Heritage Care Center
909 17th Street, Fairbury, NE 68352 · Non profit - Corporation · 100 certified beds · (402) 729-2289 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- it has an abuse, neglect, or exploitation citation (F0602), cited Jun 2023
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 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 | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 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 | 34.4% | 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 | 0.6% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.6% | 2.8% | 2.0% | better |
| 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 | 2.7% | 4.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.8% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.3% | 19.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 20.4% | 25.9% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 20.7% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
* 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: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| 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 | 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 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 100 beds and averages 47.9 residents a day — about 48% occupied, or roughly 52 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 2.70 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.51 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.37 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 2.12 hrs/resident/day on weekends vs 2.93 on weekdays — 28% thinner on weekends — a notable drop. RN hours go from 0.57 to 0.36 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as 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
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.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · E2025-08-05 · 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)(4)Based on observations, record review, and interviews, the facility failed to reevaluate and update interventions to prevent elopement on two residents (Resident 1 and Resident 4) of the four sampled residents, and the facility failed to revise interventions to prevent falls on one resident (Resident 7) of three sampled residents. The facility census was 48. A.A record review of Resident 1's Clinical Census revealed an admission date of 5/13/2025.A record review of Resident 1's Minimum Data Set (MDS)(this comprehensive assessment evaluates each resident's functional capabilities) dated 05/19/2025 revealed a brief interview for mental status (BIMS) score of one which indicated the resident had severe cognitive impairment. A record review of Resident 1's Care Plan with an admission date of 5/13/2025 revealed a diagnosis of Alzheimer's Disease (A progressive disease that destroys memory and other important functions). A record review of Resident 1's Care Plan with…
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 · F2025-06-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.11(C) Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure recipes were followed during food preparation (prep) and food reached the required minimum final cooking temperature (temp), ensure all stored food was labeled, dated. and sealed, ensure kitchen surfaces were clean to prevent potential foodborne illness. This had the potential to affect all residents that consumed food from the kitchen. The total facility census was 50. Findings are: A. A record review of the facility's Roasted Fresh Summer Squash recipe dated Spring/Summer 2025 revealed: Ingredients for 50 servings: • 12 and ½ pounds (lbs) yellow fresh squash cut into ½ inch thick half [NAME] • 1 cup and 1 tablespoon (tbsp) vegetable oil • 2 tsp iodized salt • 1 tsp garlic powder • 1 tsp black ground pepper • May substitute zucchini for squash • May substitute olive oil for vegetable oil • May use other spices in place of salt, pepper,…
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 · F2025-06-17 · tag F0908 — failed to keep essential equipment working — widespreadKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.19(A)(i) Based on observation, interview, and record review, the facility failed to ensure the ovens in the facility's kitchen were maintained in a safe and operating condition. This had the potential to affect all residents that consumed food from the kitchen. The total facility census was 50. Findings are: A record review of the facility's Roasted Fresh Summer Squash recipe dated Spring/Summer 2025 revealed the oven temp required was 400 degrees Fahrenheit (F) or 375 degrees F for convection oven. Final internal cooking and holding temp should have been 135 degrees F. A record review of the facility's Mashed Sweet Potatoes recipe dated Spring/Summer 2025 revealed the oven temp was not listed. Final internal cooking and holding temp should have been 135 degrees F. A record review of the facility's Honey Glazed Turkey recipe dated Spring/Summer 2025 revealed final internal cooking temperature should have been 165 degrees Fahrenheit (F) for greater than (>) 1 second. A record review of the facility's Temperature Log sheets dated 05/01/2025 -…
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 · D2025-06-17 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, interviews, and record reviews; the facility failed to ensure medications were administered at the right time for 2 (Residents 29 and 49) of 7 sampled residents for medication administration. The facility also failed to ensure the medication error rate was less than 5%. Observations of 25 opportunities of medication administration revealed 2 medication errors, resulting in an 8% medication error rate. The facility census was 50 at the time of survey. Findings are: Record review of the facility provided policy titled Safe Medication Administration Practices with a revised date of May 19, 2025 revealed: -nurses must adhere to the five rights of medication administration to include right resident, right medication, right dose, right time, and right route prior to administrating the medication -medication error that does not cause harm is referred to as a potential adverse drug event -need to ensure timely administration of scheduled medications…
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 · D2025-06-17 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10(D) Based on observations, record review, and interviews; the facility failed to ensure 2 (Residents 29 and 49) of 2 sampled residents for insulin administration were free from significant medication errors. The facility census was 50 at the time of survey. Findings are: Record review of the facility provided policy titled Safe Medication Administration Practices with a revised date of May 19, 2025 revealed: -nurses must adhere to the five rights of medication administration to include right resident, right medication, right dose, right time, and right route prior to administrating the medication -medication error that does not cause harm is referred to as a potential adverse drug event -need to ensure timely administration of scheduled medications -be sure to administer medications identified as time critical within 30 minutes of the intended administration time. Record review of the facility's provided insulin administration policy date revised May 19, 2025 revealed…
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 before2025-02-19 · tag F0580 — failed to tell family and doctor about changes — patternImmediately 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 12-006.09(H) Based on interview and record review; the facility failed to notify the medical practitioner of a positive rapid COVID-19 (COVID-a mild to severe respiratory illness that is caused by a coronavirus) POC (point of care) test result in a timely manner for two (Resident 1 and Resident 4) and incorrectly notified the medical practitioner of a residents COVID-19 test result for one (Resident 3) of four sampled residents. The facility census was 48. Findings are: Review of facility provided list of residents COVID positive last 3 months, undated, revealed: Resident 1 and Resident 4 both tested positive on 12/27/24. Resident 3's name was not on the list. A. Review Resident 1's December 2024 Electronic Medication Administration Record (EMAR) revealed that on 12/27/24 Resident 1 had a positive COVID POC test. Review of Resident 1's progress notes revealed a note on 12/27/24 at 7:53 PM that revealed: Resident representative [name] updated of resident testing positive 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.
- Potential for harm · D2025-02-19 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(f)(i)(5) Based on interview and record review; the facility administered Paxlovid (a medication used to treat COVID-19 (COVID-a mild to severe respiratory illness that is caused by a coronavirus)) that was not positive of COVID per a rapid COVID POC (point of care) test for one (Resident 3) of 4 sampled residents. The facility census was 48. Findings are: In an interview on 2/19/25 at 1:34 PM, Resident 3 confirmed that [gender] had not tested positive for COVID and that [gender] received a medication for COVID. Resident 3 further confirmed that Resident 4 is [gender] roommate and that [gender] had tested positive for COVID. A. Review Resident 4's December 2024 Electronic Medication Administration Record (EMAR) revealed that on 12/27/24 Resident 4 had a positive COVID POC test. Review of Resident 4's progress notes revealed a note on 12/27/24 at 6:18 AM that revealed: Resident COVID tested. Results positive. No s/s (signs/symptoms) of COVID at this time. No nausea or vomiting. No c/o (complaints of) not feeling well, pain or discomfort 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 · D2024-05-02 · tag F0826 — isolatedProvide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.
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 12-006.09D1b Based on record review and interview, the facility failed to ensure Occupational Therapy (OT) Services were provided to Resident 3 as ordered by the physician. This affected 1 Resident sampled for rehabilitation. The facility census was 51. Findings are: A review of Resident 3's admission Record printed 04/30/2024 revealed the resident was admitted on [DATE] and had diagnoses of major depressive disorder (MDD-a mood disorder that causes persistent sadness and loss of interest in activities), chronic obstructive pulmonary disorder (COPD-a group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness). A record review of Resident 3's Quarterly Minimum Data Set, dated [DATE] (MDS-a comprehensive assessment of each resident's functional…
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 · D2024-05-02 · 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 12-006.17D Based on observation, record review, and interview, the facility failed to perform hand hygiene during catheter cares for 1 (Resident 54) of 1 sampled resident. Facility census was 51 Findings are: A review of the Catheter Care steps for procedure dated 2019 revealed hand hygiene is to be completed during and after catheter care at the following times: -before contact with catheter insertion site, -after coiling the catheter tubing to the resident's bed, -after cleaning supplies and returning to storage, -prior to leaving the resident's room, -Standard precautions should be always maintained, with no contamination. An Observation on 5/1/24 at 2:45 PM of Nursing Assistant-B (NA-B) and NA-H completing catheter cares on Resident 34 revealed the resident was in [gender] room lying in bed. NA-B and NA-H completed hand sanitization and donned (put on) gown and gloves. NA-B and NA-H enter residents' bathroom and gathered supplies from a cabinet located above the toilet. NA-H (with donned gloves) touched own face and door handle of bathroom…
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 before2023-06-16 · 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
Based on interviews and record review, the facility failed to notify the physician when 1 (Resident 22) of 3 residents reviewed for insulin use had a blood sugar reading out of the prescribed parameters. Findings included: Record review of an admission Record indicated the facility admitted Resident 22 on 03/04/2023 with diagnoses that included type 2 diabetes mellitus. Record review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/09/2023, revealed Resident 22 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident received insulin daily during the last seven days. Rcord review of Resident 22's care plan initiated 10/25/2022, revealed the resident had a potential for abnormal blood sugars. Interventions instructed staff to monitor the resident's blood sugar as ordered and monitor for and report to the charge nurse any signs and symptoms of hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). Record review of Resident 22's Order…
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 · D2023-06-16 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record review, the facility failed to prevent misappropriation of property for 1 (Resident 17) of 1 resident reviewed for abuse. Specifically, the facility failed to ensure placement of Resident #17's fentanyl patch to prevent misappropriation of the medication. Findings included: The facility's policy, titled, Discrepancies, Loss and/or Diversion of Medications, dated May 2021, indicated, All discrepancies, suspected loss and/or diversion of medications, irrespective of drug type or class, are immediately investigated and report filed. Procedures A. Immediately upon the discovery or suspicion of a discrepancy, suspected loss [sic] of diversion, the Administrator, Director of Nursing (DON) and Consultant Pharmacist are notified and an investigation conducted. The Director of Nursing leads the investigation. The facility's policy, titled, Abuse and Neglect Prevention Standard, dated January 2023, indicated, Misappropriation of Resident Property (property' includes medications), Federal Definition: The deliberate misplacement, exploitation, or wrongful,…
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
No federal fines in the current CMS record.
Part of a chain
This home belongs to VETTER SENIOR LIVING — 22 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 3 of 5 | 4.2 | -1.2 vs chain |
| Health inspection | 3 of 5 | 3.9 | -0.9 vs chain |
| Staffing | 3 of 5 | 4.3 | -1.3 vs chain |
| Quality measures | 4 of 5 | 3.8 | +0.2 vs chain |
The other 21 homes this chain runs (chain average 4.2★, 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| VETTER SENIOR LIVING | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 12/23/2016 |
| SLOANE, MARTINA | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/21/2017 |
| STROKLUND, REBECCA | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 08/20/2021 |
| STUHR, BRIAN | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VANEKEREN, GLENN | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VETTER, ELDORA | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VETTER, JACK | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VSL VETTER HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2017 |
CMS files one row per role, so the 19 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $296K paid to related parties (affiliated landlords or management companies) in its most recent 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 285262. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-17, 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.