Heritage Of Webster County
Heritage of Webster County in Red Cloud, NE — inspection on August 14, 2025.
Found 11 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
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.
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.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
285225 08/14/2025
Heritage of Webster County 636 North Locust Street Red Cloud, NE 68970
deciliter (mg/dL) and insulin was or should have been withheld:
6/20 at 12:00 PM =97mg/dL - Medication date and time on the MAR states HL. 6/26 at 5:00 PM =96mg/dL - Medication marked as given, Progress Notes for dates [DATE] 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] Resident 1 refused the medication. 7/3 at 12:00 PM =105mg/dL - Medication marked as given, Progress Notes for dates [DATE] 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] 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] 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] 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.
285225 08/14/2025
Heritage of Webster County 636 North Locust Street Red Cloud, NE 68970
Resident 29 on 3/21/2024 with diagnosis of dementia (a usually progressive condition marked by the
comprehensive assessment tool used to determine a resident's functional capabilities and helps
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
285225 08/14/2025
Heritage of Webster County 636 North Locust Street Red Cloud, NE 68970
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.
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.
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.
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.
ownership and/or administrative personnel.
failed to notify the department of a change in Director of Nursing within 5 working days as required.
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.
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.
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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.