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Crowell Memorial Home

245 South 22nd Street, Blair, NE 68008 · Non profit - Corporation · 74 certified beds · (402) 426-2177 Medicare & Medicaid certified

Call the home — (402) 426-2177 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0604, F0605, F0607, F0609, F0610) — most recent Feb 20261 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0605, F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (90%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
810 N 22nd St · (402) 426-1239 · Call to confirm hours
Pharmacy
1260 Washington St · (402) 533-8444 · Call to confirm hours
Grocery
238 S 8th St · (402) 426-4757 · Call to confirm hours
Park
1871 Davis Dr · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.2%19.0%15.4%typical
Long-stay residents who lose too much weight2.4%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.3%1.4%0.9%worse
Long-stay residents with a urinary tract infection9.5%2.8%2.0%worse
Long-stay residents with depressive symptoms1.8%4.3%6.5%better
Long-stay residents who were physically restrained13.7%0.3%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.0%4.5%3.3%worse
Long-stay residents whose ability to walk worsened18.3%18.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication39.4%19.3%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers2.9%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control8.8%25.9%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table35.2%20.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%2.0%1.4%better
Long-stay hospitalizations per 1,000 resident days2.221.811.67worse
Long-stay outpatient ER visits per 1,000 resident days4.551.921.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

11.5%U.S. median 10.7%
Went back to hospital
0.19U.S. median 0.31
Therapy hours / resident / day
0.04hours / resident / day
Physical therapy
0.14hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.19 therapist hours per resident per day in 2026Q1 — more than 20% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.0–17.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.651.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.66
RN hours/ resident / day
0.21
LPN hours/ resident / day
3.24
Aide hours/ resident / day
4.11
Total nurse hours/ resident / day
0.61
RN hoursweekends
90.5%
Total nursing turnover
90.9%
RN turnover

How full it usually is: this home is certified for 74 beds and averages 67.2 residents a day — about 91% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.11 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.66 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.24 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.72 hrs/resident/day on weekends vs 4.26 on weekdays — 13% thinner on weekends. RN hours go from 0.68 to 0.61 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 90% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

5
deficiencies at the latest standard inspection (2025-06-12)
5
at the previous standard inspection (2024-04-16)

Deficiencies are unchanged from the previous inspection. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

28 citations, most serious first. The 12 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · Gcited before2026-02-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview and record review the facility failed to implement interventions identified on the care plan to prevent falls for 3 (Resident 1, 2 and 4) of 4 residents sampled. The facility census was 77. Findings are:Record review of the facility's undated policy titled Fall Prevention Program revealed the following:-each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -the facility uses a standardized risk assessment for determining a resident's fall risk.-the risk assessment categorizes residents according to low, moderate or high risk.-for program purposes the facility utilizes High Risk protocols and Low/Moderate risk protocols. -upon admission the nurse will complete a fall risk assessment to determine the resident's level of risk.-the nurse will indicate the resident's fall risk and initiate interventions on the resident's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2023-12-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from significant medication error for 1 (Resident 3) of 3 sampled residents. The facility had a total census of 59 residents. Findings are: Record review of Resident 3's undated Face Sheet revealed, the resident was admitted to the facility with a diagnosis of chronic kidney disease and unspecified dementia. A review of Medication Error Report dated 11/27/23 revealed, Resident 3's Lasix 80 mg one time per day was held on 11/21/23, 11/22/23, and 11/23/23. According to Medication Error Report, Resident 3 was taken to emergency room for assessment on 11/26/23. A review of Resident 3's 11/2023 MAR (Medication Administration Record) revealed, order for Lasix (a diuretic that may cause dehydration and electrolyte imbalance) 80 mg (milligrams) with start date of 10/24/23. Resident 3's Lasix 80 mg once per day was not administered on 11/21/23, 11/22/23, 11/23/23 and 11/25/23 as medication was unavailable according to 11/2023 MAR.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Past Non-Compliance
  • Potential for harm · Dcited before2026-02-18 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report a significant injury to the state agency in appropriate time frames for 1(Resident 2) of 4 residents sampled. The facility census was 77. The findings are:Record review of the facility's policy dated 09-23-2022 titled Abuse, Neglect and Exploitation revealed it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Under section Identification of Abuse, Neglect and Exploitation:-the facility will have procedures to assist staff in identifying the different types of abuse.-possible indicators of abuse include but are not limited to: --Resident, staff or family report abuse,--Physical marks such as bruises --Physical injury of a resident of unknown source--Resident reports theft of property--Verbal abuse of a resident is observed--Physical abuse of a resident is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-09-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09(I)Based on record review and interview; the facility staff failed to implement assessed interventions to prevent falls for 1 (Resident 4) of 3 sampled residents. The facility staff identified a census of 66. Findings are:Record review of Resident 4's Face Sheet dated 9/15/2025 revealed Resident 4 had the diagnoses of Parkinson's disease, Spinal stenosis (narrowing of the spaces between spinal bones) of the Lumbar area, Radiculopathy ( a pinched or pressed nerve) in the spine of the lumbar area, hypertension, muscle weakness and Depression.Record review of Resident 4's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 7/24/2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS, method to evaluate cognitive status) was a 10. According to the MDS Manual, a score of 8 to 12 indicates moderately impaired cognition.-Required partial to moderate assistance with eating, oral hygiene, upper body dressing, personal hygiene, sitting to standing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-07 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 175 NAC 12-006.09(H)(iv)(5)Based on record review and interview, the facility failed to ensure monitoring of bowel function for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 63 residents.Findings are:A. A review of the facility Bowel Program dated 12/10 revealed the following procedure:- 1. The charge nurse is to monitor the BM [bowel movement] sheet and or caretracker every shift.- 2. On day 1 with no bowel movement, give 4 oz. of Prune juice to resident. Do not give to diabetics or no Concentrated (NCS) diets.- 3. On day 2, with no bowel movement, give prune juice and oral laxative (MOM [Milk of Magnesia], Sorbitol, Cascara, etc.) per MD [Medical Doctor] orders.- 4. On day 3 with no bowel movement, give prune juice and suppository (Dulcolax or Bisadocyl) per MD Orders. - 5. If no BM, notify the resident's physician for possible new orders.- 6. [NAME] meds given on MAR every shift.- 7. Monthly, complete the Bowel Assessment on every resident. B. A review of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.05(G) Based on record reviews and interviews, the facility failed to provide a rationale for not conducting a Gradual Dose Reduction (GDR, Stepwise tapering of a dose to determine whether or not symptoms, conditions, or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued) for 1 (Resident 2) of 3 residents sampled. The facility census was 62. Findings are: Record review of Resident 2's 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 5/11/2025 revealed Resident 2 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) score of 13/15. The MDS manual identified a score of 13 as cognitively intact. Record review of Resident 2's medication order summary revealed Risperidone solution 1 milligram per milliliter (mg/mL) was ordered and the amount to be administered was 0.5 mL to be taken 3 times per day for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report an allegation of misappropriation within the required timeframe to Adult Protective Services [APS] and the Department of Health and Human Services [DHHS] for 1 (Resident 39) of 5 facility investigations reviewed. The facility census was 61. Findings are: Record review of facility policies and procedures entitled Abuse, Neglect and Exploitation and dated 9/23/22 revealed the following information: The definition of an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has yet to be investigated and , if verified, could be an indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property. Reporting and response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the admin, state agency, adult protective services and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation for 1 (Resident 39) of 5 facility investigations reviewed. The facility census was 61. Findings are: Record review of facility policies and procedures entitled Abuse, Neglect and Exploitation and dated 9/23/22 revealed the following information: The definition of an alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has yet to be investigated and , if verified, could be an indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect or abuse, including injuries of unknown source and misappropriation of resident property. Investigation of abuse, neglect and exploitation: a. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. Identifying staff responsible for the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-06-12 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09(H)(v) Based on record reviews and interviews, the facility failed to provide services as care planned to help prevent further decrease in range of motion for 2 (Residents 40 and 8) out of 2 residents sampled. The facility census was 61. Findings are: A. Record review of Resident 40's 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 04/25/2025, revealed Resident 40 had a Brief Interview for Mental Status (BIMS, a brief screener that aids in detecting cognitive impairment) blank score. The MDS manual identified a score of blank as resident was unable to complete the interview. Record review of Resident 40's diagnoses revealed muscle wasting and atrophy, contracture of left hand and anoxic brain damage. Record review of Resident 40's restorative care plan dated 05/12/2025 revealed staff should be performing bed mobility and passive range of motion (PROM, range of motion that is performed by the staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-06-12 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B) & 12-006.09(H)(vi)(3)(g) Based on observation, record review and interview; the facility failed to date oxygen tubing for 1 (Resident 11) of 1 sampled resident. The facility also failed to utilize Personal Protective Equipment (PPE, includes clothing, gloves, face shields, goggles, facemask's, respirators, and other equipment to protect front-line workers from injury, infection, or illness) for Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) for 1 (Resident 51) of 5 sampled residents and failed to perform hand hygiene prior to donning gloves during the provision of medication…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(G) Based on observation, interview, and record review, the facility staff failed to ensure individualize use of restraints to include identification of medical symptoms for use, duration of use, evaluation of less restrictive alternatives, review of risk and benefits, and re-evaluation of need for a restraint in accordance with facility policy for restraint use for 3 [Residents 1, 2, and 5] of 3 sampled residents. The facility had a total census of 63 residents. Findings are: A. A review of undated facility policy titled Restraint Free Environment revealed the following: -Physical Restraint: refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to: .Placing a resident in an enclosed framed wheeled walker, in which the resident cannot…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-17 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 12-006.09(D) Based on record review and interview, the facility failed to accurately code MDS [Minimum Data Set; a comprehensive assessment used in care planning] related to use of restraint for 2 [Residents 1 and 2] of 3 sampled residents utilizing a Merry Walker. The facility had a total census of 63 residents. Findings are: A. A review of Resident 1's Face sheet revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident 1's quarterly MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 3/28/25 revealed the following -Resident 1 had a BIMS [Brief Interview for Mental Status] score of 4. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 1 required supervision or touching assistance for walking -Resident 1 used a bed alarm, chair alarm, and wander/elopement alarm daily -Resident 1 was not identified as utilizing a restraint A review of Resident 2's Care Plan…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Dcited before2025-04-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 006.09(I) Based on observation, interview, and record review, the facility failed to ensure supervision to protect residents from elopement for 3 [Residents 1, 4, and 6] of 3 sampled residents at risk for elopement. The facility had a total census of 63 residents. Findings are: A. A review of Resident 1's Face sheet revealed Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. A review of Resident 1's quarterly MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 3/28/25 revealed the following -Resident 1 had a BIMS [Brief Interview for Mental Status] score of 4. A review of the MDS manual revealed a score of 0-7 indicates severe cognitive impairment -Resident 1 required supervision or touching assistance for walking -Resident 1 used a bed alarm, chair alarm, and wander/elopement alarm daily A review of Resident 1's Care plan revealed a problem dated 9/14/23 of falls with the following interventions: -Ensure Resident 1's pad…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-04-16 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure reference Number 175 NAC 12-006.11E Nebraska Food Code 4-601.11(C) Based on observation, interview, and record review; the facility staff failed to ensure dietary staff wore beard restraints that fully enclosed all hair on the face during 2 meal service observations, failed to ensure scoops were stored separate from the flour and sugar, failed to ensure that the surface of plates stored in a plate warmer were not exposed to potential contaminants and failed to maintain the cleanliness and condition of floors, ventilation covers and ceiling tiles, the interior of conventional ovens and convection ovens, the exterior of the stove, stove back splash, convection ovens, shelf above the stove, floors in the walk in cooler, fans in the walk in cooler, pan storage units, electric slicer, and the large commercial mixer in the facility kitchen. These practices had the potential to cause food borne illness. This had the potential to affect 60 residents that resided in the facility and ate foods prepared in the facility kitchen. The facility census was 60. Findings are: A. Record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-16 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 Based on observation, and interview, the facility failed to maintain the cleanliness and condition of walls, floors, fixtures, ceilings, and baseboards in 24 (rooms: 102, 105, 106, 113, 116, 122, 123, 125, 131, 132, 134, 144, 146, 158, 159, 162, 203, 205, 212, 215, 225, 233, 236, and 238) of 59 occupied resident rooms and the 2nd floor north hallway nurses station of the facility. The facility census was 60. Findings are: Observation on 04/15/24 between 8:05 AM and 09:30 AM, during the environment tour with the facility Maintenance Director [MD] and the Administrator, revealed the following concerns with the facility environment: - There were several scrapes on the walls by beds in resident rooms 106, 113, 223 and 236. - There were several scrapes on the wall under the window in room [ROOM NUMBER]. - There were several scrapes on the wall behind the recliner in room [ROOM NUMBER]. - There were several scrapes on the walls in the bathroom by the toilet in room [ROOM…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-16 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview the facility failed to maintain a medication error rate of less than 5% which affected 1(Resident 44) of 3 sampled residents. There were 26 opportunities and 2 errors observed resulting in a 7.69% medication error rate. Facility Census was 60. Findings are: Record Review of Resident 44's active orders listing printed on 04-16-2024 revealed an order for aspirin 81 milligram (mg) delayed release tablet, take one tablet by mouth daily. Do not crush. The listing also revealed an order for DOK (generic name Docusate Sodium, a stool softener) 100 mg tablet take by mouth twice daily. An observation on 04-16-2024 at 7:30 AM of Medication Assistant (MA) D preparing medications for Resident 44, revealed MA-D took the Aspirin 81 mg medication card out and popped the pill into a clear medication cup. MA D also took the DOK 100 mg card out and popped the pill into the same clear medication cup. MA D poured the medications into a clear pouch and then placed the pouch in the pill crusher and crushed the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-16 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review the facility failed to handle linens and a catheter drainage bag in a manner to prevent the potential for cross contamination for 1(Resident 44) of 3 sampled residents. The facility census was 60. Findings are: A. Record review of Resident 44's Comprehensive Care Plan (CCP, Care that is planned and coordinated around the resident's physical, mental and cognitive health needs) with a review date of 04-02-2024 revealed Resident 44 had a diagnosis of Chronic Kidney Disease Stage 3 (CKD3, mild to moderate loss of kidney function) and had a hospitalization in March of 2024 for an Acute Kidney Injury (AKI, is the sudden loss of kidney function) and returned to the facility with an indwelling catheter (a tube inserted into the bladder to drain urine). The approaches listed on the CCP to care for the indwelling catheter are: -Be sure catheter tubing does not become kinked or placed under the legs to promote adequate drainage. -Do not allow any part of the drainage system to touch the floor.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 175 NAC 12-006.09D1c Based on interview and record review, the facility failed to ensure baths were being offered in accordance with resident preferences for 2 (Residents 1, and 2) of 3 sampled residents. The facility had a census of 59 residents. Findings are: A. A review of undated Resident Face Sheet revealed, Resident 2 was admitted to the facility on [DATE] with a diagnosis of bipolar disorder (a disorder with extreme mood swings) and difficulty in walking. A review of Resident 2's Care Plan revealed the following: -Resident 2 preferred 2 baths per week dated 11/2/23 -Resident 2 utilizes limited to total assist with ADL's (activities of daily living) with level of assist varying with review/revised date of 11/6/23. -Resident 2 utilizes a sit-stand lift with assist of 2 staff for transfers with review/revise date of 11/6/23. -Resident 2's Brief Interview for Mental Status completed 11/1/23 identified Resident 2 as having a score of 15 indicative of cognitive intactness. In an interview…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2023-04-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    175 NAC 12-006.11.E Based on observation, record review and interviews, the facility staff failed to 1) ensure hair restraints were worn by staff and 2) failed to ensure food temperatures were maintained at a level to prevent potential food-borne illness. This practice had the potential to affect 55 residents. The facility staff identified a census of 55. Findings are: A. Observation on 4/17/23 at 8:45 AM in the kitchen revealed Cook-I did not have a hair restraint. Observation on 4/18/23 at 12:30 PM Cook-I delivered a taste tray to the conference room with a cap on and no hair restraint. Observation on 4/19/23 at 10:15 AM revealed Cook-I in the kitchen serving food without a hair restraint on. Interview on 4/19/23 at 10:15 A.M. Cook-I revealed Cook-I was unaware if a hair restraint needed to be worn. Interview on 4/19/23 at 2:30 p.m. Administrator revealed dietary staff are to wear a hair restraint. Record review of the facility Employee Sanitary Practices Policy dated 2000 revealed: 1) Wear hair restraints and clean clothes.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-20 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility staff failed to provide SNFABN (Skilled Nursing Facility Advance Beneficiary Notice-a notice issued to a resident and/or their responsible party to inform them that Medicare will likely no longer pay for their services) for Resident 46 and Resident 112. This affected 2 of 3 sampled residents. The facility identified a census of 55. Findings Are: Record review of the NOMNC (Notice of Medicare Non-Coverage) for Resident 46 revealed a last covered day of Medicare part A services would be on 12/9/22. The NOMNC contained a handwritten note signed by the Director of Nursing (DON) which revealed Resident 46's representatives were contacted on 12/6/22 and Resident 46's last covered skilled day was 12/9/22. Record review of the NOMNC for Resident 112 revealed a hand written note signed by the DON revealed Resident 112's daughter was contacted on 11/2/22 and Resident 112's last covered skilled day was 11/4/22. Record review of the QAA (Quality Assessment and Assurance) Committee Meeting Minutes dated 11/17/22 at 10:00 AM revealed the DON will…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-20 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide notice of the bed-hold policy to Resident 6 or their Representative upon transfer to the hospital. This affected 1 of 1 sampled residents for hospitalization. The facility census was 55. Findings Are: Record review of the Electronic Medical Record (EMR), per a tab of census information, revealed Resident 6 was on hospital leave from 2/11/23 and returned to the facility on 2/22/23. Interview on 04/20/23 at 2:01 PM with the DON (Director of Nursing) revealed the facility did not complete a bed hold policy for Resident 6 when hospitalized on [DATE].

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09C Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan (a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) that reflected the care needs of Resident 3 and Resident 16. This affected 2 of 2 sampled residents. The facility identified a census of 55. Findings are: A. Record review of Resident 3's admission Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 2/21/23, revealed Resident 3 had an indwelling catheter (inserted into the bladder for continuous drainage of urine). The Care Area Assessment (CAA-provides guidance on how to focus on key issues identified during a comprehensive MDS assessment) for Urinary Incontinence and Indwelling Catheter indicated that a care plan would be initiated. Record review of Resident 3's comprehensive care plan, dated 4/18/23,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-20 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to provide bathing assistance for one (Resident 16) of 2 sampled residents that required assistance with activities of daily living. The facility census was 55. Findings are: Interview on 4/17/23 at 2:03 PM Resident 16 indicated that Resident 16 had gone extended periods without bathing. Record review of Resident 16's Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated 2/7/23, revealed that Resident 16 required extensive assistance from one staff member for bathing. Record review of Resident 16's bathing record, dated January 2023 to April 2023, revealed Resident 16 did not receive any type of bathing for a period of 16 days, from 3/13/23 to 3/28/23. Interview on 4/20/23 at 9:30 AM the Administrator revealed the facility does not have a policy regarding bathing. Interview on 4/20/23 at 10:14 AM, Medication Aide-G revealed that Resident 16 enjoyed when Resident 16 received a bath, had not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D2 Based on observation, record review and interview, the facility failed to obtain treatment orders for 1 (Resident 106) of 1 sampled resident. The facility census was 55. Findings are: Record review of Resident 106's face sheet, dated 4/18/23, revealed that Resident 106 admitted to the facility on [DATE]. Observation on 4/17/23 at 10:07 AM revealed a strong odor upon entering Resident 106's room. The observation further revealed edemawear (compression stocking to prevent swelling) and gauze present to Resident 106's right lower extremity (RLE) with drainage present on edemawear approximately 2.5 centimeters (cm) x 1.5cm. Interview on 4/17/23 at 10:07 AM, Resident 106 revealed that Resident 106 had gone to the emergency room (ER) because of a right heel wound. Resident 106 further revealed that staff had not changed the dressing since Resident 106 was admitted and that Resident 106's physician was to have seen Resident 106 at the facility after Resident 106 admitted ,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-04-20 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    LICENSURE REFERENCE NUMBER 175 NAC 12-006.12 Based on observation, record review, and interview, the facility failed to ensure the provision of services of medications and biologicals to meet the needs of 2 (Resident 10 and Resident 105) of 3 sampled residents. The facility identified a census of 55. Findings Are: Observation of medication administration on 04/18/23 at 09:06 AM revealed MA-A preparing 8:00 A.M. medications for Resident 10. The following medications were prepared and given; - Calcium plus Vitamin D (an over-the-counter supplement) 1 tablet po (by mouth) BID (twice daily) scheduled for 08:00 AM and 02:00 PM - Docusate Sodium (a stool softener) 100mg 1 capsule po BID scheduled for 8:00 AM and 2:00 PM - Duloxetine (an antidepressant medication ) 20mg po q (every) day - Hydrochlorothiazide (a diuretic medication) 25mg po q day *give with Losartan* - Losartan (a medication used to lower blood pressure) 100mg po q day *give with Hydrochlorothiazide* - Multivitamin (an over-the-counter supplement) 1 tab q day - Tylenol (an over-the-counter pain reliever) 2 tabs 325mg TID…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-20 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure a medication error rate of 5% or less. The sample size was 3. The facility identified a census of 55. Findings: Observation of medication administration on 04/18/23 at 09:06 AM revealed MA-A to be passing medications and preparing 0800 meds for Resident 10. The following medications were prepared and given; - Calcium plus Vitamin D (an over-the-counter supplement) 1 tablet po (by mouth) BID (twice daily) scheduled for 08:00 AM and 02:00 PM - Docusate Sodium (a stool softener) 100mg 1 capsule po BID scheduled for 08:00 AM and 02:00 PM - Duloxetine (an antidepressant medication ) 20mg po q (every) day - Hydrochlorothiazide (a diuretic medication) 25mg po q day *give with Losartan* - Losartan (a medication used to lower blood pressure) 100mg po q day *give with Hydrochlorothiazide* - Multivitamin (an over-the-counter supplement) 1 tab q day - Tylenol (an over-the-counter pain reliever) 2 tabs 325mg TID (three times daily) scheduled for 08:00 AM, 12:00 PM and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-04-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview, the facility failed to clean and store one (Resident 106) of one sampled resident Positive Airway Pressure (PAP-a machine used to deliver pressure to the airway to keep it open during sleep) mask to prevent the potential for cross contamination. The facility census was 55. Findings are: Record review of Resident 106's face sheet, dated 4/18/23, revealed that Resident 106 admitted to the facility on [DATE] with the diagnosis of Acute Respiratory Failure with hypoxia (low oxygen levels in body tissues). Observation on 4/17/23 at 10:07 AM of Resident 106's room revealed Resident 106's PAP mask laying across the bed. Observation on 4/18/23 at 12:37 PM of Resident 106's room revealed Resident 106's PAP mask hanging on the edge of the bed. Interview on 4/18/23 at 12:37 PM, Resident 106 revealed the PAP mask had not been cleaned since admission. Record review of Resident 106's Treatment Administration Record (TAR, dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2024-04-16 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview the facility failed to conduct adult and child protective service (APS and CPS) registry checks upon hire for 1 (Nursing Assistant, NA G) of 5 sampled new employee files. Record Review of NA G's employee file revealed NA G was hired on 03-04-2024. Further review of NA G's employee file revealed results from registry checks with APS and CPS were not observed in the file. An interview conducted with the Administrator (Admin) on 4-16-2024 at 2:20 PM revealing APS and CPS registry checks are completed on hire and employees should not be allowed to work until the results are back. An interview conducted on 4-16-2024 at 2:40 PM with the Administrative Assistant confirmed APS and CPS registry checks were not completed for NA G. Record Review of the facility policy Background Investigations dated June 2015 revealed a policy statement of personal reference checks, driving record investigations, background investigations are conducted on all personnel employed with this facility. Listed under policy…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record. 1 Medicare payment denial on record.

  • Medicare payment denial — starting 2026-03-17 for 6 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
ROLLAND, JACLYNIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 12/04/2017
BENNER, STACYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2017
ANDERSON, DOUGIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 10/01/2017

CMS files one row per role, so the 8 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$6.8M
Net patient revenuemost recent cost report
-6.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 81%Medicare 1%Other / private 18%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$325per resident / day
operating cost
$9,874per month
≈ monthly operating cost
$306per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NE

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.

Typical monthly cost in Nebraska
$8,377/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,350/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285210. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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