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Emerald Nursing & Rehab Columbus

2855 40th Avenue, Columbus, NE 68601 · For profit - Corporation · 145 certified beds · (402) 564-8014 Medicare & Medicaid certified

Call the home — (402) 564-8014 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 20231 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (61%) runs well above the national median (45%)

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

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

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3763 39th Ave Ste 600 · (402) 564-9610 · Call to confirm hours
Pharmacy
4306 38th St · (402) 562-8627 · Call to confirm hours
Grocery
3318 23rd St · (402) 563-1884 · Call to confirm hours
Park
45TH Ave · (402) 564-7441 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased16.2%19.0%15.4%typical
Long-stay residents who lose too much weight6.5%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder0.7%1.4%0.9%better
Long-stay residents with a urinary tract infection0.9%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained1.6%0.3%0.1%worse than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.3%4.5%3.3%worse
Long-stay residents whose ability to walk worsened17.2%18.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication22.2%19.3%18.9%worse
Long-stay residents given the seasonal flu vaccine92.9%96.1%95.3%typical
Long-stay residents with pressure ulcers5.3%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control33.7%25.9%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table26.8%20.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication3.3%2.0%1.4%worse
Short-stay residents given the seasonal flu vaccine77.6%75.9%79.4%typical
Short-stay residents rehospitalized after admission25.4%20.7%22.6%worse
Short-stay residents with an outpatient ER visit19.8%11.4%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.751.811.67typical
Long-stay outpatient ER visits per 1,000 resident days2.231.921.80worse

* 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.

45.0% 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 106 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.0%U.S. median 51.5%
Got home and stayed home
9.7%U.S. median 10.7%
Went back to hospital
41.0%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.21hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 41.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 83 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

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

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF45.0%CMS range 36.8–53.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.7%CMS range 6.7–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge41.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge22.9%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge44.6%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS 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 settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.6–11.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

0.39
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.51
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.28
RN hoursweekends
60.9%
Total nursing turnover
33.3%
RN turnover

How full it usually is: this home is certified for 145 beds and averages 73.5 residents a day — about 51% occupied, or roughly 72 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 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.39 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 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 3.24 hrs/resident/day on weekends vs 3.71 on weekdays — 12% thinner on weekends. RN hours go from 0.44 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

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

Inspection trend

2
deficiencies at the latest standard inspection (2025-08-21)
8
at the previous standard inspection (2024-07-18)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2026-05-28 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.18ABased on observations, record review and interviews, the facility failed to ensure resident room walls were free from moisture and a black/gray substance in rooms B-4, B-6 and B-8; failed to ensure walls were free of gouges and bubbling paint in rooms B-2, B-6 and B-12; and failed to ensure walls in room B-10 were clean. The facility census was 69. Findings are: An observation on 5/27/26 at 11:00 AM revealed the following: B-2, dirty vents, with cracks and a small gouge (into the drywall) in the wall. B- 4, outside wall was moist with the grayish color stain appropriately 1 feet by 1 feet resembling mildew or a mold like substance.B- 6, outside wall was moist with a black/gray substance resembling mildew and had several bubbles and cracks in the paint.B-8, outside wall felt moist to touch with a blackish/gray substance appropriately 2 feet by 2 feet resembling mildew or a mold like substance.B- 10, streak/stains going down the outside wall. B-12, cracks in the drywall and streaks down the wall with bubbling paint. A record review of 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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-04-29 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09Based on record reviews, observations and interviews, the facility failed to ensure that medications were administered as ordered by a health care provider for 1 of 3 sampled residents and failed to administer insulin injections per professional standards for 1 of 2 sampled residents The census at the time of the survey was 75. Findings are: ARecord review of the facility's policy titled Medication Administration dated 05/2017 revealed that the purpose of the policy is to ensure that residents are given the correct medication and dosage, at the scheduled time and by the right route (by mouth, injection, in eyes, nose, ears, etc.). Number 15 revealed that documentation of administration must be entered into the Medication Administration Record (MAR) as soon as medication is given and if the medication is not given, a reason for the omission must be documented. Record review of the facility's policy titled Medication Errors dated 11/17/2024 revealed that for each…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18Based on observation, record review and interviews, the facility failed to ensure Enhanced Barrier Precautions (EBP - an infection control strategy that focuses on prevention of the spread of Multidrug Resistant Organisms (MDRO's) in nursing homes) were followed when cares were provided to 1 out of 3 sampled residents, and the facility failed to ensure hand hygiene with glove changes for 2 out of 3 sampled residents, and the facility failed to clean and sanitize glucose monitor machine when used between 2 residents. The facility census was 75. Findings are:Record review of facility policy dated 1/2024 titled PPE Enhanced Barrier Precautions revealed EBP requires the use of gown and gloves for high-contact resident care activities.Record review of facility policy, titled Infection Control Standard Precautions - Handwashing, dated last revised 1/2024 revealed for staff to perform hand hygiene before and after contact with residents, and before applying gloves and 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-08-21 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to provide comfortable and safe water temperatures in 4 shared bathroom sinks down East Hall. This had the potential to affect the 7 residents who live in rooms 1, 3,5, and 7. The facility census was 85. Licensure Reference Number 175 NAC 1-009.04 (D)(i) An observation and interview conducted with the Maintenance Director on 08/19/2025 at 7:28 AM using a thermometer supplied by the facility revealed water temperatures from the bathroom sinks to be more than 120 degrees Fahrenheit (F, a temperature scale where water freezes at 32 degrees and boils at 212 degrees) in the following bathrooms down East Hall: The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 126.1 degrees F. The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 126.9 degrees F. The shared bathroom between rooms [ROOM NUMBERS] revealed a water temperature of: 131 degrees F. The shared bathroom between rooms [ROOM…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-08-21 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observations, interview and record review, the facility failed to ensure the nasal cannula was not on the floor for 1 out of 8 sampled residents (Resident 51) to prevent cross contamination. The facility census was 85. Findings are: Record review of Resident 51's admission record dated 8/19/25 revealed resident's admission to the facility was on 7/31/25. Record review of Resident 51's MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 8/6/25 revealed:-Section C: BIMS (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) was 15 indicating the resident was cognitively intact.-Section G: uses walker and wheelchair. Needs set up for eating, supervision assists with oral, personal hygiene, toileting hygiene, upper dressing, lower dressing, and footwear. Upper body needs moderate assist,…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    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(H)(iii)(2) Based on observation, record review and interview; the facility failed to follow practitioner's orders regarding a dressing change for 1 (Resident 2) of 5 sampled residents. The facility census was 79. Findings are: Review of Resident 2's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 7/10/24 revealed the resident was admitted [DATE] with diagnoses of anemia, high blood pressure, diabetes, anxiety, manic depression, and chronic obstructive pulmonary disease. The following was assessed regarding Resident 2: -short- and long-term memory loss with severely impaired decision-making skills, -required total assistance with bed mobility, transfers, dressing, personal hygiene, and toilet use, -feeding tube which provided 51 percent (%) or more of total calories and 501 cubic centimeters (cc) per day or more of average fluid intake, and -had two unhealed stage 3 pressure ulcers (full thickness tissue loss.…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-14 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 Based on observation, record review, and interview; the facility failed to: 1) utilize the required Personal Protective Equipment (PPE-can include items such as gowns, gloves, masks, goggles, face shields, and foot coverings) when performing direct cares for Residents 3 and 4 who were on Enhanced Barrier Precautions; and 2) complete hand hygiene (hand washing using soap and water or an alcohol based hand rub) and gloving techniques during the provision of a treatment to prevent potential cross contamination during the provision of wound care for Resident 3. The sample size was 5 and the facility census was 79. Findings are: A. Review of the facility policy PPE-Enhanced [NAME] Precautions (EBP) with a revision date of 1/24 revealed EBP are an infection control intervention designed to reduce transmission of resistive organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with wounds 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-07-18 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number NAC 175 12-006.18 Based on record review and interview; the facility failed to implement their legionella water management policy to prevent the potential for water-borne illness. This had the potential to affect all residents. The facility census was 73. Findings are: Review of the facility policy: Legionella (bacteria that causes pneumonia like illness) Water Management Program, last revised 1/2024 revealed the following: -the water management team would consist of at least the infection preventionist, the administrator, the medical director, the director of maintenance, and the director of environmental services, -the purpose was to identify areas in the water system where Legionella bacteria could grow and spread, and to reduce the risk of Legionnaire's disease (severe form of pneumonia), and -the water management program would include the following: a. an interdisciplinary water management team, b. a detailed description and diagram of the water system, c. identification of areas in the water system that could encourage the growth and spread 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-07-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19 (A) Based on observation, and interview, the facility failed to maintain the cleanliness and condition of walls, floors, and a baseboard in 5 (rooms: Northwest 7 and 10, Northeast 4, East 7 and [NAME] 5) of 68 occupied resident rooms and the Northwest corridor between rooms [ROOM NUMBERS]. The facility census was 73. Findings are: Observations on 7/18/24 from 11:30 AM to 12:06 PM, during the environment tour, revealed the following concerns with the facility environment: Northwest corridor -missing base board in the hallway between rooms [ROOM NUMBERS], -room [ROOM NUMBER] with scrapes and gouges and a hole in the drywall approximately 4 by 10 inches underneath of the air conditioning unit and the adjacent wall with gouged/scraped areas, -room [ROOM NUMBER] in the resident's bathroom above the stool was a hole/gouged area in the drywall which measured approximately 4 by 6 inches. Northeast Corridor -room [ROOM NUMBER] had an area underneath of the window with a patch…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-07-18 · tag F0801 — pattern
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 12-006.04(H) Based on observation, interview, and record review; the facility failed to ensure they employed a Certified Dietary Manager (CDM) and staffing sufficient to clean the kitchen environment, food preparation equipment and storage equipment in a manner to prevent potential food borne illness. This had the potential to affect all residents who ate food prepared by the facility. The facility census was 73. Findings are: Review of the facility Job Description for Manager of Dining Services dated 10/1/16 revealed the following: -The Dietary Manager managed the operation of the dietary department to include staff, food ordering and preparation, food delivery and clean-up in accordance with facility policies, physician's orders, patient care plans and appropriate regulations. -Ensured food was nutritional, appetizing, prepared per menu and recipes and served in a timely manner. -Ensured equipment and work areas were clean, safe and orderly, ensured strict adherence to procedures regarding cleaners and or hazardous materials or objects, ensured…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · E2024-07-18 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure the kitchen environment, food storage, and preparation equipment were maintained in a manner to prevent the potential for food borne illness. This had the potential to affect all facility residents who ate food prepared by the facility kitchen. The facility census was 73. Findings are: Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: -4-602.13 Nonfood contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residue. -4-601.11(B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. -4-601.11(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. -4-903.11(A) cleaned equipment and utensils,…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-07-18 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(l)(i) Based on observations, record review and interviews; the facility failed to implement fall interventions and to revise current interventions and/or develop new intervention to prevent ongoing falls for Resident 69. The sample size was 5 and the census was 73. Findings are: A. Review of the facility policy Falls Management with a revision date of 1/24 revealed the residents were to be assessed to determine fall risk and then the interdisciplinary team (IDT) were to identify and implement appropriate interventions to reduce the risk of falls or injuries. The following procedures were indicated: -assess the resident's fall risk at admission, quarterly, with a change in condition or a fall. -implement goals and interventions based on the individual's needs. -communicate interventions to the team. -educate the staff, resident, and responsible party regarding interventions. -provide training to staff as needed and document. B. Review of Resident 69's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure 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 175 NAC 12-006.12(A)(vi) Based on record review and interview, the facility failed to ensure residents were free from unnecessary medications related to long term use of an antibiotic medication for Resident 22. The antibiotic did not specify a duration and had no supporting documentation for clinical use based on laboratory results. The sample size was 2 and the facility census was 73. Findings are: A. Review of the facility Antibiotic Stewardship Policy dated 11/17 revealed the following: -the purpose of the program was to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. -antibiotic stewardship was to be part of the Infection Control Program. -the facility was to track antibiotic use daily. -all nurses were to be educated regarding proper assessment for infection prior to calling a physician. -the facility was to ensure the pharmacy reviewed all antibiotic usage for appropriateness. -the facility would monitor for any adverse reactions/outcomes related to use of antibiotics. B. Review of Resident 22's medical…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5 percent (%). Observations of 27 medications administered revealed 6 errors resulting in an error rate of 22.22%. The medication errors were related to 3 (Residents 5, 19 and 68) of 6 residents. The facility staff identified a census of 73. Findings are: A. Review of the facility policy Medication Errors with a revision date of 1/24 revealed the facility was to ensure residents were free of medication error rates of 5% or greater. A medication error was defined as the observed or identified preparation or administration of medications which were not in accordance with the prescriber's order or the manufacturers specifications regarding the preparation and administration of the medication. B. Review of Resident 5's Medication Administration Record (MAR) dated 7/2024 revealed the resident had an order dated 4/13/23 for Metformin (medication used to treat diabetes) 1000 milligrams (mg) to take 1 tablet twice a day…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-07-18 · tag F0804 — failed to serve food at safe, palatable temperature — isolated
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    LICENSURE REFERENCE NUMBER 175 NAC 12-006.11D Based on observation, record review and interview; the facility failed to ensure room trays were palatable and served at the proper temperature. This affected 2 (Residents 34 and 66) of 4 residents served a breakfast room tray. The facility staff identified a census of 73. Findings are: A. Review of the facility Beginning Food Cooking Temperatures log (form used to document food temperatures before each meal service) revealed the serving temperatures of all hot food was to be a minimum of 140 degrees Fahrenheit (F) before serving to the residents. Further review of the log revealed on 7/15/24 at the breakfast meal the scrambled eggs had a temperature of 182 degrees. B. Observations on 7/15/24 revealed the following: -8:10 AM a serving cart was positioned next to the Nurse's Station by the [NAME] corridor. The cart contained 4 breakfast room trays with a thermal cover over each of the plates. -8:50 AM (40 minutes later) Nurse Aide (NA)-S approached the cart, removed one of the trays and deliver the room tray to Resident 34. NA-S removed…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D1c Based on record review and interview; the facility failed to provide bathing services for Residents 1, 4, and 5. The sample size was 3 and the facility census was 73. This had the potential to affect all residents. Findings are: A. Review of the facility policy Activities of Daily Living (ADL's), last revised 1/2024 revealed the following: -the facility would ensure a resident's ADL's would not deteriorate unless deterioration was unavoidable which included bathing, dressing, grooming, transferring, ambulate, toilet use, eating and speech, and -a resident who was unable to carry out ADL's would receive the necessary services to maintain good nutrition, grooming, personal hygiene, and oral hygiene. B. During a confidential Resident interview conducted on 4/30/24 at 10:20 AM the resident revealed not receiving baths on a regular schedule. Further interview revealed the resident had gone 3 weeks without a bath in February and the resident told the facility they would…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0725 — failed to have enough nursing staff — isolated
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 175 NAC 12-006.04C Based on record review and interview; the facility failed to provide sufficient nursing staff for the provision of bathing for Residents 1, 4, and 5. The sample size was 3 and the facility census was 73. This had the potential to affect all residents. Findings are: A. During confidential Resident interview conducted on 4/30/24 at 10:20 AM the resident revealed not receiving baths on a regular schedule. Further interview revealed the resident had gone 3 weeks without a bath in February and the resident told the facility they would like to have 2 baths weekly. When the resident complained, the resident was told the bath aide was on vacation and that staff had called in. B. Review of Resident 1's Minimum Data Set (MDS-a federally mandated tool used in care planning) dated 3/21/24 revealed the resident had severe cognitive impairment; had diagnoses of aphasia (language disorder caused by brain damage that affects the ability to understand or express speech), stroke,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D7 Based on observations, record review and interview, the facility failed to ensure interventions were implemented to prevent a potential burn injury from a hot liquid spill for 2 residents (Resident 1 and 2). The sample size was 3 and the facility census was 77. Findings are: A. Review of Resident 1's electronic medical record revealed the following: -The resident was admitted to the facility on [DATE], was cognitive, independent with eating and had diagnoses of Diabetes Mellitus, Chronic Kidney Disease, weakness and Nutritional Deficiency. -Progress Note dated 9/17/23 at 11:41 PM, revealed the resident spilled a cup of hot tea onto self during breakfast. The resident had several areas of blisters located on both inner thighs that required a treatment of Silvadene Cream (a topical antimicrobial drug use for the prevention and treatment of wound infections in patients with second- and third- degree burns) twice a day. -The undated Care Plan indicated there was 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-17 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.02(8) Based on record reviews, interviews, and record review, the facility failed to provide a safe environment to prevent resident-to-resident abuse which involved 2 (Resident #44 and Resident #45) of 4 residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, created May 2017, revealed, It is the policy of (Facility) that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-17 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference 175 NAC 12-006.02 (8) Based on interview, and record reviews, the facility failed to timely report an allegation of abuse to the State Agency which involved 2 (Resident #44 and Resident #45) of 4 residents reviewed for abuse. Findings included: Review of the facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, created May 2017, revealed, External Reporting: Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegations: If an incident or allegation is considered reportable, the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09D(1) Based on interviews and record review, the facility failed to ensure 1 (Resident #275) of 3 residents reviewed for activities of daily living received a shower as preferred. Findings included: A review of Resident #275's admission Record revealed the facility admitted the resident on 01/19/2023, with diagnoses that included histoplasmosis, peripheral vascular disease, lymphedema, chronic non-pressure ulcers of bilateral lower extremities, and weakness. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date of 01/26/2023, revealed Resident #275 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required extensive assistance with bathing. A review of Resident #275's care plan with an initiated date of 01/21/2023, indicated the resident had an activities of daily living self-care performance deficit and required assistance with daily care. In a telephone interview on 08/17/2023 at 12:57 PM, Resident #275…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2026-04-29 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interviews, the facility failed to ensure that the Daily Nurse Staff Posting was posted as required. This had the potential to affect all residents residing in the facility. The facility census was 75.Findings are:Record review of the facility policy titled Nurse Staff Posting and dated 1/2024 revealed the nurse staffing information will contain the following information:facility namethe current datefacilities current censusthe total number and actual hours workedThe facility will post the nurse staffing total at the beginning of each shift, and the posted information will be maintained for 18 months.An observation on 4/28/2026 at 9:37 AM during a facility walk through revealed no daily nursing staff posting in the facility.During an interview on 4/28/2026 at 9:37 the Director of Nursing (DON) confirmed the daily nurse posting was not posted anywhere and should have been. During an interview on 4/28/2026 at 9:40 DON confirmed that the facility census was 75 and there is 1 nurse on the floor scheduled for the dayshift and 1 nurse scheduled 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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

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

  • Medicare payment denial — starting 2025-11-21 for 21 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.

Part of a chain

This home belongs to EMERALD HEALTHCARE — 14 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 51.3-0.3 vs chain
Health inspection 3 of 51.5+1.5 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 1 of 52.0-1.0 vs chain
The other 13 homes this chain runs (chain average 1.3★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
JW NEBRASKA OPERATIONS, LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/01/2023
CHAFETZ, YISROELIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2023
REISMAN, ADINAIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2023
SEGAL, CARYNIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2023
WALDEN, JACOBIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2019
BANK OF OKLAHOMAOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2025
EMERALD HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/22/2025
EVOLVE THERAPY SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/22/2025
LIMESTONE FISCAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/22/2025
MERCH PAY INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2025
NEXUS SERVICE GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2025
SAUL N FRIEDMAN & COMPANYOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2025
ZIMMET HEALTHCARE SERVICES GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/24/2025
FLEISCHMANN, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
GOFF, KILEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/15/2024
GOPIN, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
GRONENTHAL, MEGANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/19/2023
MOLT, MELINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2019
ROAN, CHELSEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/18/2019
SATTAR, ARIFIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2019
WICHMAN, JERI JOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/29/2022

CMS files one row per role, so the 41 rows in the source record cover these 21 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.

9 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$10.4M
Net patient revenuemost recent cost report
+4.1%
Operating marginrevenue minus expenses
$1.6M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 59%Medicare 13%Other / private 29%

This home reported $1.6M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$357per resident / day
operating cost
$10,854per month
≈ monthly operating cost
$372per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285092. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-08-21, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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