01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-13 | 16 | 2025-05-13 | 8 |
| Cycle 2 | 2024-04-26 | 8 | 2024-04-26 | 8 |
| Cycle 3 | 2023-05-16 | 9 | 2023-05-16 | 7 |
CMS CCN 2850192026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Douglas County Health Center
4102 Woolworth Avenue · Omaha, NE 68105 · Douglas County
Certified beds254CMS provider file
Recent citation rows56current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
56 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 11 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-10-30 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-10-30 · HEALTHF0760Severity G · isolated actual harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-12-12 · complaint2025-05-13 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · HEALTHF0605Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-06-27 · complaint2025-05-13 · HEALTHF0610Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-06-27 · complaint2025-05-13 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0699Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0712Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Correction field: Deficient, Provider has date of correction · 2025-06-27 · complaint2025-05-13 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-272025-05-13 · FIREK0311Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · FIREK0341Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-13 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-06-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-10-30 | Payment Denial | $0 | 8 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NELSON, ERINIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 07/01/2019
- NELSON, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2019
- BORGESON, MARY ANNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/1995
- BOYLE-MANGANARO, MAUREENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2021
- CAVANAUGH, JAMESIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2015
- FRIEND, MIKEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2021
- GARCIA, ROGERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2021
- MORGAN, PJIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2010
- NELSON, ERINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2019
- ROGERS, CHRISIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/2005
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.78per resident day
RN hours1.01per resident day
Weekend nurse hours4.39per resident day
Staff turnover14.9%CMS reported field
06 / LOCAL RECORDS
Open the Omaha ledger →Other published facilities nearby
Ambassador Health Of Omaha146 beds · CMS overall 5/521 citation rowsBrookestone Village140 beds · CMS overall 5/527 citation rowsEmerald Nursing & Rehab Legacy Pointe Llc108 beds · CMS overall 1/543 citation rowsEmerald Nursing & Rehab Omaha155 beds · CMS overall 1/584 citation rowsEmerald Nursing & Rehabilitation Mercy174 beds · CMS overall 1/5132 citation rowsFlorence Home126 beds · CMS overall 4/524 citation rowsGood Samaritan Society - Millard106 beds · CMS overall 4/534 citation rowsHillcrest Millard Llc76 beds · CMS overall 1/537 citation rows