Christian Homes Health Care Center
1923 West 4th Avenue, Holdrege, NE 68949 · Non profit - Corporation · 86 certified beds · (308) 995-4493 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- no federal fines or payment denials on record
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its independent health-inspection rating is low (2/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (58%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 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 | 1 of 5 |
| Long-stay residentspeople who live here | 1 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 fell from 3 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.9% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.4% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.4% | 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 | 8.0% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 22.6% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 23.7% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 98.4% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.0% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 27.8% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 29.7% | 20.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.4% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 89.7% | 75.9% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 22.3% | 20.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 13.6% | 11.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.59 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 2.94 | 1.92 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
42.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 76 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 24.6% 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 69 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 0.08 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 42.0%CMS range 34.0–52.0 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 8.9%CMS range 6.6–13.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 24.6% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 26.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 21.7% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 98.9% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.9%CMS range 3.2–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 86 beds and averages 70.4 residents a day — about 82% occupied, or roughly 16 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 3.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.53 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.44 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 3.35 hrs/resident/day on weekends vs 3.87 on weekdays — 13% thinner on weekends. RN hours go from 0.59 to 0.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 58% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.
- Potential for harm · F2026-03-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.11(E) Based on record review, observations, and interviews, the facility failed to label and date foods stored in the kitchen and failed to ensure that foods were prepared and served in a manner to prevent food-borne illnesses. The facility also failed to ensure hand hygiene was followed during meal service. This had the potential to affect all individuals who received foods from the kitchen and dining rooms. The facility census was 71. Findings Are: Record review of the United States Department of Agriculture (USDA) 2022 Food Code dated 01/18/2023 revealed that the Food Code addresses risk factors of food borne illnesses and identified risk factors of improper temperatures, proper hygiene, contaminated equipment, inadequate cooking times, and foods from unsafe sources. The Food Code addresses several controls for risk factors and further establishes 5 key public health interventions to protect consumer health. Specifically, these interventions are demonstration of knowledge, employee health controls, controlling hands as a vehicle of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-11 · tag F0550 — failed to protect resident dignity and rights — patternHonor 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
Licensure Reference Number 175 NAC 12-006.05(S)Based on observation, record review, and interview the facility failed to consecutively serve meals to all residents seated at the same table to maintain resident dignity for 10 of 12 residents observed (Residents 62, 41, 27, 35, 72, 47, 36, 70, 31, and 12). The facility census was 71.Findings are:Record review of the facility admission Agreement dated 8/6/24 revealed that the facility will provide the resident with three meals a day. The resident and responsible person acknowledge being informed orally and in writing of Resident Rights. Record review of the facility Resident Handbook dated March 2024 revealed that the nutritional services department is directed by a Dietary Manager under the direction of a Consulting Registered Dietician. Meals are prepared in the facility and are served at established meal times. The section titled Resident Rights revealed that it is the facility policy to protect and promote the rights of each resident. The facility will care for residents in a manner and an environment that promotes maintenance 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 · E2026-03-11 · tag F0552 — patternEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(D)&(E) Based on record reviews, observations and interviews, the facility failed to inform the resident and/or resident representative, in advance of care, of the risks and benefits and possible alternatives of treatment for 5 of 6 residents sampled (Residents 1, 4, 10, 53, and 60). The facility census was 71.Findings Are: Record review of the facility policy Psychotropic Medication Checklist dated May 2021 revealed that upon receiving physician orders staff must have permission from the Designated Power of Attorney (DPOA) (a legal document that authorizes a trusted person (the agent or attorney-in-fact) to manage the financial, legal, or medical affairs of another (the principal) person when that person is no longer able to make decisions) or the resident before administering medications. Verbal permission with a new order or order change may be obtained. Staff must give information to the DPOA and/or resident about possible side effects and benefits and place a care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-11 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview the facility failed to ensure an baseline care plan (a written plan required to be developed within 24 hours of admission detailing the instructions needed for staff to provide initial effective and person-centered quality care for a resident) was completed within 24 hours of admission for 7 (Residents 18, 60, 11, 53, 70, 2, and 9) of 10 sampled residents and failed to provide a written summary of the baseline care plan to the resident or their representative for 9 (Residents 18, 74, 60, 11, 53, 3, 70, 2, and 9) of 10 sampled residents. The facility census was 71. Findings are:Record review of the facility policy titled Care Plans dated January 2026 revealed that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission (24 hours in Nebraska). The preliminary care plan will be used until the staff can conduct a comprehensive assessment and develop an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility failed to ensure the Ombudsman was informed of all resident discharges and transfers. This affected 2 (Residents 74 and 76) of 2 sampled residents. The facility census was 71. In an interview with the Social Services Director (SSD) on 03/10/2026 at 11:20 AM it was revealed that the SSD sent a list of emergency transfers to the ombudsman monthly. A.Record review of Resident 74's Progress Notes dated 1/2/2026 revealed the resident had an emergency transfer to the hospital on that date at 7:45 AM.Record review of the Emergency Transfers from Facility for January 2026 revealed there were three residents listed on the form, which was provided to the ombudsman. Resident 74 was not included on this form. B.A record review of Discharge Instructions dated 2/9/2026 for Resident 76 revealed the resident was transferred from the facility on 02/09/2026.Record review of the Emergency Transfers from Facility dated February 2026 revealed there were two residents listed on the transfer form, which was provided to the ombudsman. Resident 76 was not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(D)Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) for 2 (Residents 1 and 63) of 18 sampled residents. The facility census was 71.Findings are:Record review of a facility policy titled Minimum Data Set (MDS) dated 10/2021 revealed it was the responsibility of the MDS Coordinator (MDSC) to complete both section H: Bladder and Bowel and Section N: Medications of the MDS as well as the submission of the MDS. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated 10/2025 revealed:-Coding Instructions for H0100C to code if the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F) Based on record review and interview the facility failed to ensure the Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) reflected a discharge plan and goals for 1 (Resident 11) sampled resident, and accurately reflected a therapeutic diet and antipsychotic medication use for 1 (Resident 53) of 4 sampled residents. The facility census was 71. Findings are:Record review of a facility policy titled Care Plans dated 01/2026 revealed it was the policy of the facility that the Interdisciplinary team was responsible for the development of an individualized person centered comprehensive care plan for each resident. Record review of a facility policy titled admission of a Resident dated 01/15/2026 revealed the interdisciplinary plan of care should be developed within 21 days of admission. A.Record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to follow physician/providers orders for the administration of an as needed medication for 1 (Resident 11) of 1 sampled residents. The facility census was 71. Findings are:Record review of a Clinical Census dated 03/09/2026 revealed that the facility admitted Resident 11 on 01/19/2026 with diagnosis of orthostatic hypotension (a significant drop in blood pressure that occurs within 3 minutes of standing up, leading to dizziness, lightheadedness, or fainting). Record review of Resident 11's undated Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) revealed a focus of the resident being at risk for falls due to hypotension with the latest revision date being 02/19/2026. Record review of Resident 11's Physician Order Summary dated 03/10/2026 revealed an order for Midodrine (a medication used to treat orthostatic…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-11 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.15 Based on record review and interview the facility failed to identify a resident's preference to, or not to, have dental services on admission to the facility for 1 (Resident 53) of 1 sampled residents. The facility census was 71. Findings are:Record review of a facility policy titled Dental Services and dated 01/2026 revealed it was the policy of the facility to assist the residents to obtain routine and emergency dental care. The resident and or their representative during the admission process are notified of dental services available under the State Plan, and of the potential charges that may apply in case of routine or emergency dental care provided by outside resources. An interview completed on 03/09/2026 at 2:41 PM with Resident 53 revealed that the resident was getting a food texture that they did not like due to not having any teeth. The resident stated that they previously had dentures for a long time and was not sure how long it had been since they used dentures. The resident stated the dentures stopped fitting a while ago so…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-11 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.18(D) Based on record review and interview, the facility failed to perform hand hygiene between glove changes during completion of catheter care and wound care for 1 (Resident 11) of 1 sampled resident. The facility census was 71. Findings are:Record review of a facility policy titled Hand Hygiene dated 01/2026 revealed it is the policy of the facility that all staff will perform proper hand hygiene procedures to prevent the spread of infection, and it applies to all staff working in all locations within the facility. The policy stated that hand hygiene should be performed after removing gloves and prior to applying new gloves. Record review of a Clinical Census on 03/10/2026 revealed that the facility admitted Resident 11 on 01/19/2026 with a diagnosis of stage 3 pressure ulcer (which is a severe, full thickness wound extending through the skin into the subcutaneous fatty tissue often appearing as a deep crater). Record review of Resident 11's Order Summary revealed the resident had provider orders dated 01/19/2026 stating to complete a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · Dcited before2025-07-21 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.18(B) Based on record review, observations, and interviews, the facility staff failed to ensure sanitization of multiuse equipment between residents to prevent the potential for cross contamination for 2 (Residents 1 and 3) of 4 residents sampled. The facility identified a census of 69.Findings Are: A record review of a facility policy titled, Infection Prevention and Control Program dated 01/2025 revealed in the Policy section that this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per acceptable national standards and guidelines. In the Equipment Protocol it stated all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. A record review of a facility policy titled, Safe…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-04-08 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(H) Based on record reviews and interviews, the facility failed to have qualified dietary staff working in the kitchen. This had the potential to affect all residents who reside in the facility. The facility census was 75. Findings are: A record review of the employee list revealed that SR-A had not been an employee of the facility. A record review of the Dietary Aide job description with a copyright date of 2023 revealed: Required Qualifications: -15 years or older, working towards GED, and or High School diploma -As a condition of employment, completes all assigned training and skills competency. An interview on 4/7/25 at 11:30 AM with the Dietary Manager (DM) confirmed that SR-A was (genders) child. DM confirmed that SR-A was in the kitchen on 3/29/25 helping peel potatoes due to being short-staff in the kitchen. DM confirmed that SR-A was not qualified to be working in the kitchen and should not have been working in the kitchen. An interview on 4/8/25 at 1:30 PM with the Administrator confirmed that (gender) had not been aware of SR-A…
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 · F2025-04-08 · tag F0844 — widespreadFollow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
What the surveyor found here — the official record, unedited, may be distressing
Licensure Reference Number 175 NAC 12-006.04 (E) Findings are: Based on record review and interview, the facility failed to notify the State Agency of a change in the Director of Nursing position within the required 5 days. This failure had the potential to affect all the residents residing in the facility. The facility census was 75. A record review of the Change of Administrator of Director of Nursing Notification form revealed that the Director of Nursing was changed on 11/8/24 and the notice to the State agency was received on 1/15/25. A interview on 4/8/25 at 1:30 PM with the Administrator confirmed that the Notification of a change in the Director of Nursing was not sent to the State Agency in the required time frame and the notification should have been.
- Potential for harm · Dcited before2025-01-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an allegation of abuse for 1 (Resident 1) of 3 sampled residents. The facility census was 64. Findings are: A record review of the facility Abuse Policy and Procedures, revised January 2025, revealed the following: -Key points to remember: Remember that ALL allegations of abuse, neglect, or misappropriation must be reported even if made by a resident who has a cognitive impairment. An allegation is a claim or assertion that someone has done something wrong, typically one made without proof. -Investigations: Allegations will be investigated and reported to the Department of Health and Human Services (DHHS). -VII/ Reporting/Response: report all alleged violations, reasonable suspicion of a crime, and all substantiated incidents to the state agency and to all other agencies as required within the prescribed time limits, and take all necessary corrective actions depending on the results of the investigation; alleged violation includes mistreatment, neglect,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-05 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to identify specific target behaviors for the use of an antidepressant (used to treat depression) medication for 5 (Residents 3, 35, 37, 44, 55), antianxiety (used to treat anxiety) medication for 2 (Residents 35 and 55) and an antipsychotic (used to treat psychosis) for 2 (Residents 44 and 55) of 5 residents reviewed for psychotropic (group of medications used to treat mental health disorders) medication use. The facility census was 61. Findings are: Review of the facility Psychotropic Medication Policy and Procedure, dated August 2018, revealed the following: -The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. -Nursing: will monitor for the presence of target behaviors daily,…
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 · D2024-12-05 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.05(B) Based on record review and interview, the facility failed to ensure the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a required notice of the cost of continuing to receive skilled services) and the Notice of Medicare Non-Coverage (NOMNC-a required notice allowing the resident to appeal the facility decision to end Medicare Part A coverage) were provided to Resident 3 and Resident 44 or their representatives to notify them of charges for non-covered care items and services prior to a change in Medicare A coverage. This affected 2 of 3 residents sampled for Advance Beneficiary Notification. The facility census was 61. Findings are: A. A record review of the SNF [Skilled Nursing Facility] Beneficiary Protection Notification Review form for Resident 3 revealed a Last Covered Day (LCD) for Medicare Part A services of 10/05/2024. A review of the SNF ABN for Resident 3 revealed a resident signature dated 10/07/2024. An interview on 12/03/2024 at 3:48 PM with the Social Services Director (SSD) confirmed that the SNF ABN and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to report a suspected allegation of abuse to the state agency within the required time frame after a allegation was made and failed to report the follow-up investigation in the required 5 working days for 1 (Resident #53) out of 16 sampled residents. The facility census was 61. The findings are: A record review of the Christian Homes abuse policy and procedures revised January 2024 revealed the following: -If the alleged abuser is a staff member: -If possible and reasonably safe to do so, ask for the employee's written statement -Allegations will be investigated and reported to the state. -The Administrator or the Director of Nursing will be responsible for ensuring the investigation and timely reporting to DHHS. Allegations will be investigated and reported to the Department of Health and Human Services. A record review of admission Record revealed Residents #53 was admitted on [DATE] with the diagnosis of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) The facility staff failed to investigate an alleged incident of abuse for 1 (Resident 53) out of 16 sampled residents. The facility census was 61. The findings are: A record review of the Christian Homes abuse policy and procedures revised January 2024 If the alleged abuser is a staff member: -If possible and reasonably safe to do so, ask for the employee's written statement -Allegations will be investigated and reported to the state. -For allegations which do not involve a physical danger to the resident, the neighborhood charge nurse will consider the case and decide on one of the following options 1) to place the employee under the supervision of a supervisor or other staff member in the same or another section of the nursing home or to place in nonresident duties 2) to suspend and send the employee home ,pending further investigation. The Administrator or the Director of Nursing will be responsible for ensuring the investigation and timely reporting 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.
- Potential for harm · Dcited before2024-12-05 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure the Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) reflected a Level II PASARR (Preadmission Screening and Resident Review -that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. Level 2 screening is triggered by evidence of a serious mental illness (SMI), Intellectual/Developmental Disabilities (ID/DD) or condition related to Intellectual or Developmental Disabilities (RC) as defined by Medicaid) for one (Resident 1) and failed to code the use of an antibiotic for one (Resident 35) of 16 sampled residents. The facility census was 61. Findings are: Review of the facility MDS and Comprehensive Care Plan policy, revised [DATE], revealed the following: -MDS: 3. All MDSs will be completed according to the CMS (Centers for Medicare and Medicaid…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(E)(i) Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan (CCP-a written interdisciplinary comprehensive plan detailing how to provide quality care for a resident) that accurately reflected the care needs of the resident for 2 (Residents 3 and 35) of 16 sampled residents. The facility census was 61. Findings are: A. Review of Resident 35's admission Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care), dated /21/23, revealed Resident 35 took the following classifications of medications: antidepressant (used to treat depression), antianxiety (used to treat anxiety) and anticoagulant (used to prevent/reduce blood clots). A review of Resident 35's CCP, dated 12/3/24, revealed no resident-centered care plan related to antidepressant, antianxiety and anticoagulant use. In an interview on 12/4/24 at 1:52 PM, the MDS…
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 · D2024-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(iii) Based on observation, record review, and interview, the facility failed to revise the Comprehensive Care Plan to include the current use of a Positive Airway Pressure device for Resident 14 and Resident 62, and failed to revise the Comprehensive Care Plan for Resident 2 related to falls. This affected 3 of 16 residents reviewed for care plan revision. The facility census was 61. Findings are: A. A record review of Resident 14's admission Record printed 12/04/2024 revealed Resident 14 was admitted to the facility on [DATE] and had diagnoses of dementia (a term for several diseases that affect memory, thinking, and the ability to perform daily activities), leukemia (a type of cancer involving the blood), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), high blood pressure, irregular heartbeat, and obstructive sleep apnea (a common sleep disorder that occurs when the upper airway…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B), 175 NAC 12-006.18(D) Based on observations, record reviews and interviews, the facility failed to implement Enhanced Barrier Precautions (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] in nursing homes. EBP involves wearing a gown and gloves during high-contact resident care activities, such as personal hygiene, transferring, and care of indwelling medical devices such as catheters, for residents known to be colonized or infected with a MDRO as well as residents at increased risk of MDRO acquisition [for example, residents with wounds or indwelling medical devices]) and ensure hand hygiene was performed in a manner to prevent cross contamination during catheter cares for 1 Resident (Resident 3) of 2 residents sampled for catheter cares, and the facility failed to ensure the mask and water chamber for a Continuous Positive Airway Pressure (CPAP-a machine that keeps the airway open by blowing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor 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
Licensure Reference Number NAC 12-006.05(6) Based on record reivew, observations, and interviews, the facility failed to ensure the catheter drainage bag was covered to protect 1 (Resident 15) of 3 sampled residents for dignity. The census was 51. Findings are: A review of a facility policy dated 04/05/2023 titled Catheter Care revealed: - It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care, maintain their dignity and privacy when indwelling catheters are in use. - Privacy bags will be available and catheter drainage bags will be covered at all times while in use. An observation on 1/29/24 at 11:50 AM revealed, Resident 15 was in their room sitting in [gender] recliner chair. Resident 15's catheter drainage bag was uncovered and hooked onto their recliner chair. An observation on 01/29/24 at 12:48 PM revelaed, that Resident 15 was in their recliner chair finishing the noon meal. Resident 15's catheter drainage bag was uncovered and hooked on to the recliner chair. The uncovered catheter drainage bag was visible from…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-01 · 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 12-006.17 Based on record review, observations, and interviews, the facility failed to ensure C-PAP (CPAP or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It requires a machine that generates by a machine, delivered through a tube into a mask that fits over the nose or mouth), mask and tubing was cleaned after use to prevent the spread of infection that affected 2 (Resident # 156 and #1) of 2 sampled residents. The facility census was 51 at time of survey. Findings are: A. A record review of the CPAP/BIPAP cleaning policy last revised on 4/5/23 revealed, under the policy explanation and compliance guidelines section 6) Clean mask frame daily after use with CPAP cleaning wipe or soap and water, and dry well. 7) weekly cleaning activities a) wash headgear/straps in warm, soapy water and air dry, b) wash tubing with warm, soapy water, soak in 50% vinegar and water for 30 minutes minimum, rinse and allow to air dry. A record review of the Physician Diagnosis…
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.
- No harm found · C2024-12-05 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(D)(i) Based on record reviews and interviews, the facility failed to designate a licensed Registered Nurse (RN) to work full time hours as the Director of Nursing. This had the potential to affect all residents in the facility. The facility census was 61. Findings are: A record review of the Archived Time Card Report forms for Registered Nurse (RN) E from 04/28/2024 to 08/03/2024 revealed RN E had clocked out at 4:40 PM on 05/01/2024, and had not clocked back in until 08/01/2024. The forms dated 05/12/2024 to 05/25/2024, 05/26/2024 to 06/08/2024, 06/09/2024 to 06/22/2024, 06/23/2024 to 07/06/2024, and 07/07/2024 to 07/20/2024 all had LOA hand written on them, meaning Leave of Absence. An interview on 12/03/2024 at 2:13 PM with the Director of Nursing (DON) confirmed that RN E had been the previous DON, and that RN E had gone on maternity leave in May 2024 for 12 weeks. The DON stated that while RN E was on leave, the Assistant Director of Nursing, who was a Licensed Practical Nurse (LPN) had been performing some of the responsibilities 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| MIDWEST DISTRICT OF THE EVANGELICAL FREE CHURCH OF AMERICA | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/01/1987 |
| BERGSTROM, JANET | Individual | W-2 MANAGING EMPLOYEE | — | since 03/17/2003 |
| ANDERSON, MARLYS | Individual | CORPORATE DIRECTOR | — | since 03/18/2009 |
1 organizational owner 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.
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 285246. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-11, 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.