Callaway Good Life Center, Inc
600 West Kimball Street, Callaway, NE 68825 · Non profit - Corporation · 38 certified beds · (308) 836-2267 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0602), cited May 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — 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
- the CMS record shows $34,608 in federal fines (most recent 2024-02-29)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.8% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.1% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.1% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.8% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 0.9% | 4.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 21.3% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 12.7% | 19.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.0% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 12.7% | 25.9% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 5.8% | 20.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 44.0% | 75.9% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 29.5% | 20.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 8.8% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.36 | 1.81 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.83 | 1.92 | 1.80 | typical |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ 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.
43.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.9%CMS range 33.6–57.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.8–16.9 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.6–13.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 38 beds and averages 29.6 residents a day — about 78% occupied, or roughly 8 beds typically open. It usually has some room. 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 3.95 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.63 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 3.40 hrs/resident/day on weekends vs 4.17 on weekdays — 18% thinner on weekends. RN hours go from 0.84 to 0.56 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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
Deficiencies are more than at the previous inspection — worsening. 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.
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 before2024-03-05 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 Licensure Reference Number 175NAC 12-006.10D Based on record review and interview, the facility failed to protect residents from significant medication errors for 1 resident (Resident 1) of 5 residents reviewed. This caused the resident to require hospitalization for treatment. The facility census was 33. Findings are: Record review of the facility policy titled Pain Management dated 2022 revealed that opioids (pain relief medications- a narcotic) will be prescribed and dosed in accordance with current professional standards of practice and manufacturers guidelines to optimize their effectiveness and minimize adverse consequences. Facility staff will reassess resident's pain management for effectiveness and/or adverse consequences such as Sleepiness-dizziness-and/or confusion; Depression; Itching and Sweating. Record review of the facility policy titled Administering Topical Medications (medications absorbed through the skin) dated 2010 revealed the purpose of the procedure is to provide guidelines for the safe…
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.
- Actual harm · Gcited before2024-02-29 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 Licensure Reference Number 175 NAC 12.006.10D Based on observation, interview, and record review, the facility failed to ensure 1 resident (Resident 6) out of 5 sampled residents in the facility receiving insulin, received the correct amount of insulin. This caused the resident to be transported to the hospital for treatment. The total facility census was 32. Findings are: A record review of the facility's policy titled Insulin Administration dated September 2014 revealed, dosage requirements must be verified before administration. Review of the facility's document titled Insulin Pen updated 1/11/2024 revealed, to always review physician orders prior to administering medication and all med aides will co-sign with a nurse before administration. A record review of Resident 6's undated admission Record revealed, the resident was admitted to the facility on [DATE] and had a diagnosis of Type 2 diabetes mellitus. A record review of Resident 6's Minimum Data Set (MDS - a comprehensive assessment of each 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.
- Potential for harm · F2026-04-22 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Licensure Reference Number 175 NAC 12-006.04(B)(ii)(2)The facility failed to ensure that 12 hours of required ongoing education was documented for nurse aides and medication aides who had been working in the facility for longer than one year and who required 12 hours of yearly training for 3 of 3 sampled staff. This had the potential to affect all residents. The census was 29.Findings were:Record review of the facility policy Abuse, Neglect, and Exploitation dated 12/01/2025 and signed by the Former Facility Director (FFA) revealed that existing staff will receive annual education through planned in-services and as needed.Record review of the facility policy Resident Rights with a copy right date of 2016 revealed that the nursing facility must provide a safe, clean, comfortable environment ensuring that the residents can receive care and services safely.In an interview with the Facility Administrator (FA) on 4/21/2026 at 10:15 AM it was revealed that the Director of Nursing (DON) had all of the information pertaining to 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.
- Potential for harm · Fcited before2026-04-22 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 12-006.12(D)(i)Based on observation and record review the facility failed to ensure items the medication room refrigerator was stored separately by route of administration and food stuff items were not stored with medication items. This had the potential to affect all the residents in the facility. The facility census was 28.Findings are:Record review of a facility policy titled Medication Storage and dated 01/21/2026 revealed Medications are stored separately ensuring proper sanitation and segregation.In an observation completed on 04/21/2026 at 11:30 PM of the facilities medication room a square dorm sized refrigerator was in the medication room. Inside the refrigerator on the bottom shelf were multiple boxes of insulin pens (an injectable medication) and medication bottles with suppositories (a medication placed inside the rectum) kept in them. On the same bottom shelf were 8-ounce plastic containers of liquid nutritional supplement drinks (a food stuff item).In an interview completed on 04/21/2026 at 2:45 PM with the Director of Nursing, the DON…
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.
- Potential for harm · F2026-04-22 · tag F0851 — widespreadElectronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure that the Payroll Based Journal was submitted for the first quarter of 2026 by the due date of February 14, 2026. This had the potential to affect all residents. The facility census was 29. Record review of the Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (PBJ) (a CMS-mandated system for nursing facilities to electronically report auditable staffing data, including hours worked, job roles, and pay types, to ensure transparency and quality of care, revealed that the PBJ data which must be submitted and received by the end of the 45th calendar day (11:59 PM Eastern Standard Time) after the last day in each fiscal quarter to be considered timely) was not submitted to or received by CMS by the date that the PBJ was required. The PBJ Staffing Data Report for the first quarter of 2026 dated October 1 to December 31, 2025, was due on February 14, 2026. In an interview with the Facility Administrator (FA) on 4/20/2026 at 9:05 AM revealed that the FFA would look into this…
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.
- Potential for harm · Ecited before2026-04-22 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 12-006.11(E)Based on observation, record review, and interview the facility failed to ensure that staff delivered resident meals in a sanitary manner to prevent the potential for foodborne illness and cross-contamination. This affected 15 of 22 residents in the facility dining room (Residents 22, 28, 19, 10, 35, 27,15, 20, 17, 16, 23, 21, 18, 25, and 9). The facility census was 29.Findings are:Record review of the facility policy titled Hand Hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among residents and health care personnel) dated 1/21/26 revealed that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations of the facility. Hand hygiene is indicated and will be performed between resident contacts, after handling contaminated objects, before and after handling clean or soiled items. Record review of the FDA (Food and Drug…
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.
- Potential for harm · D2026-04-22 · tag F0605 — failed to not use drugs as a restraint — isolatedPrevent 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 12-006.12(A)Based on record review and interview the facility failed to ensure a prescribed psychotropic medication had an approved diagnosis or indication for use for 1 resident (Resident 5) of 5 sampled residents. The facility census was 28.Findings are:Record review of a facility policy titled Use of Psychotropic Medication and dated 01/21/2026 revealed an adequate indication for use means that the medication administered is consistent with manufacturer's recommendations.Record review of a document titled Highlights of Prescribing Information (www.fda.gov/drugsatfda) and dated 2013 revealed Seroquel or Quetiapine Fumarate (an antipsychotic psychotropic medication) had indications and usages listed as Schizophrenia, Bipolar 1 disorder, and bipolar disorder.Record review of an admission Record revealed the facility admitted Resident 5 on 08/30/2023 with diagnosis of Dementia(a progressive decline in cognitive function that effects memory, language, and behavior), Psychotic disturbance of mood and Anxiety (a severe anxiety or mood disorder), 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.
- Potential for harm · D2026-04-22 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(G)(ii)Based on record review and interview, the facility failed to complete a summary or recapitulation of stay as required for 1 resident (Resident 32) of 2 sampled residents. The facility census was 28.Findings are:Record review of Resident 32's Electronic Medical Health Record (EMHR) revealed the facility admitted Resident 32 on 02/05/2026 and discharged Resident 32 on 02/14/2026.Record review of Resident 32's Progress Notes revealed that on 02/14/2026 at 9:55 AM the facility discharged Resident 32 from the facility to their private home accompanied by their spouse and that personal belongings, discharge instructions, and a medication list was provided to the resident's spouse. There was no documentation of a summary or recapitulation of the residents stay at the facility in the progress notes.In an interview conducted on 04/22/2026 at 2:45 PM with the facility Director of Nursing (DON), the DON confirmed that Resident 32 discharged from the facility on 02/14/2026. The DON confirmed that a summary or recapitulation of the residents…
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.
- Potential for harm · Dcited before2026-04-22 · tag F0641 — isolatedEnsure 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 175 NAC 12-006.09(D)Based on record review and interview the facility failed to accurately code the 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) for 2 residents (Resident 5 and Resident 6) of 5 sampled residents and failed to comprehensively complete the Care Area Assessment (CAA) a critical component of MDS that functions as a decision making frame work to determine if a specific person centered care plan intervention is required) for 1 residents (Resident 5) of 5 sampled residents, and failed to complete an Prospective Payment System (PPS) a standardized, Medicare-required evaluation used to classify patients into payment groups based on clinical needs) Discharge assessment as required for 1 resident (Resident 1) of 5 sampled residents. The facility census was 28.Findings are:A.Record review of the Long-Term Care Facility Resident Assessment…
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.
- Potential for harm · D2026-04-22 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 12-006.09FBased on record review and interview the facility failed to complete a baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed for staff to provide initial effective and person-centered quality care for a resident) within 24 hours as required for 1 of 3 residents (Resident 15) and failed to provide a written summary of the baseline care plan to the resident/resident representative for 1 of 3 residents (Resident 16). The facility census was 29.Findings are:A.Record review of the facility policy titled Baseline Care Plan dated 2/18/26 revealed that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission (the baseline care plan is required to be…
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.
- Potential for harm · D2026-04-22 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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
Licensure Reference Number 175 NAC 12-006.09(E)(i)Based on record review and interview the facility failed to develop a comprehensive care plan (an individualized written interdisciplinary comprehensive plan detailing how to provide quality care for a resident based on the resident comprehensive assessment) for resident care needs identified in the resident assessment for 2 of 2 residents reviewed (Residents 16 and 12). The facility census was 29.Findings are:A.Record review of the facility policy titled Comprehensive Care Plans dated 2/18/26 revealed that it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The care planning process will include an assessment of the resident's strengths and needs. The comprehensive care plan will be developed within 7 days after completion 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.
- Potential for harm · D2026-04-22 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(F)Based on observation, record review, and interview, the facility failed to ensure a residents Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) was revised reflecting a resident current fall prevention intervention was listed for 1 resident (Resident 5) of 5 sampled residents. The facility census was 28.Findings are:Record review of a facility policy titled Comprehensive Care Plans dated 02/18/2026 revealed it is the policy of the facility to develop and implement a comprehensive care plan for each resident.In an observation completed on 04/21/2026 at 2:45 PM Resident 5 was observed to be lying in their bed with both of their legs over the edge of the bed on the floor and a alarm was sounding in the resident's room. Staff entered the room and assisted the residents with care needs.In an interview completed on 04/22/2026 at 8:15 AM with Medication Aide F (MA-F), MA-F…
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.
Show the remaining 16 citations
- Potential for harm · D2026-04-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
Licensure Reference Number 175 NAC, 12-006.09Based on observation, interview, and record review the facility failed to ensure a topical medication gel was applied in the amount as ordered by the provider for 1 resident (Resident 20) of 1 sampled resident. The facility census was 28.Findings are:Record review of a facility policy titled Administering Medications and dated 2019 revealed medications are administered in accordance with prescriber orders.Record review of Resident 20's Order Summary on 04/21/2026 revealed a provider order stating Diclofenac Sodium External Gel (a medication that is applied topically to relieve pain) 1% with directions to apply 2grams topically to joints every 6 hours as needed.In an observation completed on 04/21/2026 at 9:57 AM of medication administration to Resident 20 by Medication Aide F (MA-F), MA-F squeezed an unmeasured amount of a opaque white gel onto their gloved hand. The MA rubbed the unmeasured amount of the gel onto the residents' left hip. The MA then squeezed another unmeasured amount of the gel onto their gloved hand and rubbed 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.
- Potential for harm · Fcited before2025-05-19 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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 175NAC 12-006.11(E) Based on record review, observation and interviews, the facility failed to ensure that food was stored and prepared in a manner to prevent food borne illnesses. This had the potential to affect all residents eating food prepared in the kitchen. The facility census was 28. Findings are: Record review of the Policy and Procedure Manual for Long Term Care operation manual revised December 2014 sub-section refrigerators and freezer on page 24 revealed; 2.) monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 4.) food service managers and designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 7.) all food shall be appropriately dated to ensure proper rotation by expiration dates. 8.) supervisors will be responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past the perish dates. Record review of the menu for the noon meal revealed the kitchen staff were to prepare and serve…
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.
- Potential for harm · D2025-05-19 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 record review and interview, the facility failed to report allegations of abuse and misappropriation of resident property within the regulated time period. This affected one resident (Resident 1). The facility census was 28. Findings are: Record review of the Abuse and Neglect Reporting policy 05/15/2025 revealed that the facility will not condone resident abuse or neglect, misappropriation of property or exploitation by anyone. If alleged abuse, neglect, misappropriation of property or exploitation does occur, the facility will take appropriate action to intervene, document incidents, investigate, take measures to prevent further occurrences and report it to the proper authorities. Under the subheading Policy interpretation and Implementation revealed 1.) All staff, residents, visitors, etc. are required to immediately report any incidents or suspected incidents of resident mistreatment, abuse, or neglect, exploitation, including injuries of unknown source and misappropriation of property. Such reports…
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.
- Potential for harm · Fcited before2025-02-10 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews, the facility failed to prepare and serve food in a safe manner to prevent the potential for foodborne illness. This had the potential to affect all facility residents eating out of the kitchen. The facility census was 28. Findings are: On 02/04/2025 at 8:28 AM upon initial observation, Dietary Aide-I (DA-I) was observed wearing gloves at the time of meal service. DA-I prepared plates of food to be served to residents sitting in the dining room. DA-I was observed picking up biscuits with gloved hands breaking them open, then picking up the ladle which scooped a white gravy, then poured the product on the biscuit. DA-I picked up a plastic card that contained writing on it and handed the card to Dietary Aide-H (DA-H) and the plate of food, where DA-H then retrieved the plate and brought it out to the resident to eat. DA-H hand sanitized after providing that plate and obtaining another plate for another resident.…
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.
- Potential for harm · F2025-02-10 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175NAC 12-0006.04(B) Based on record review and interview the facility failed to ensure that Nurse Aides completed the required continuing education hours for 3 of 5 sampled Nurse Aides. The facility census was 28. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide M (NA-M) had completed 2.37 hours of continuing education hours from 01/01/2024 to 02/10/2025. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide N (NA-N) had completed 1.63 hours of continuing education hours from 01/01/2024 to 02/10/2025. A record review of a facility supplied document titled Course Completion History dated 02/10/2025 revealed that Nurse Aide O (NA-O) had completed 4 hours of continuing education hours from 01/01/2024 to 02/10/2025. In and interview completed on 02/10/2025 at 3:00 PM with the facility Director of Nursing (DON), the DON confirmed that NA-M, NA-N, and NA-O had not completed the minimum of 12 hours of continuing education…
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.
- Potential for harm · E2025-02-10 · tag F0923 — patternHave enough outside ventilation via a window or mechanical ventilation, or both.
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 12-007.04(D) Based on observation and interview, the facility failed to ensure that the ventilation system was operational in in rooms 7, 8, 9, 10, 11, 14, 15, and 19. This affected 8 bathrooms used by 13 residents. facility census was 28. An observation on 02/04/2025 at 11:45 AM revealed that bathrooms in rooms [ROOM NUMBER] did not have functional ventilation as tested when a 1-ply square of toilet paper was held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. An observation on 02/04/2025 at 1:30 PM revealed that bathrooms in rooms 7, 8, 9, 10, and 11 did not have functional ventilation as tested when a 1-ply square of toilet paper was held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. An observation on 02/10/2025 at 4:00 PM with the Administrator (Admin) revealed that…
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.
- Potential for harm · D2025-02-10 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175NAC 12-006.09 C Based on record review and interview the facility failed to ensure a comprehensive resident assessment was completed once every 12 months for 1 resident (Resident #8) of 3 sampled residents, and a Quarterly Assessment (which a non-comprehensive assessment of a resident) was completed at least every 92 days for 1 resident (Resident #4) of 3 sampled residents. The facility census was 28. A. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2024 revealed an comprehensive annual assessment must be completed on an annual basis at least every 366 days. Review of a facility policy titled Comprehensive Assessments dated 03/2022 revealed the annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis or at least every 366 days. A review of Resident #8's electronic…
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.
- Potential for harm · Dcited before2025-02-10 · tag F0641 — isolatedEnsure 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 175NAC 12-006.09 (B) Based on record review and interview the facility failed to ensure that 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) assessments were completed accurately for 2 (Resident #8 and Resident #25) of 5 sampled Residents. The facility census was 28. A. Review of a facility policy titled Resident Assessments dated 05/2022 revealed that the resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and all persons who have completed any portion of the MDS for must sign the document attesting to the accuracy of the information. Review of Resident #8 Quarterly MDS dated [DATE] revealed in section N 0350 documentation that Resident #8 received insulin injections 7 days a week during the look back period. This section was signed by Licensed Practical Nurse…
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.
- Potential for harm · D2025-02-10 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175NAC 12-0006.12 Based on interview and record review the facility failed to ensure residents medication regimen were free from unnecessary medications for 1 resident (Resident #25) of 3 sampled residents. The facility census was 28. Record review of Drugs.com on 02/06/2025 revealed Ketoconazole is an antifungal medication that is only recommended when other effective antifungal therapy is not available or tolerated. Record review of Drugs.com on 02/06/2025 revealed Nystatin Powder is a topical antifungal medication. Record review of Resident #25 Physician Orders on 02/06/2025 revealed Resident #25 had orders to receive Ketoconazole External Cream 2% to affected areas topically at bedtime dated 05/20/2024 and Nystatin External Powder topically every morning and at bed time under the right breast dated 07/02/2024. In an interview completed on 02/04/2025 at 5:10 PM with Resident #25, Resident #25 stated that they self-apply Nystatin Powder under their right breast when it is red and itchy. The resident stated that the nurses apply a cream to the same area…
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.
- Potential for harm · D2025-02-10 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175NAC 12-00006.12 Based on record review and interview the facility failed to ensure that an antipsychotic medication had the correct diagnosis for use. This affected 1 resident (Resident # 3) of 5 sampled residents. The facility census was 28. Record review of a facility policy titled Behavioral Assessment Intervention and Monitoring revealed the facility will comply with regulatory requirements related to the use of medication. Indications and usage for Seroquel (an antipsychotic medication) listed as Schizophrenia (a mental illness that is characterized by disturbances in thought, perception, and behavior, by a loss of emotional responsiveness and extreme apathy, and by noticeable deterioration in the level of functioning in everyday life), and Bipolar Disorder (a condition characterized by dramatic shifts in mood, energy, and activity levels that affect a person's ability to carry out day-to-day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by everyone). Review of an admission 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.
- Potential for harm · D2025-02-10 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 175NAC 12-006.10(D) Based on observation, record review, and interview the facility failed to ensure a medication error of less than 5% with an actual observed medication error rate of 7%. This affected 2 residents (Resident # 13 and Resident #4) of 6 observed medication administrations. The facility census was 28. Review of a facility policy titled Insulin Pen and dated 01/11/2024 revealed to prime the insulin pen by dialing 2 units by turning the dose selector clockwise and with the needle pointing up push the plunger and watch to see that at least one drop of insulin appears on the tip of the needle the turn the selector to the desired dose. In an observation of medication administration completed on 02/05/2025 at 11:27 AM by Registered Nurse-C (RN-C) the following was observed: -RN-C obtained an insulin pen from the medication cart. The RN wiped the tip of the pen with an alcohol wipe and then placed the needle cap onto the end of the insulin pen. RN-C then turned the dose selector to 6 then proceeded to Resident # 13 room and administered the insulin…
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.
- Potential for harm · Dcited before2025-02-10 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175NAC 12-0006.12(D)(i) Based on observation, record review, and interview the facility failed to ensure that medications were securely stored. This affected 1 resident (Resident #25) of 3 sampled residents. The facility census was 28. Record review of a facility supplied policy titled Storage of Medications dated 11/2020 revealed drugs and biologicals used in the facility are stored in locked compartments. In an observation completed on 02/04/2025 at 5:00 PM an opaque plastic bottle with a white cap and a pharmacy label with Resident #25's name and Nystatin Powder apply to red skin folds may keep at bed side was located within eyesight on the residents over bed table beside the resident's recliner. In an interview completed on 02/04/2025 at 5:10 PM with Resident #25, Resident #25 stated that the Doctor had approved for them to keep the Nystatin Powder in their room and apply it independently when skin folds get itchy. The resident denies staff completing an observation or assessment of them applying the powder. The resident denied staff education to 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.
- Potential for harm · D2024-02-29 · tag F0609 — failed to report abuse allegations — isolatedTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interviews; the facility failed to notify and submit a written investigation report to the State Agency within the required timeframe for 2 (Resident 136 and Resident 14) of 3 sampled residents. The facility census was 32. Finding are: A. A record review of Resident 136's Face Sheet revealed the resident admitted on [DATE] with diagnoses of: hematuria, chronic kidney disease, hypertensive chronic kidney disease, acidosis, and unspecified dementia without behavior disturbance. A record review of Resident 136's Minimum Data Set (MDS, a comprehensive assessment of each resident's functional abilities used to develop a resident's Care Plan in the nursing home) dated 10/17/2023 revealed Resident 136 had a BIMS score (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) of 01 which indicated the resident was severely…
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.
- Potential for harm · D2024-02-29 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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(5) Based on record review and interviews the facility failed to provide transfers for 2 (Resident 12 and Resident 7) of 2 sampled residents, to the Ombudsman. Facility census was 32. A. A record review of Resident 12's undated Facesheet revealed, that the facility admitted Resident 12 on 9/10/20. A record review of Residnet 12's Progress Notes revealed, that Resident 12 had been sent to the hospital on 8/13/23 and returned to facility on 8/15/23. The Progress Notes did not reveal, any documentation that Ombudsman had been notified of Resident 12's transfer to the hospital. In an interview with the Administrator on 02/28/24 at 3:09 PM revealed, that when [gender] called the Ombudsman office, the Ombudsman representitive confirmed that the office had not received any notifications for transfers or discharges from the facility in over a year. The Administrator further revealed, that the facility was not aware they were to notify the Ombudsman's office of transfers 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.
- Potential for harm · D2024-02-29 · tag F0625 — isolatedNotify 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 — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to provide a notice of the bed hold policy to the resident or resident representative which affected 2 (Resident 12 and Resident 7) of 2 sampled residents. The facility census was 32. Findings are: A record review of the facility's Bed Hold Policy undated revealed, that The nursing facility's bed hold policies apply to all residents. The first notice of bed-hold policies could be given well in advance of any transfer. -Reissuance of the first notice would be required if the bed-hold policy under the state plan or the facility's policy were to change. -The second notice, which specifies the duration of the bed-hold policy, must be issued at the time of transfer. -In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. The requirement is met if the resident's copy of the notice is sent with other papers accompanying the resident…
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.
- Potential for harm · D2024-02-29 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 12-006.09C3 Based on interview and record review, the facility the facility failed to complete a recapitulation of stay for 1 (Resident 33) of 1 resident sampled for discharged residents. The facility census was 32. Findings are: A record review of Resident 33's undated admission Record revealed, the resident was admitted to the facility on [DATE]. A record review of Resident 33'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 12/26/23 revealed, a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 12, which indicated the resident had moderately impaired cognition. A record review of Resident 33's Progress Notes dated 12/30/2023 revealed, the resident discharged from facility on 12/30/2023. A record review of Resident 33'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.
“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.
- 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.
Fines & penalties
$34,608 in federal fines across 2 penalties. 1 Medicare payment denial on record.
- $17,148 — penalty dated 2024-02-29
- $17,460 — penalty dated 2024-02-29
- Medicare payment denial — starting 2024-04-03 for 2 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 / manager | Type | Role | Since |
|---|---|---|---|
| SUTHERLAND, TODD | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2023 |
| KEENEY, MARCIA | Individual | CORPORATE OFFICER | since 11/01/2012 |
| ROSS, MARY | Individual | CORPORATE OFFICER | since 04/10/2018 |
CMS files one row per role, so the 4 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. 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
Straight from this home’s Medicare cost report (CMS, FY2023). 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
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.
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 285200. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-22, 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.