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Emerald Nursing & Rehab Lakeview

1405 West Hwy 34, Grand Island, NE 68801 · For profit - Corporation · 95 certified beds · (308) 382-6397 Medicare & Medicaid certified

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1 immediate-jeopardy citation$13,426 in federal fines1 Medicare payment denial
Insights

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

Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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
  • the CMS record shows $13,426 in federal fines (most recent 2026-01-29)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)

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

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

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

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2820 E U.S. 34 · (308) 210-2025 · Call to confirm hours
Pharmacy
2105 S Locust St · (308) 382-3784 · Call to confirm hours
Grocery
1600 S Eddy St · (308) 258-3480 · Call to confirm hours
Park
3315 Blaine St S · (308) 389-0290 · 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 held steady at 1 stars. From monthly CMS archive snapshots.

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

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased8.2%19.0%15.4%better
Long-stay residents who lose too much weight4.8%5.1%5.4%better
Long-stay residents with a catheter left in their bladder1.3%1.4%0.9%worse
Long-stay residents with a urinary tract infection5.8%2.8%2.0%worse
Long-stay residents with depressive symptoms2.4%4.3%6.5%better
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.8%4.5%3.3%better
Long-stay residents whose ability to walk worsened8.8%18.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication19.2%19.3%18.9%typical
Long-stay residents given the seasonal flu vaccine89.7%96.1%95.3%typical
Long-stay residents with pressure ulcers8.4%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control27.8%25.9%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table38.0%20.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.3%2.0%1.4%worse
Short-stay residents given the seasonal flu vaccine90.5%75.9%79.4%better
Short-stay residents rehospitalized after admission26.8%20.7%22.6%worse
Short-stay residents with an outpatient ER visit16.8%11.4%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.441.811.67worse
Long-stay outpatient ER visits per 1,000 resident days2.701.921.80worse

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

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

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

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

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

46.2% 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 43 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.2%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
45.2%U.S. median 56.6%
Met the expected recovery
0.22U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 45.2% 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 31 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 0.22 therapist hours per resident per day in 2026Q1 — more than 26% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF46.2%CMS range 32.5–65.951.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 6.2–13.610.7%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 discharge45.2%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 discharge38.7%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 discharge45.2%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF 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 worsened13.0%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 hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.031.02Oct 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

0.37
RN hours/ resident / day
0.64
LPN hours/ resident / day
2.48
Aide hours/ resident / day
3.50
Total nurse hours/ resident / day
0.15
RN hoursweekends
43.1%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 95 beds and averages 74.5 residents a day — about 78% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.50 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.37 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.48 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 3.10 hrs/resident/day on weekends vs 3.66 on weekdays — 15% thinner on weekends. RN hours go from 0.46 to 0.15 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 43% is about the same as the national median of 45%. 1 administrator has left in the past year.

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

10
deficiencies at the latest standard inspection (2026-01-29)
8
at the previous standard inspection (2024-12-05)

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.

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 11 most serious are shown; the remaining 11 are one tap away and print in full.

  • Immediate jeopardy · J2026-01-29 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 review and interview the facility failed to ensure that the resident choice for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) matched the physician signed advanced directive for 2 of 24 residents reviewed (Residents 47 and 71). This had the potential for the facility to not follow the resident preference for CPR in the event of cardiac arrest. The facility census was 74. The facility Administrator was notified on [DATE] at 5:15PM of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. Findings are: A.Record review of the facility policy titled Advance Directive Policy and Procedure dated 1/2024 revealed that it is the policy of the facility to establish, implement, and maintain written policies and procedures for advanced directive. The resident has the right, and the facility will…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-01-29 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Based on record review and interview the facility failed to ensure that nurse aides and medication aides completed at least 12 hours of continuing education annually as required for 5 of 5 sampled staff. The facility census was 74.Findings are:A.Record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides dated 1/2024 revealed that it is the policy of the facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. The facility will provide at least 12 hours of in-service training annually based on the employment date and not on the calendar year. Documentation of in-services will be forwarded to the Human Resources Director and maintained in the employee's personnel file. In-service training will be provided by qualified personnel and will be based on the needs of the residents in the facility. Minimum training will include: Effective communication; Dementia management and…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-01-29 · 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)Licensure Reference Number 175 NAC 12-006.19(B) Based on record review, observation, and interview the facility failed to maintain a sanitary, orderly, and comfortable interior and exterior for 16 of 74 residents (Resident 1, 5, 7, 9, 10, 13, 19, 21, 24, 32, 36, 48, 58, 71, 75, and 85.) Facility census was 74. Findings are: Record review of the facility's undated admission Agreement included a copy of Federal-Resident Rights, upon which the resident and/or resident representative signs and dates in agreement that the facility will provide the following:Safe Environment: The resident has the right to a safe, clean, comfortable, and homelike environment, including ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. A.An observation with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-01-29 · tag F0923 — pattern
    Have enough outside ventilation via a window or mechanical ventilation, or both.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-007.04(D) Based on observation and interviews the facility failed to ensure the ventilation system was in working order in 12 resident bathrooms (rooms 501,502,503, 504, 505, 506, 508, 510, 511, 512, 513, 514) of 24 sampled resident rooms. Findings are:A. An observation with the Facility Administrator (FA), Maintenance Supervisor (MS), and the Housekeeping Supervisor (HS) on 1/29/26 at 11:15 AM a walk through of 500-hall room [ROOM NUMBER] bathroom ventilation system was not pulling when a 1-ply tissue was pressed upon the ventilation system, confirming the vent was non-operational. FA and MS confirmed the ventilation was not working, and that there is no window in the bathroom. During an interview on 1/29/26 at 11:20 AM the MS reveals that no one checks the ventilation system and this is not part of the maintenance program. During an interview on 1/29/26 at 11:20 AM the MS was unaware that ventilation system was not working and that no one alerted (gender) the ventilation…

    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 · D2026-01-29 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(S)Based on record review, observation, and interview the facility failed to ensure resident dignity by not storing incontinent products out of public sight and for not ensuring residents' body parts were covered for 2 residents (Resident 2 and Resident 5) of 2 sampled residents. The facility census was 74.Findings are:Record review of a facility policy titled Facility Responsibilities dated 01/2024 revealed the residents have a right to a dignified existence, the facility must treat each resident with respect, dignity, and care for each resident in a manner and environment that promotes or enhances their quality of life.A.A record review of an admission Record revealed the facility admitted Resident 2 on 1/02/2026 with a diagnosis of a stroke, (which is the blockage of blood circulation to one or more areas of the brain) affecting the left side of the resident's body.The admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to…

    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 · D2026-01-29 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17(E)(ii)Based on record review and interview, the facility failed to notify the local state ombudsman of resident transfers in and out of the facility for 1 resident (Resident 75), and failed to provide the resident or their responsible party written information regarding bed hold at the time of transfer for 1 resident (Resident 75). The facility census was 74.Findings are:Review of an admission Record revealed the facility admitted Resident 74 on 01/13/2022 with diagnosis of cerebral palsy, which is a group of permanent movement, muscle tone, or posture disorder caused by abnormal brain development or damage, and functional quadriplegia, which is a medical condition defined by complete immobility due to severe physical frailty or advanced cognitive impairment without underlying brain or spinal cord injury. Review of Resident 47's Census record revealed the resident was transferred out of the hospital on paid hospital leave on 08/09/2025, 11/05/2025, and 11/15/2025.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-29 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09(H)(i)(2)Based on observation, interview, and record review the facility failed to provide treatment and services to maintain or restore a resident's level of functional ability for 1 (Resident 2) of 1 sampled resident. The facility census was 74.Findings are:Record review of a facility policy titled Activities of Daily Living (ADL's) and dated 1/2024 revealed the facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome.A record review of an admission Record revealed the facility admitted Resident 2 on 1/02/2026 with a diagnosis of a stroke, which is the blockage of blood circulation to one or more areas of the brain, affecting the left side of the resident's body.The admission Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify…

    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 before2026-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to thoroughly assess a resident after a possible/probable accident/incident and failed to notify a resident's provider after a possible/probable incident/accident that could result in deterioration of health and need to alter treatment for 1 (Resident 83) of 1 sampled resident, and the facility failed to follow practitioner orders of providing medications as prescribed for 1 (Resident 89) of 1 sampled resident. The facility census was 74. Findings are:A. Record review of a facility policy titled Notification of Changes and dated 01/2024 revealed it is the policy of the facility that changes in a residents' condition or treatment are immediately reported to the physician. Requirements for notification were defined as a significant change including deterioration in health and a need to alter treatment due to adverse consequences. Record review of an admission Record revealed the facility admitted Resident 83 on 06/21/2023 with diagnosis of dementia a usually progressive condition…

    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 · D2026-01-29 · tag F0712 — isolated
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.08(B)(i)Based on record review and interview the facility failed to ensure that the physician performed the resident initial 30 day visit as required for 1 of 3 residents reviewed (Resident 47). The facility census was 74.Findings are: Record review of the facility policy titled Physician Services dated 1/2026 revealed that the medical care of each resident is under the supervision of a licensed physician. The physician will visit the resident at appropriate intervals. Physician visits are provided in accordance with current regulations and facility policy. The resident must be seen at least once every 30 days for the first 90 days after admission. Record review of federal regulation statute 483.30(c) Table 1 revealed that the Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist may not perform the initial Comprehensive Visit (required 30 day visit) in place of the physician. Record review of the admission Record dated 1/26/26 for Resident 47 revealed that Resident 47 admitted into the facility on 8/15/25. The admission…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-29 · 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

    Licensure Reference Number 175 NAC 12-006.18(B)Based on observation, interview, and record review, the facility failed to ensure staff donned (put on) and doffed (took off) the required PPE (personal protective equipment) during cares for a resident that requires staff to wear PPE for EBP (enhanced barrier precautions), to prevent the potential spread of microorganisms. This affected 1 resident (Resident 4) of 1 sampled resident. The facility failed to clean glucometers per manufacturer recommendations after use affecting 1 resident Resident 76 of 2 sampled residents, and failed to change disposable medical care equipment as ordered for 1 resident Resident 2 of 1 sampled residents. The facility census was 74. Findings are: A. Record review of a document titled Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings dated 2007 from the Centers from Disease Control revealed IV.E.1. the facility is to establish policies and procedures for containing, transporting, and handling patient-care equipment and instruments/devices that may be…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-05 · 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 1-009.01 Based on observation and interview, the facility failed to ensure the facility was neat clean and in good repair. This affected 11 of 69 facility residents. Facility stated a census of 69. Findings are: On 12/02/2024 a walk through was completed from 10:00 AM to 10:32 AM where the following was observed. -Cobwebs with debris visible in the windows of the Activities room of the secured care unit. -Chipped and peeling paint exposing unsealed wood on the door frames of resident rooms 411, 404, 405, 403, 207, 209, 102, 107, 108, and room [ROOM NUMBER]. -Missing light fixture cover on a light located in the ceiling of the Activities room on the secured unit. -In room [ROOM NUMBER] bathroom [ROOM NUMBER] pieces of material in different shades of white attached with black screws to the ceiling surrounding the vent located in the ceiling of the bathroom. -In the hallway of the secured care unit inside of the main double doors multiple pieces of white material secured to the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 11 citations
  • Potential for harm · E2024-12-05 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    License Reference Number 175 NAC 12-006.11 Based on record review, observation, and interviews, the facility failed to ensure the menus were followed as written and that use of the correct size serving spoons were used when meals are served resulting in less than required caloric intake. This affected 13 (Residents 40, 65, 22, 223, 6, 54, 44, 49, 43, 221, 222, 55, and 59) of 15 residents served meals. The facility census was 69. Findings are: An interview on 12/02/2024 at 8:00 AM with the facility [NAME] reveled the cook reviewed the menu for the week. The cook also took the time to discuss the serving spoons that are used in the facility when serving meals. The serving spoons all had different colors and were in separate containers by serving size. The 8 ounce serving spoons were stored together and were orange and green in color. Record review of the Menu titled Dietary Spreadsheet for week 3 used by the dietary department for meal planning. The document copyright date was 2024. The meal served at noon on 12/03/2024 was scheduled for Day 17 and included the following items:…

    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 · Ecited before2024-12-05 · tag F0880 — failed to prevent and control infections — pattern
    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 175NAC 12-006.19(C)(i) Licensure Reference Number 175NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure that staff performed laundry delivery to residents in a manner to prevent the potential for cross-contamination for 20 of 20 residents observed (Residents 57, 10, 15, 26, 7, 27, 37, 11, 30, 36, 31, 223, 22, 54, 6, 60, 59, 43, 55, and 41). The facility census was 69. Findings are: Record review of the facility Infection Prevention and Control Program dated 5/20/17 revealed that the facility will establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Laundry and direct care staff will handle, store, process, and transport linens so as to prevent the spread of infection. The section titled Hand Hygiene Protocol revealed that all staff shall wash their hands between resident contacts and after handling contaminated objects. Observation on 12/3/24 at 1:38…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to provide an assessment by a licensed professional nurse for 1 (Resident 23) of 1 sampled residents with symptoms of a potential respiratory infection. The facility identified a census of 69. Findings are: A record review of Resident 23's Order Summary dated 12/2/24 reveal diagnoses of Allergic Rhinitis (an allergic reaction that causes sneezing, congestion and sore throat) entered on 06/08/23 and Chronic Sinusitis (an inflammation of the sinus or nasal passages occurring for more than 12 weeks at a time) entered on 07/25/24. The Order Summary dated 12/2/24 also revealed an order entered on 10-16-2024 for Mucinex (a medication that helps loosen congestion in the chest and throat, making it easier to cough out through the mouth) for the indication of cough. Instructions for the medication stated the medication should be administered as needed twice a day. The order did not include a stop date. A record review of Medication Administration Record (MAR) for the month of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · 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

    Licensure Reference Number 175 NAC 12.006.09(H)(iii)(2) Based off observation, interview, and record review, the facility failed to routinely assess a pressure ulcer (a localized area of damaged skin or tissue that can occur when pressure is applied to an area for a prolonged period) and monitor the effectiveness of the treatment for the wound for 1 (Resident 26) of 1 sampled residents. The facility identified a census of 69. Findings are: A record review of Resident 26's Minimum Data Set (MDS, a federally mandated tool used to assess the health of nursing home residents who are enrolled in Medicare or Medicaid) dated 10/30/24 revealed that Resident 26 was fully dependent on nursing staff for all activities of daily living (ADLs). The MDS further revealed a diagnosis of Pressure Ulcer of Other Site, Unspecified. A record review of Resident 26's Order Summary dated 12/4/24 revealed the following diagnoses: Spastic Quadriplegic Cerebral Palsy; Contractures of Muscle, Right Upper Arm; Other forms of Scoliosis, Lumbar Region; Contractures of Muscle, Left Upper Arm; Severe Intellectual…

    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 · D2024-12-05 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(h)(v) Based on observation, interview, and record review, the facility failed to implement interventions to prevent the potential worsening of a contractures for 1 (Resident 23) of 1 sampled resident. The facility identified a census of 69. Findings are: A record review of Resident 23's face sheet dated 12/2/24 revealed an admission date of 05/23/21 and a diagnosis of contractures, (a permanent tightening of the muscles, tendons, skin, or nearby tissues that limits the range of motion of a joint or body part) of the left hand was added on 06/08/23. A record review of the undated Care Plan revealed no documentation for a contractures of the left hand or interventions for the contractures. A Record review of Resident 23's admission Minimum Data Set (MDS, a federally mandated tool used to assess the health of nursing home residents who are enrolled in Medicare or Medicaid) dated 04/22/2021 revealed no documentation of a contractures. A Record review of MDS dated [DATE]…

    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 · D2024-12-05 · 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 12-006.10 (D) Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% with an observed medication error rate of 7.41% (27 administrations and 2 errors). This affected 2 (Residents 14 and 17), of 10 sampled residents. The facility stated census of 69. Findings are: A. Record review of a facility policy titled Clinical Management Medication Administration dated 05-2017 revealed to verify the pharmacy prescription label on the drug and the medication administration record or the physician orders. If there is a discrepancy check the original physician order and notify the pharmacy do not give the medication until clarified. In an observation completed on 12/03/2024 at 12:15 PM Medication Aide G, (MA-G), obtained a box labeled with Resident 17's name and Ultra Eye Preservative Free Drop 0.4-0.3% with directions to instill one drop into both eyes every 2 hours as needed for dry eyes. MA-G then proceeded to administer the eye drop to Resident 17. In an interview on 12/03/24 12:32 PM 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-05 · tag F0808 — failed to follow doctor-ordered diets — isolated
    Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY License Reference Number 175 NAC 12-006.119(A)(iv) Based on record reviews, observations, and interviews, facility failed to provide a physician ordered therapeutic diet with increased protein for 1 (Resident 22) of 1 resident sampled. The facility census was 69. Findings are: Record review of the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents and for use when creating Care Plans) dated 11/10/24 for Resident 22 revealed the resident had a Brief Interview of Mental Status (a short cognitive screening tool used to assess a person's mental abilities in long-term care facilities) score of 14 a score of 13 to 15 means the individual is cognitively intact. Record review on 12/03/24 of the working Care Plan (a document outlining a resident's individual healthcare needs, including medical conditions, personal preferences, and specific care strategies to provide the best possible support and treatment) revealed that Resident 22…

    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 · F2023-11-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to store and distribute foods and liquids in accordance with the facility policy and to prevent potential cross contamination and foodborne illness. This had the potential to affect 68 of 69 residents. Findings Are: A record review of the facility policy labeled Nutrition Services Food Storage dated 03/14/2014 revealed dry storage room items should be stored to ensure freshness, in bulk, and in tightly covered containers. The policy revealed all containers must be labeled and dated. In addition, scoops for items stored in bins, such as sugar, flour, rice and other items should be covered in a protected area near the food containers. The policy revealed for refrigerated items to be dated, labeled and tightly sealed. All items should include name of item and a use by date. The policy revealed frozen items should be stored in moisture proof wrap and/or containers that are labeled and dated. A. Observation on 10/30/2023 during the initial Kitchen tour from 8:52 AM to 9:20…

    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 · Ecited before2023-11-02 · 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 — the official record, unedited, may be distressing

    Licensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to ensure that the bathroom ventilation vents were free from dirt and dust affecting 10 (Residents 6, 16, 35,19, 44, 51, 53, 119, 120, and 121) of 20 sampled residents. The facility census was 68. Findings are: Observation on 10/30/23 between 12:36 PM- 3:19 PM revealed the bathroom vents in the resident rooms that were occupied by Resident 6, 16, 35, 19, 44, 51, 53, 119, 120, and 121 were soiled with a white gray fuzzy substance. Observation on 11/2/23 at 11:30 AM with the facility Administrator and the Maintenance Director confirmed the bathroom vents in the resident rooms that were occupied by Resident 6, 16, 35, 19, 44, 51, 53, 119, 120, and 121 were soiled with a white gray fuzzy substance. The facility Administrator and Maintenance Director revealed the vents needed to be cleaned.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-02 · 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 12-006.18E3 Based on observation, interview, and record review the facility failed to ensure that hot water temperatures were within a safe range to prevent the potential for resident skin injury for 1 of 24 residents (Resident 64). The facility census was 68. Findings are: Record review of the undated facility admission Agreement revealed that basic services include lodging. The section titled Resident Rights revealed that the facility must care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. Record review of the facility policy titled Water Temperatures, Safety of dated December 2009 revealed that tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 120 degrees Fahrenheit (F), or the maximum allowable temperature per state regulation. Maintenance staff shall conduct periodic tap water…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review, and interview the facility failed to ensure safe and sanitary practices related to changing and labeling disposable medical equipment used for respiratory therapy for 1 resident (Resident #20), and for disposable enteral feeding equipment for 1 resident (Resident #29). This affected 2 of 3 sampled residents. The facility census was 69. Findings are: A. A record review of Resident #20's admission Record dated 11/01/2023 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: chronic systolic congestive heart failure (a condition in which the heart doesn't pump blood as efficiently as it should) and chronic obstructive pulmonary disease (a condition that causes airflow blockage and breathing related problems). A record review of Resident #20's significant change Minimum Data Set (MDS) (The Long-Term Care Minimum Data Set (MDS) which is a standardized, primary screening and assessment tool of health…

    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

“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

$13,426 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $13,426 — penalty dated 2026-01-29
  • Medicare payment denial — starting 2026-02-26 for 15 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 1 of 51.5-0.5 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
YCNE OPERATIONS, LLCOrganizationDIRECT OWNERSHIP INTERESTsince 11/01/2023
CHAFETZ, YISROELIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/17/2017
REISMAN, ADINAIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2023
SEGAL, CARYNIndividualINDIRECT OWNERSHIP INTERESTsince 11/01/2023
BANK OF OKLAHOMAOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/03/2021
EMERALD HEALTHCARE LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/09/2025
EVOLVE THERAPY SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
LIMESTONE FISCAL SERVICES LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
MERCH PAY INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/31/2025
SAUL N FRIEDMAN & COMPANYOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
WELLSKY CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
ZIMMET HEALTHCARE SERVICES GROUP LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/2025
FLEISCHMANN, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/01/2023
FRANKLIN, BRENDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2019
GOFF, KILEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2024
GOPIN, BRIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2019
GUERRERO, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2022
HINRIKUS, ADAMIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/03/2023
SATTAR, ARIFIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2019
WICHMAN, JERI JOIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/30/2021

CMS files one row per role, so the 38 rows in the source record cover these 20 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.

$8.2M
Net patient revenuemost recent cost report
+2.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 6%Other / private 13%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$324per resident / day
operating cost
$9,837per month
≈ monthly operating cost
$332per 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 285106. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-29, 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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