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Mother Hull Home

125 East 23rd Street, Kearney, NE 68847 · Non profit - Corporation · 58 certified beds · (308) 234-2447 Medicare & Medicaid certified

Call the home — (308) 234-2447 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0605) — cited Feb 2026
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — 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 (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • nursing-staff turnover (97%) 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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3219 Central Ave Ste 200 · (308) 865-2370 · Call to confirm hours
Pharmacy
2123 Central Ave · (308) 237-2178 · Call to confirm hours
Grocery
7 W 25th St · (308) 236-5041 · Call to confirm hours
Park
2005 1st Ave · (308) 237-4644 · Typically dawn to dusk
Place of worship
13 E 22nd St

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 4 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 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 rating2★
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 increased15.4%19.0%15.4%typical
Long-stay residents who lose too much weight2.9%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 infection1.3%2.8%2.0%better
Long-stay residents with depressive symptoms1.4%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 injury4.5%4.5%3.3%worse
Long-stay residents whose ability to walk worsened15.1%18.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication0.7%19.3%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers2.5%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control25.2%25.9%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table13.7%20.7%17.1%better
Short-stay residents who newly got an antipsychotic medication1.1%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine100.0%75.9%79.4%better
Short-stay residents rehospitalized after admission12.0%20.7%22.6%better
Short-stay residents with an outpatient ER visit9.1%11.4%12.0%better
Long-stay hospitalizations per 1,000 resident days1.591.811.67typical
Long-stay outpatient ER visits per 1,000 resident days1.821.921.80typical

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.

46.7% 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 73 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

46.7%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
31.7%U.S. median 56.6%
Met the expected recovery
0.25U.S. median 0.31
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 31.7% 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 41 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 0.25 therapist hours per resident per day in 2026Q1 — more than 35% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% 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 SNF46.7%CMS range 38.5–55.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 6.2–13.310.7%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 discharge31.7%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 discharge29.3%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 discharge39.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final 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 worsened1.9%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.6%CMS range 3.7–10.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.941.02Oct 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

0.50
RN hours/ resident / day
1.08
LPN hours/ resident / day
3.26
Aide hours/ resident / day
4.85
Total nurse hours/ resident / day
0.24
RN hoursweekends
97.2%
Total nursing turnover
85.7%
RN turnover

How full it usually is: this home is certified for 58 beds and averages 44.9 residents a day — about 77% occupied, or roughly 13 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 4.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 3.26 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 4.09 hrs/resident/day on weekends vs 5.15 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.61 to 0.24 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 97% is well above 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

8
deficiencies at the latest standard inspection (2026-02-09)
5
at the previous standard inspection (2024-12-18)

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.

17 citations, most serious first. The 10 most serious are shown; the remaining 7 are one tap away and print in full.

  • Potential for harm · F2026-02-09 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.11(D)Based on observation, interview, and record review the facility failed to follow approved recipes when preparing resident foods and failed to ensure food temperature was maintained for hot food at or above 135 degrees Fahrenheit. This had the potential to affect all the residents receiving food items from the kitchen. The facility census was 45.Findings are:A.A record review of a facility supplied document titled Dining Manager Garlic Roasted Chicken and dated 2026 revealed instructions to arrange chicken pieces on a paper lined baking sheet and to evenly coat the chicken with 2 tablespoons and 2 teaspoons of lemon juice. To combine 1 tablespoon of dried oregano and 1 ounce of minced garlic an evenly spread the mixture on the chicken.In an observation on 02/05/2026 at 9:35 AM Dietary [NAME] A (DC-A) placed pieces of chicken into a metal bowl. The DC then added 2 tablespoons of lemon juice into the bowl and shook in a unmeasured amount of dried oregano into the bowl. The DA then added an unmeasured amount of poultry seasoning to the bowl…

    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 · Fcited before2026-02-09 · 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 Refrence Number 175 NAC 12-006.11 Based on observation, record review, and interview, the facility failed to complete hand hygiene using the approved technique during meal preparation. This had the potential to affect all of the residents receiving food stuff from the kitchen. The facility census was 45.Findings are:Record review of a facility policy titled Hand Hygiene and dated 2021 revealed staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Listed under hand hygiene technique when using soap an water to dry hands thoroughly with a single use towel and use a clean towel to turn off the faucet.In an observation completed on 02/05/2026 from 8:41 AM through 12:08 AM of Dietary [NAME] A (DC-A) preparing food the following was observed:-DC-A used scissors and gloved hands to cut open plastic wrapping from raw ground beef and placed the meat into a pan. The DC-A removed their gloves from both of their hands and walked over to the sink. The cook performed hand hygiene using soap and water. DC-A shut off 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-09 · tag F0605 — failed to not use drugs as a restraint — isolated
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    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 reviews, observations and interviews, the facility failed to provide adequate indications for use consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that are published in medical and/or pharmacy journals and a documented clinical rationale for administering an antipsychotic medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any safer treatments have been deemed clinically contraindicated for 2 of 5 sampled residents (Resident 5 and Resident 11). The facility census was 45.Findings are:A.Record review of a facility policy titled Use of Psychotropic Medications dated 2025 revealed adequate indications for use referred to the identified documented clinical rational for administering of a medication. Also, adequate indication for use means that the medication is…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-09 · 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(H)(iii)(3)Based on record review, and interview the facility failed to evaluate and monitor resident skin issues for 2 (Resident 4, and Resident 7) of 2 sampled residents. The facility census was 45.Findings are: A. Record review of a document titled Best Practices for Wound Assessment and Documentation and dated 04/17/2025 from the Wound Care Education Institute (wcei.net/best-practices-wound-assessment-documentation) revealed wound assessment and documentation serve as crucial clinical tools for effective care planning, etiology, measurements, and wound characteristics to guide treatment. High-quality documentation fosters interprofessional communication and aids in tracking healing progress while aligning with care standards. Record review of a document titled What is standard of care in wound care and dated 05/31/2022 from Wound Source (https://www.woundsource.com/blog/what-standard-care-in-wound-care) revealed to detect signs of healing progress wounds are assessed on a weekly basis and documentation of a wound assessment is a vital…

    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 · D2026-02-09 · 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)(1) and (2)Based on observation, record review, and interview the facility failed to assess and monitor pressure related skin issues to ensure documentation of wound healing or decline for 2 residents (Resident 1 and Resident 6) of 2 sampled residents, failed to ensure the settings for a specialty low air loss mattress were at the correct setting to promote healing of a pressure related wound for 1 resident (Resident 6) of 2 sampled residents and failed to cleanse pressure related wounds per professional standards of practice to promote healing for 1 resident (Resident 6) of 2 sampled residents. The facility census was 45.Findings are:Record review of a document titled Pressure Injury Prevention Guidelines dated 2018 revealed to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries it is the policy of this facility to implement evidence-based interventions for all residents assessed at risk or who have pressure injury present. The Assistant Director of Nursing or designee 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 · Dcited before2026-02-09 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 8% (25 medication administration observations and 2 errors). This affected 2 of 7 residents observed (Residents 28 and 53). The facility census was 45.Findings are: A. Record review of the facility policy titled Insulin Pen dated 2024 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of dosing. Insulin pens contain multiple doses of insulin but are used for a single resident only. A new needle will be used for each injection. Always review physician orders prior to administering any medication. The procedure revealed that staff will gather supplies needed: correctly labeled insulin pen, alcohol preps, and sterile insulin pen needle. Perform hand hygiene. Put on gloves. Verify resident identification. Check the expiration date on the pen and discard if…

    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 · D2026-02-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10(D)Based on observation, record review, and interview the facility failed to ensure that residents were free of significant medication errors for 2 of 7 residents observed (Residents 28 and 53). The facility census was 45.Findings are: A. Record review of the facility policy titled Insulin Pen dated 2024 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of dosing. Insulin pens contain multiple doses of insulin but are used for a single resident only. A new needle will be used for each injection. Always review physician orders prior to administering any medication. The procedure revealed that staff will gather supplies needed: correctly labeled insulin pen, alcohol preps, and sterile insulin pen needle. Perform hand hygiene. Put on gloves. Verify resident identification. Check the expiration date on the pen and discard if expired. Remove the pen cap from the insulin pen. Wipe the rubber seal with an alcohol pad. Screw…

    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 · Dcited before2026-02-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B)Licensure Reference Number 175 NAC 1-005.06(F)Based on observation, record review, and interview the facility failed to ensure that staff disinfected medication administration equipment as required for 1 of 2 residents observed (Resident 28); and the facility failed to ensure that hand hygiene was performed between glove changes during wound care for 1 resident (Resident 6) to prevent the potential for cross contamination. The facility census was 45.Findings are: A. Record review of the facility policy titled Insulin Pen dated 2024 revealed that it is the policy of the facility to use insulin pens in order to improve the accuracy of dosing. A new needle will be used for each injection. Always review physician orders prior to administering any medication. The procedure revealed that staff will gather supplies needed: correctly labeled insulin pen, alcohol preps, and sterile insulin pen needle. Perform hand hygiene. Put on gloves. Verify resident identification. Check…

    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 · E2024-12-18 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19 Based on observation and interview, the facility failed to ensure a clean and sanitary environment in resident's bathrooms for 5 (rooms 9, 11, 16, 18, and 23 ) of 12 sampled rooms and failed to ensure hand sanitizer dispenser was working for 1 (Resident 23) of 49 sampled residents with a facility census of 49. Findings are: In an observation completed on 12/18/2024 at 8:05 AM the following was noted: -In the bathroom of room [ROOM NUMBER] the call light box was secured to the wall of the bathroom to the left of the toilet. The porous cord hanging from the call light that the resident would use to activate the call light was yellow brown from the middle of the cord to the end of the cord. On the faucet of the sink beneath the hot and cold-water knobs there is a buildup of porous white material that has both green and black areas on top of the white material. There is yellow white flaky build up material to the bottom portion of the faucet where it is connected 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
  • Potential for harm · Ecited before2024-12-18 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 12-006.09(H)(iii) Based on record reviews, interviews, and observations, the facility failed to ensure interventions for constipation were put into place to promote bowel movements for 2 (Residents 6, and Resident 12) of 5 sampled residents, and the facility failed to provide wound care that prevented cross contamination for 1 (Resident 14) of 1 sampled residents. The facility census was 49. Findings are: A. Record review of the undated Bowel Movement Assessment/Monitoring policy and protocol stated the purpose is to monitor bowel regularity while taking into consideration any knowledge of bowel habit history on an individual basis. The procedure included reviewing bowel and bladder records nightly and making a note as to those who had not had a Bowel Movement (BM) for 2 days. This is forwarded to the day shift nurses who would then assess for needs of a laxative. If there had been no BM by the following morning, the day shift nurse was to assess for further laxative needs. Further…

    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
Show the remaining 7 citations
  • Potential for harm · Ecited before2024-12-18 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.10D Based on observation, interview, and record review, the facility failed to ensure medications were administered according to the 5 rights of medicaiton administration for 4 residents, (Resident 14, 199, 26, and 34) of 8 sampled residents. This made an error rate of 16.13 %. The facility census was 49. A. Record review of Resident 14's Physician Orders dated 12/16/24 revealed Resident 14 had a physician order to apply Diclofenac Sodium which is a topical pain relief or analgesic cream. Directions to apply 2 grams to both resident's knees and lower back three times a day. In an observation on 12/17/24 at 11:30 AM with Registered Nurse-B(RN-B) revealed RN-B with a gloved hand used their fingers to scrape a clear thick gel like substance from a clear medication cup that was sitting on Resident 14's bed side table. RN-B stated to the resident this was their pain cream and would apply it to the resident's knees. Resident 14 pulled up the pant legs of their pants above both knees and RN-B applied the ointment to the left knee and rubbed it in…

    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 · D2024-12-18 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of 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 Based on record reviews and interviews, the facility failed to ensure that resident assessments were coded incorrectly for hypoglycemic and antiplatelet on the Minimum Data Set (MDS, a standardized assessment tool used to comprehensively evaluate the health and functional capabilities of residents nursing homes to create individualized care plans based on their specific needs) . This affected 2 residents (Residents 6 and 12) of 3 sampled residents. The facility census was 49. Findings are: A. Record review of the Physician Orders reviewed on 12/16/2024 for Resident 6 revealed an order for Humalog insulin subcutaneous three times daily before meals and once at bedtime given on a sliding scale based on Resident 6's blood sugar. The physician orders also revealed an order for Levemir 12 units subcutaneous at bedtime. Record review of the MDS dated [DATE] for Resident 6 revealed the resident had a diagnosis of diabetes. Section N (Medications) subsection N0300 this resident received injections 7 days a week and in…

    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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-18 · 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 1-005.06(E) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review, and interview, the facility failed to ensure that staff wore both a gown and gloves during resident care as required for Enhanced Barrier Precautions (An infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Precautions involve gown and glove use during high-contact resident care activities (Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or Assisting with toileting) for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition such as residents with wounds or indwelling medical devices) for 1 (Resident 201) of 3 residents sampled to prevent the potential for cross-contamination and multidrug-resistant organisms. The facility census was 49. Findings are: Record review of the facility policy titled Enhanced Barrier Precautions dated 9/18/24 revealed that it is the policy of the facility 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-12-27 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    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 12-006.09D6(7) The facility failed to ensure respiratory equipment was cleaned and stored in a manner to prevent the potential for cross contamination related to oxygen tubing when not in use for 3 residents (Residents 2, 6, and 22) of 4 sampled residents and related to the CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) mask for 1 resident (Resident 36) of 1 sampled residents. The facility identified a census of 46. Findings Are: A record review of the undated facility policy titled Oxygen Safety read as follows: 7. Oxygen tubing shall be monitored for cleanliness, monitored to assure tubing is not kinked, that it does not touch the floor, and is properly stored when not in use. Tubing is change weekly by nursing staff. A. A record review of the demographic information revealed Resident 2 had been accepted into the facility on 1/19/23 with diagnoses of: included Chronic Kidney Disease (CKD) (a 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 · Ecited before2023-12-27 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.11E Based on observation, interview, and record review the facility failed to ensure that dietary sanitizer solution (a substance or preparation for killing germs on food-processing surfaces and equipment) was at the required concentration (The amount of the sanitizer (chemical) in the water. Too high of a concentration is toxic, and too little will not ensure sanitation) to prevent the potential for foodborne illness. This affected all 46 residents that ate food prepared by the facility kitchen. The facility census was 46. Findings are: Record review of the Nebraska Food Code, Effective date 7/21/16 section 4-501.116 revealed that the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. Record review of the Sink and Surface Cleaner Sanitizer dated 2020 revealed that test strips should be changed out every time solution in the bucket is changed out. The food code requires a new solution to be prepared every 4 hours, so it is recommended to change the strip at the same time. The strips…

    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 before2023-12-27 · 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 175 NAC 12-006.17 Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interview, the facility failed to perform hand hygiene to prevent the potential for food borne illness during meal service, which had the potential to affect 46 residents; and failed to ensure a resident had a cleanable sleeping surface for infection prevention for 1 resident (Resident 6). Facility stated census of 46. Findings are: A record review of facility supplied document labeled Hand Washing Guidelines Dietary Employees revealed frequency of hand washing should be after hands have touched anything unsanitary, after hands have touched bare human body parts, and after engaging in any activity that may contaminate the hands. A. During a meal service observation on 12/24/2023 at 12:10 PM Dietary Aide (DA)-D obtained a used coffee cup from a resident and took it over to the coffee pot to refill the cup and then returned it to the resident. DA-D did not complete any form of hand hygiene prior to serving a plate of food to another resident. During 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-27 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    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 12-006.09D3(1) Based on observation, record review, and interview, the facility failed to provide perineal care (which is cleansing of the genatalia of a resident) in a manner to prevent cross contamination of 2 sampled residents (Resident #5 and Resident #14). The facility census was 46. Findings are: A. A record review of Resident #14's Face Sheet dated 12/20/2023 revealed, that the facility admitted Resident #14 on 09/07/2016, with diagnoses of: Epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures), Parkinson's disease (a progressive disease of the nervous system causing tremors and muscular rigidity), myocardial infarction (which is blockage of blood flow to the heart), and Benign prostatic hyperplasia (a non-cancerous enlargement of the prostate gland). A record review of Resident #14's Quarterly Minimum Data Set (MDS), (which is an resident assessment and care screening tool that is used by nursing homes), dated 08/17/2023 revealed,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
SIMMONS, STEPHANIEIndividualW-2 MANAGING EMPLOYEE; CORPORATE DIRECTORsince 05/20/2008
BRAUER, SIEGIndividualCORPORATE DIRECTORsince 09/17/2010
COOPER, SHARONIndividualCORPORATE DIRECTORsince 06/20/2003
HAYS, RANDALLIndividualCORPORATE DIRECTORsince 09/18/2007
SMITH, ANITAIndividualCORPORATE DIRECTORsince 09/20/2002
SMITH, BRENDAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 09/15/2012
STANDAGE, MONTEIndividualCORPORATE OFFICERsince 09/15/2014

CMS files one row per role, so the 9 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$4.9M
Net patient revenuemost recent cost report
-3.8%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 52%Medicare 12%Other / private 36%

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

$317per resident / day
operating cost
$9,644per month
≈ monthly operating cost
$306per day
avg. revenue, all payers

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

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 285254. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-09, 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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