Clarkson Community Care Center Inc
212 Sunrise Drive, Clarkson, NE 68629 · Non profit - Other · 51 certified beds · (402) 892-3494 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (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
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,593 in federal fines (most recent 2023-09-26)
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Long-stay residentspeople who live here | 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 fell from 3 to 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 | 18.1% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.0% | 5.1% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.8% | 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 | 9.1% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 16.6% | 18.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 23.3% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.3% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 28.0% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.8% | 20.7% | 17.1% | worse |
| Short-stay residents rehospitalized after admission | 14.9% | 20.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.6% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.01 | 1.81 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 3.84 | 1.92 | 1.80 | worse |
* 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.
Therapy staffing: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | not 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 SNF | 11.0%CMS range 6.8–16.8 | 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 — 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 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 | 5.0% | 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 | 5.0% | 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 | not 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 SNFs | 1.04 | 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 51 beds and averages 31.4 residents a day — about 62% occupied, or roughly 20 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 1.43 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.35 is below the 0.55-hour RN benchmark and nurse-aide staffing of 0.94 is below 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 1.28 hrs/resident/day on weekends vs 1.49 on weekdays — 14% thinner on weekends. RN hours go from 0.38 to 0.26 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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2024-10-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.9 Based on observations, interviews, and record reviews; the facility failed to follow Resident 1's physician orders regarding fluid consistency. The sample size was 3. The facility census was 27. Findings are: Record review of the facility's policy titled Thickened Liquids dated 2022, revealed that thickened liquids are needed for individuals with difficulty swallowing. Definitions included Nectar like liquids are mildly thick and Honey like liquids are moderately thick. Record review of the facility's Accident/Unusual Occurrence report completed on 10/27/24 at 8:30 PM revealed that Resident 1 was sent to the emergency room after noted to be coughing after drinking thin liquids. The resident's diet was nectar thick liquids. Record review of Resident 1's undated facility admission record revealed an original entry to facility on 1/16/2019 and that the resident was readmitted to the facility on [DATE] with a diagnosis of pneumonitis (swelling and irritation, or…
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 before2026-06-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 interview; the facility failed to investigate and submit a completed investigation report related to abuse and neglect to the State Agency within the required time frame for Residents 1 and 2. The sample size was 3 and the facility census was 29.Findings are: A. Review of the facility policy Abuse, Neglect and Exploitation with an implementation date of 9/2017 revealed each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. In response to allegations of abuse, neglect exploitation or mistreatment, the facility was to: -ensure all alleged allegations were reported immediately, but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. But not later than 24 hours if the advents that caused the allegation did not involve abuse and did not result in serious bodily injury. To be reported 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 · Dcited before2026-06-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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(l)(i) Based on record review and interview; the facility failed to identify causal factors of falls and to revise and/or develop interventions based on those factors to prevent ongoing falls for Residents 1 and 3. The sample size was 3 and the facility census was 29. Findings are:A. Review of the facility policy Fall Risk Assessment with an implementation date of 10/21/25 revealed it was the policy for the facility to provide an environment that was free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. An explanation and compliance guidelines included the following: -a risk assessment was to be completed upon admission, quarterly or when a significant change was identified. -the risk assessment was to identify environmental hazards and individual risks, including the need for supervision and to evaluate and analyze hazards and risks. -an at risk care plan was 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 · F2025-09-03 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number: 175 NAC 12-006.04D(i) Based on record reviews and interviews; the facility failed to provide full time hours for the designated Director of Nursing (DON) who was working as a Charge Nurse. This failure had the potential for affecting nursing care to all the residents. The total sample size was 15 and the facility census was 30.Findings are: Review of an undated Job Description for the Director of Nursing (DON) revealed the DON was responsible for effective overall management of the Nursing Department and coordination with other disciplines to provide quality care to all residents. The following duties and responsibilities were identified:-ensure nursing interventions meet the physical, personal, and cognitive needs of each resident as well as maximize their self-care capacities, identify, independence, choice, and opportunity for social interaction. -monitors the outcomes of nursing service activity by evaluating the performance of nursing staff, ensuring compliance with all facility and regulatory agencies standards, coordinating the facility committees,…
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 · E2025-09-03 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
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(E)Based on record review and interview; the facility fails to obtain informed consent for the use of psychotropic (medications that effect the brain and alter mental processes, emotions, and behavior) medications for Residents 12,16, 17, and 29. The sample size was 5 and the facility census was 30. Findings are: A. Review of the facility undated policy Use of Psychotropic Medication revealed the following;-Residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). -The indications for use of psychotropic drugs were documented in the medical record. -Targeted symptoms for monitoring were documented in the resident record.-Residents and/or their representative/s were educated on the risks and benefits of psychotropic 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 · E2025-09-03 · tag F0657 — failed to keep the care plan current — patternDevelop 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview; the facility failed to review and revise Care Plans to accurately reflect Residents 5 and 6's Enhanced Barrier Precautions (EBP-an infection control strategy that involves the use of gown and gloves during high contact resident care activities to reduce the spread of drug resistant organisms in settings such as nursing homes) and Residents 7, 12, 16, and 24's fall interventions. The sample size was 12 and the facility census was 30. Findings are: A. Review of the facility policy Baseline Care Plan undated revealed the following:-The facility developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the residents that met professional standards of quality. Review of the undated facility policy Comprehensive Care Plans revealed the following;-The facility developed and implemented a comprehensive person-centered care…
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 before2025-09-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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)(i)Based on interview and record review; the facility failed to review for causal factors and implement measures to prevent ongoing falls for Resident's 12, 16, 7, and 24. The sample size was 4 and the facility census was 30. Findings are: A. Review of the undated facility policy Accidents and Supervision revealed the following;-The resident environment remained as free from accident hazards as possible.-Each resident received adequate supervision and assistive devices to prevent accidents. -The facility established and utilized a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents through Identification, Evaluation and Analysis, Implementation of Interventions, and Monitoring and Modification. Review of the undated facility Fall Checklist revealed the following;-The fall and an intervention were to be added to the resident care plan.-The investigation included a root cause analysis of the fall and an…
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 · D2025-09-03 · 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(H) Based on record review and interview; the facility failed to report a fall with injury for Resident 24 and an injury of unknown origin for Resident 7 as potential allegations of abuse and/or neglect. The sample size was 2 and the facility census was 30. Findings are: A. Review of the undated facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed it was the policy of the facility to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of resident property. Allegations were to be reported immediately to the Administrator and to other appropriate agencies in accordance with current state and federal regulations within the prescribed timeframes. The Administrator or designee was to notify the appropriate agencies immediately; as soon as possible, but no later than 24 hours after the discovery of the incident. In the case of serious bodily injury, no later than 2 hours…
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 before2025-09-03 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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(H)Based on interview and record review; the facility failed to investigate and to submit the results of the investigation to the State Agency within the required time frame a fall with significant injury for Resident 24 and an injury of unknown origin for Resident 7. The sample size was 2 and the facility census was 30. Findings are: A. Review of the undated facility policy Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed it was the policy of the facility to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation of resident property. Allegations were to be reported immediately to the Administrator. The Administrator or designee were to ensure all alleged or suspected violations were thoroughly investigated and were to prevent further potential abuse while the investigation was in progress. The results of all investigations were to be reported to other officials in accordance…
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 · D2025-09-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: 1Number of residents cited: 1Based on record review and interview; the facility failed to ensure a comprehensive discharge summary for completed for Resident 35. Licensure Reference Number NAC 175-12 006.09(G)(i)7Based on record review and interview; the facility failed to document a recapitulation (a complete summary of the residents stay in nursing facility from admittance to discharge) for a resident-initiated discharge for 1 (Resident 35) of 1 sampled resident. The facility identified a census of 30. Findings are: A. Review of the facility Discharge Summary and Plan with a revision date of 12/2016 revealed when a resident's discharge was anticipated, a discharge summary and post-discharge plan were to be developed to assist the resident to adjust to their new living environment. The discharge summary was to include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge. The summary was to include 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 · D2025-09-03 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
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(C)(ii)Based on record review and interview; the facility failed to ensure a Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) was completed for Resident 12 for a hospice admission. The sample size was 12 and the facility census was 30.Findings are: Review of the undated facility policy MDS 3.0 Completion revealed the following;-The residents were assessed, using a comprehensive assessment which used core elements for use in assessing nursing home residents.-According to Federal regulation, the facility conducted initial and periodic comprehensive, accurate and standardized assessment of each resident's functional capacity, using the resident assessment instrument specified by the State. -Assessments completed included initial/admission assessment, annual assessment, and significant change assessment.-All disciplines followed the guidelines used in the current Resident Assessment Instrument (RAI-a standardized,…
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 15 citations
- Potential for harm · Dcited before2025-09-03 · 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(B)(iv)Based on record review and interview; the facility failed to ensure Resident 2's MDS (Minimum Data Set-federally mandated comprehensive assessment used to develop resident care plans) was coded accurately to reflect which type of medications were being administered. The sample size was 12 and the facility census was 30.Findings are: Review of the undated facility policy MDS 3.0 Completion revealed the following;-The residents were assessed, using a comprehensive assessment which used core elements for use in assessing nursing home residents.-According to Federal regulation, the facility conducted initial and periodic comprehensive, accurate and standardized assessment of each resident's functional capacity, using the resident assessment instrument specified by the State. -Assessments completed included initial/admission assessment, annual assessment, and significant change assessment.-All disciplines followed the guidelines used in the current 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 · D2025-09-03 · tag F0645 — isolatedPASARR screening for Mental disorders or Intellectual Disabilities
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 12-006.09ABased on record review and interview: the facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) screen was completed accurately for 1 (Resident 6) of 1 sampled residents. Findings are: Review of the facility policy Resident Assessment Coordination with PASARR Program, undated revealed the following:-the facility would coordinate assessments with the preadmission screening and resident review to ensure that individuals with a mental disorder, intellectual disability, or a related condition received care and services in the most integrated setting appropriate for their needs,-all applicants would be screened for serious mental disorders, intellectual disabilities and related conditions,-a negative Level I screen permitted admission and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later,-a positive Level I screen necessitated a PASARR Level II evaluation prior to admission,-PASARR…
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 · D2025-09-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(E)Based on record review and interview; the facility failed to ensure Resident 2's Care Plan was comprehensive and accurately reflected the residents diagnoses and high-risk medication use. The sample size was 12 and the facility census was 30. Findings are: Review of the facility policy Baseline Care Plan undated revealed the following:-The facility developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality. Review of the undated facility policy Comprehensive Care Plans revealed the following;-The facility developed and implemented a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental health and psychosocial needs and all services that are identified in 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.
- Potential for harm · D2025-09-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to complete an assessment for Resident 6 for potential adverse effects from antipsychotic ( a type of medication that alters the chemicals in the brain to effect change in behavior, mood and emotion). The sample size was 5 and the facility census was 30. Findings are: Review of the facility undated policy Use of Psychotropic Medication revealed the following;-Residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s),-the indications for use of psychotropic drugs were documented in the medical record,-targeted symptoms for monitoring were documented in the resident record,-Residents and/or their representative/s were educated on the risks and benefits 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 · Dcited before2025-09-03 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 12-006.18(B)Based on observation, record review, and interview; the facility failed to ensure hand hygiene was completed at appropriate intervals during wound care for Resident 16 to prevent potential cross-contamination. The sample size was 12 and the facility census was 30. Findings are: Review of the facility policy Hand Hygiene with a revision date of 7/1/25 revealed the following: -All staff to perform hand hygiene procedures to prevent the spread of infection to other personnel and residents. -Staff were to perform hand hygiene as indicated using proper technique consistent with accepted standards of practice. -The use of gloves did not replace hand hygiene. If the task required gloves, staff were to perform hand hygiene prior to putting on gloves and immediately after removing gloves. -Hand Hygiene is to be performed using soap and water when hands were visibly soiled, and/or soiled with blood or other body fluids, and following exposure to curtain pathogens/bacteria,after caring for a resident with known or suspected diarrhea, and /or after…
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 before2024-08-22 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 12-006.18B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interviews; the facility failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination during the provision of care for 3 (Residents 2,11, and 14) of 12 residents sampled. The facility also failed to develop and implement policies and procedures to prevent and protect residents from an onset of the communicable disease Legionella (a bacteria that thrives in water, that has the potential to cause Legionnaires Disease, a type of pneumonia). This had the potential to affect all the residents. The facility failed to prevent the potential for cross contamination for staff testing for Covid. The facility census was 33. Findings Are. A. A review of the facilities Infection Prevention and Control Program policy dated 7/9/2024 revealed the following for Standard Precautions practice: -All staff should assume that all residents are potentially infected or colonized with an organism. -Hand hygiene is to be performed per…
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 · E2024-08-22 · 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 12-007.04D Based on observations and interviews; the facility failed to ensure bathroom ventilation systems were functioning, preventing lingering odors from permeating for 11 (rooms 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214) of 12 rooms sampled. The facility census was 33. Findings are: Observations of the ventilation system in the residents bathroom's 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214 on 8/19/24 at 8:00 AM using 1 square ply of toilet paper revealed the ventilation system in the bathrooms were not functioning. Observations of the ventilation system in the residents bathroom's 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214 on 8/20/24 at 8:00 AM using 1 square ply of toilet paper revealed the ventilation system in the bathrooms were not functioning. Observations of the ventilation system in the residents bathroom's 201, 202, 203, 204, 205, 207, 209, 210, 211, 212-and 214 on 8/21/24 at 8:00 AM using 1 square ply of toilet paper…
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 before2024-08-22 · 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 12.006.09B Based on observation, interview, and record review; the facility failed to code the Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) assessment to reflect the behavior of 1 (Resident 21) of 5 sampled residents. The facility census was 33 at the time of survey. Findings are: Record review of the Resident Assessment Instrument (RAI) User's Manual dated October 2023 revealed the following: -Code 1, behavior of this type occurred 1-3 days. -Steps for Assessment: -Review the medical record for the 7-day look-back period. -Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. -Observe the resident in a variety of situations during the 7-day look-back period. Record review of Resident 21's admission…
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 · D2024-08-22 · tag F0660 — isolatedPlan the resident's discharge to meet the resident's goals and needs.
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 12-006.090D Based on record reviews and interviews; the facility failed to obtain physician discharge orders, failed to prepare the resident and document plans for discharge, and failed to complete the discharge summary for 1 (Residnet 28) of 1 sampled resident prior to discharging the resident. The facility census was 33 at the time of survey. Findings are: Record review of the facility's policy titled Discharge Summary and Plan, dated December 2016 revealed that when a resident's discharge is anticipated a discharge plan will be completed. Record review of the facility's policy titled Discharge Documentation, dated December 2016 revealed that when a resident is discharged details of the discharge will be documented in the medical record. Record review of the facility's policy titled Discharge Summary and Plan, dated December 2016 revealed that a final summary of the resident's status will be completed at the time of discharge and will include a post discharge plan completed by…
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 · E2024-05-16 · tag F0607 — failed to have anti-abuse policies — patternDevelop 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 12-006.04B1 Based on record reviews and interviews, the facility failed to ensure new employees were trained on abuse for 7 (DA-A, NA-B, DA-C, DA-D, NA-E, NA-H DA-I ) of 9 sampled employees.The facility census was 28. Findings are: Record Review of Abuse, Neglect and Exploitation dated 9/2017 revealed: 4. Employee Training a. New employees should be educated on abuse, neglect, and exploitation during initial orientation. Annual education and training is provided to all existing employees. Front line supervisors or other department heads should provide education as situations arise. 5. Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents. d. Provide education of what constitutes abuse, neglect, and misappropriation. Record review of 7 personnel files of employees that have worked at the facility less than 4 months revealed no documentation of abuse training for the following new employees: DA-A was hired on 3/29/24, NA-B was hired…
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 · E2023-09-26 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
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 12-006.09B Based on record review and interview, the facility failed to complete a quarterly Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) within the regulatory time frame for 7 (Residents 1, 3, 6, 16, 18, 22, and 29) of 9 residents reviewed. The facility census was 37. Findings are: Record review of the Centers for Medicare and Medicaid Services (CMS) RAI manual version v1.17.1, dated October 2019, revealed that a Quarterly MDS is used to track the resident's status between comprehensive assessments, and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status. The MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). Review of the facility policy, Resident Assessment Instrument, dated September 2010, revealed the following: 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely 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 · D2023-09-26 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 12-006.04C3a Based on record review, observations, and interviews, the facility failed to notify the physician of change in condition for 1 (Resident #10) of 1 resident sampled. The facility staff have identified the census to be 37. The findings are: Record review of the policy titled Change in a Resident's Condition or Status last revised 5/2017 revealed the nurse will notify the resident's Physician when there has been a significant change in the resident's physical, emotional, and mental condition or a need to alter the resident's medical treatment significantly. Record review of the policy titled Surveillance for Infections last revised 7/2017 revealed that nursing staff will monitor residents for signs and symptoms that may suggest infection and will report it to the Charge Nurse as soon as possible. The Charge Nurse will notify the Physician and the Infection Preventionist (IP) of suspected infections who will then determine if laboratory tests are indicated and whether…
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 · D2023-09-26 · 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 — the official record, unedited, may be distressing
Licensure Reference Number 175NAC 12-006.05(5) Based on record review and interview, the facility failed to provide a written notice of transfer to the resident and/or resident representative upon transfer to the hospital for 1 (Resident 18) of 1 sampled resident. The facility census was 37. Findings are: Record review of Resident 18's progress note, dated 9/2/23 at 5:00 PM, revealed that Resident 18 had been transferred to the hospital due to fever, no urine output and abdominal distention. Record review of Resident 18's progress note, dated 9/3/23 at 11:26 AM, revealed that Resident 18 had been admitted to the hospital. Record review of Resident 18's electronic health record (EHR) revealed no documentation that a written notice of transfer was provided to the resident and/or resident representative upon transfer to the hospital on 9/2/23. An interview on 09/25/23 at 11:38 AM, the Administrator confirmed that a written notice of transfer was not completed for Resident 18 upon transfer to the hospital on 9/2/23.
- Potential for harm · D2023-09-26 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09B1(1) Licensure Reference Number 175NAC 12-006.09B1(3) Based on record review and interview, the facility failed to ensure that an admission Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) for 1 (Resident 20) and an annual MDS was completed within the regulatory time frame for 2 (Residents 3 and 21) of 9 residents reviewed. The facility census was 37. Findings are: Review of the Centers for Medicare and Medicaid Services (CMS) RAI manual version v1.17.1, dated October 2019, revealed that completion of an admission MDS must be within 14 calendar days of the resident's admission. In addition, an Annual MDS must be completed within 14 days of the Assessment Reference Date (ARD). Review of the facility policy, Resident Assessment Instrument, dated September 2010, revealed the following: -1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews…
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 before2023-09-26 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 12-006.17A Based on record review, observations and interviews, the facility failed to maintain transmission-based precautionjs to prevent the spread of Covid-19 for 1 (Resident #10) of 1 sampled resident. The facility staff have identified the census to be 37. The findings are: Record review of the policy titled Surveillance for Infections last revised 7/2017 revealed that nursing staff will monitor residents for signs and symptoms that may suggest infection and will report it to the Charge Nurse as soon as possible. The Charge Nurse will notify the Physician and the Infection Preventionist (IP) of suspected infections who will then determine if laboratory tests are indicated and whether special precautions are warranted. Record review of policy titled Isolation-Initiating Transmission-Based Precautions last revised 1/2012 revealed if a resident is suspected, of having a communicable infectious disease the Charge Nurse will notify the IP and resident's Physician 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.
“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
$15,593 in federal fines across 1 penalty. 2 Medicare payment denials on record.
- $15,593 — penalty dated 2023-09-26
- Medicare payment denial — starting 2024-11-28 for 42 days
- Medicare payment denial — starting 2023-11-28 for 35 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 |
|---|---|---|---|
| HAHN, LUCY | Individual | CORPORATE OFFICER | since 10/01/2025 |
| INDRA, CHAY | Individual | CORPORATE OFFICER | since 11/01/2025 |
| MARTIN, DANIEL | Individual | CORPORATE OFFICER; TRUSTEE OF THE SNF | since 08/16/2023 |
| OENBRING, BRIAN | Individual | CORPORATE OFFICER | since 01/17/2026 |
| WILLIAMS, LINDA | Individual | CORPORATE OFFICER; ADP OF THE SNF | since 03/30/2026 |
| HASS, BRIAN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 08/01/2017 |
CMS files one row per role, so the 9 rows in the source record cover these 6 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.
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
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
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 285116. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-03, 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.