5 working days for 1 (Resident 29) of 1 sampled residents. The facility census was 28.Findings are:A review of a facility policy titled Abuse, Neglect and Exploitation dated 07/2024 revealed the facility will report all alleged violations of abuse or neglect no later then 24 hours after the event if the event does not result in serious bodily injury. The facility will report the results of an investigation of allegations within 5 working days of the incident, as required by the state agency. A review of an admission Record revealed the facility admitted Resident 29 on 3/21/2024 with diagnosis of dementia (a usually progressive condition marked by
the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior).The 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) dated 6/18/2025 revealed Resident 29 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 2 indicating the resident had severe cognitive impairment. did not have impairment to the function of their upper or lower extremities, and required staff set up or clean up assistance with eating.A record review of a facility document titled Hot Liquids Risk Assessment revealed the resident exhibited risk factors of impaired cognition, confusion, and dementia placing them at risk for hot liquid accidents.A record review of Resident 29's Progress Notes revealed on 7/30/2025 documentation stating that the resident spilled coffee on themselves while sitting at
the dinning room table. The resident was taken to their room and was observed to have a light pink area to their skin on the left side of their abdomen.A record review of an Incident Investigation dated 7/30/2025 revealed an order was placed to monitor Resident 29's burn to their abdomen.In an interview completed on 8/12/2025 at 3:30 PM with the facility Director of Nursing (DON), the DON confirmed that they did not submit the investigation into Resident 29's burn received due to a hot coffee spill to the state agency and should have.
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 REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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
08/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage of Webster County
636 North Locust Street Red Cloud, NE 68970
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 F0684
F 0684
6/3 at 12:00 PM =100mg/dL - Medication date and time on the MAR states HL=(Medication was held).
Level of Harm - Minimal harm or potential for actual harm
6/7 at 12:00 PM =101mg/dL - Medication date and time on the MAR states HL. 6/20 at 12:00 PM =97mg/dL - Medication date and time on the MAR states HL.
Residents Affected - Some 6/26 at 5:00 PM =96mg/dL - Medication marked as given, Progress Notes for dates [DATE REDACTED] revealed no notation or explanation. 6/29 at 5:00 PM =107mg/dL - Medication date and time on the MAR states DR=(Drug Refused) notation in Progress Notes on [DATE REDACTED] Resident 1 refused the medication. 7/3 at 12:00 PM =105mg/dL - Medication marked as given, Progress Notes for dates [DATE REDACTED] revealed no notation or explanation. 7/3 at 5:00 PM =101mg/dL - Medication date and time on the MAR states OT= (Other Notes); notation in Progress Notes on [DATE REDACTED] for 1700 revealed the medication was withheld per physician orders. 7/8 at12:00 PM =108mg/dL - Medication marked as given, Progress Notes for dates [DATE REDACTED] revealed no notation or explanation. 7/28 at 5:00 PM =109mg/dL - Medication date and time on the MAR states HL.
An interview on [DATE REDACTED] at 1:59 PM with the Director of Nursing (DON) agreed that nursing staff should be following physician orders for insulin administration, notifying the physician and documenting a rationale if
the medication was given when outside of physician parameters.
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
08/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage of Webster County
636 North Locust Street Red Cloud, NE 68970
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 F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
confirmed they had just placed the alarm to the resident and the alarm should have been on while the resident was in their wheelchair and was not.In an interview completed on 8/14/2025 at 9:18 AM with the DON, the DON confirmed that Resident 6 was to always have the alarm on.B.A review of an admission
Record revealed the facility admitted Resident 29 on 3/21/2024 with diagnosis of dementia (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia, and the inability to plan and initiate complex behavior).The 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) dated 6/18/2025 revealed Resident 29 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 2 indicating the resident had severe cognitive impairment. did not have impairment to the function of their upper or lower extremities, and required staff set up or clean up assistance with eating.A record
review of a facility document titled Hot Liquids Risk Assessment and dated 3/24/2025 revealed the resident exhibited risk factors of impaired cognition, confusion, and dementia placing them at risk for hot liquid accidents. The document stated the resident was to be evaluated by therapy and staff were to provide supervision with meals until evaluation was completed.A record review of Resident 29's Progress Notes revealed on 7/30/2025 documentation stating that the resident spilled coffee on themselves while sitting at
the dining room table. The resident was taken to their room and was observed to have a light pink area to their skin on the left side of their abdomen.A record review of an Incident Investigation dated 7/30/2025 revealed on order was placed to monitor Resident 29's burn to their abdomen.In an interview completed on 8/12/2025 at 3:30 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 29 was not evaluated by therapy and supervised during meals until evaluated by therapy as directed on the 3/24/2025 Hot Liquid Risk Assessment. The DON confirmed that Resident 29 did have a burn due to a hot liquid spill on 7/30/2025
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
08/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage of Webster County
636 North Locust Street Red Cloud, NE 68970
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 F0712
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0712 during a standard health inspection conducted on 2025-08-14.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0729
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0729 during a standard health inspection conducted on 2025-08-14.
Category: Nursing and Physician Services Deficiencies
The facility was found deficient in the following area: Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0756
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-08-14.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0759
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-08-14.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
F-Tag F0844
F 0844 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Licensure Reference Number 175 NAC 12-006.04(E)Based on interviews and observations, the facility failed to notify the department of a change in Director of Nursing within 5 working days as required. This had the potential to affect all facility residents. The facility census was 28. Findings are: An observation on 08/11/2025 at 10:00 AM revealed the Director of Nursing (DON). An interview with the DON on 08/11/2025 revealed they began their position about 1 month ago however had worked on the floor as a floor nurse for about 1 year prior. An interview with the Administrator (ADMIN) on 08/11/2025 at 11:15 AM revealed they come to the facility for a few hours a day to oversee operations. An interview on 8/12/2025 at 2:15 PM with
the ADMIN revealed that the previous DON left about 1 month ago and a new DON was since hired who is active at this time. When asked about when the Department was notified about the change in DON, the ADMIN stated this had not been done yet and guessed it needed to be done as soon as possible.
Event ID:
Facility ID:
If continuation sheet
F-Tag F0880
Federal health inspectors cited Heritage of Webster County in Red Cloud, NE for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-14.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 11 deficiencies cited during this inspection of Heritage of Webster County.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-25.
Heritage of Webster County in Red Cloud, 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 Red Cloud, 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 Heritage of Webster County or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.