The citation, issued under a federal tag that governs resident assessment accuracy, found that St.
Nursing Home News — Page 204
All Stories
The citation also covered a related failure: not always having a licensed nurse in charge on each shift.
The failure came to light during a complaint inspection on September 2, 2025.
The resident, identified in inspection records only as Resident #2, was sent out of the facility after the error.
The September 2 inspection, triggered by a complaint, found the violation serious enough to be cited as causing actual harm.
The wounds were stage 3 pressure ulcers, meaning they had already eaten through the full thickness of the skin and into the tissue below.
That's the core of what federal inspectors found at Maple Crest Health Center in Omaha this September.
The resident, identified in inspection records only as Resident 5, had chronic kidney disease and diabetes.
Inspectors from the Centers for Medicare and Medicaid Services visited Colonial Manor Nursing Center on September 4, 2025, responding to a complaint.
When a facility moves someone, the Ombudsman is supposed to know.
The citation fell under the category of quality of life and care deficiencies.
The facility's Safe Resident Handling Program, last reviewed on July 7, 2025, spelled out the requirements in plain terms.