Healthcare Facility Inspection of the VA Nebraska-Western Iowa Health Care System in Omaha

VA Office of Inspector General · Report 25-00239-196 · October 9, 2026 · Office of Healthcare Inspections

What the OIG found

OIG conducted a focused Healthcare Facility Inspection of the Omaha system, evaluating care across five domains: culture, environment of care, patient safety, integrated veteran care, and the veteran-centered safety net. The inspection produced four recommendations in two domains. In environment of care, inspectors found problems with patient care area cleanliness and biohazard management, a Legionella prevention assessment that did not include the Papillion community living center, and pharmaceutical waste disposal practices. In patient safety, the facility lacked service-level workflows spelling out staff roles for communicating test results to patients and providers. OIG directed the facility Director and Chief of Staff to fix the cleanliness, biohazard, Legionella, and waste-disposal issues and to create the missing test-result communication workflows.

Who it concerns

VA Nebraska-Western Iowa Health Care System in Omaha

Why it matters to a family

For families, the findings hit two basics of trust: whether abnormal test results are reliably communicated to the veteran and their providers, and whether a community living center where a loved one may live is covered by Legionella prevention checks.

The official report

The OIG’s report page · Full report (PDF)

Summary ours; the report is the OIG’s. Read it at vaoig.gov →