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Kimball County Manor

810 East 7th Street, Kimball, NE 69145 · Government - County · 49 certified beds · (308) 235-4693 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Apr 2025Behavioral-health or dementia-care citation — no harm found (F0758)1 immediate-jeopardy citation$27,606 in federal fines
Insights

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

In its favor
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0607, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $27,606 in federal fines (most recent 2025-04-21)
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)

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

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

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

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
505 S Burg St · (308) 235-1966 · Call to confirm hours
Pharmacy
129 S Chestnut St · (308) 235-3936 · Call to confirm hours
Grocery
815 E 3rd St · (308) 235-3272 · Call to confirm hours
Park
1010 E 3rd St · (308) 235-3782 · Typically dawn to dusk
Place of worship
601 S Washington St · (308) 235-2285

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 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.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.7%19.0%15.4%better
Long-stay residents who lose too much weight6.8%5.1%5.4%worse
Long-stay residents with a catheter left in their bladder1.9%1.4%0.9%worse
Long-stay residents with a urinary tract infection4.7%2.8%2.0%worse
Long-stay residents with depressive symptoms3.4%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 injury7.7%4.5%3.3%worse
Long-stay residents whose ability to walk worsened9.4%18.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.3%19.3%18.9%better
Long-stay residents given the seasonal flu vaccine97.6%96.1%95.3%typical
Long-stay residents with pressure ulcers5.7%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control20.5%25.9%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table19.8%20.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication8.3%2.0%1.4%worse
Short-stay residents rehospitalized after admission14.8%20.7%22.6%better
Short-stay residents with an outpatient ER visit24.2%11.4%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.151.811.67worse
Long-stay outpatient ER visits per 1,000 resident days3.591.921.80worse

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

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

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

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

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

33.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.3%U.S. median 51.5%
Got home and stayed home
10.9%U.S. median 10.7%
Went back to hospital
38.1%U.S. median 56.6%
Met the expected recovery
0.18U.S. median 0.31
Therapy hours / resident / day
0.07hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy

Met the expected recovery: 38.1% 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 21 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 0.18 therapist hours per resident per day in 2026Q1 — more than 18% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 5% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

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

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF33.3%CMS range 19.2–49.251.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.9%CMS range 6.5–17.910.7%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 discharge38.1%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 discharge14.3%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 discharge33.3%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 identified96.4%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 worsened3.6%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 hospitalization6.8%CMS range 2.9–13.77.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.301.02Oct 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

0.47
RN hours/ resident / day
0.50
LPN hours/ resident / day
2.59
Aide hours/ resident / day
3.57
Total nurse hours/ resident / day
0.34
RN hoursweekends
57.1%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 49 beds and averages 43.2 residents a day — about 88% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.57 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.59 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 2.97 hrs/resident/day on weekends vs 3.81 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.53 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% 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

8
deficiencies at the latest standard inspection (2026-06-25)
11
at the previous standard inspection (2025-04-21)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Immediate jeopardy · J2025-04-21 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05 (H) Based on observation, record reviews, and interviews, the facility failed to protect 1 (Resident 39) of 1 sample resident after receiving an allegation of staff-to-resident abuse. The facility identified a census of 39. The facility was notified on 4/15/2025 at 5:00 PM of an Immediate Jeopardy (IJ) which began on 4/11/2025. The IJ was removed on 4/15/2025, as confirmed by the surveyor's onsite verification. Findings are: A record review of the facility's policy Abuse Prohibition Polices and Procedures, with a date of 1/11/2017, revealed the following: - The purpose of the policy is to ensure all residents in the facility are free from verbal, physical, sexual and mental abuse, involuntary seclusion, neglect or mistreatment. - The policy defined abuse as a willful infliction of injury resulting physical harm, pain or mental anguish by an individual, including a caretaker. - The section Procedure for Training revealed the following: o Any staff member who suspects…

    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 · Fcited before2026-06-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review, and interview, the facility failed to date stored foods, and failed to ensure proper hand hygiene was performed to prevent the potential for cross contamination and food borne illness. Findings are: Observations made at 8:00 AM on 6/22/26 during the initial kitchen tour revealed the following:-A container of chicken base with no open, use by, or expiration date.-10 ceiling panels with water damage and staining and 1 ceiling tile with a hole in it-1 box baking soda w/o open date in a sealed Ziploc bag-4 boxes of krusteaz cornbread mix with no best by date, received date or expiration date.-1 box buttermilk biscuit mix open without an opened date marked-8 bottles of ketchup with no receive date or expiration date. -1 box of individual [NAME] mayo packets with no open, use-by, or expiration date-1 gallon of dill pickle relish with no open, use-by, or expiration date-1 gallon of miracle whip with a best-by date listed at…

    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 plan of correction
  • Potential for harm · E2026-06-25 · tag F0552 — pattern
    Ensure 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(E) Based on record review and interview, the facility failed to obtain informed consents from the resident or their representative prior to the use of psychotropic medication for 5 (Residents 1, 6, 7, 8, & 31) of 5 sampled residents. The facility identified a census of 39. Findings Are: An interview on 6/23/26 at 1:20 PM with the facility Administrator revealed the facility did not have any policies specific to psychotropic medications and confirmed that the facility had not obtained informed consents prior to the administration of psychotropic medications for any residents who were currently prescribed psychotropic medications. A. A record review of Resident 1's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 1's Medication Order revealed the resident had an order for mirtazapine (an antidepressant medication) 7.5 milligrams (mg) daily for a diagnosis of depression. The order had 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.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-06-25 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference number 175 NAC 12-006.09Based on record review and interview the facility failed to notify the provider of blood pressures being outside the set parameters per their order for 3 (Residents 5,6, and 31) of 5 sampled. The facility showed a census of 39Findings are: A. Record review of a facility policy with a revision date of 2/28/25 and a subject label of ' Notification of Physicians' revealed the following statements:The nurse will notify the resident's attending physician or physician on call when there has been:- specific instruction to notify the physician of changes in the residents condition-A significant change of condition is a major decline or improvement in the resident's status that: a.) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting)b.) impact more than one area of the residents healthc.) requires interdisciplinary review and/or revision to the care plan,. -The nurse will record…

    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 plan of correction
  • Potential for harm · Ecited before2026-06-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference number 175 NAC 12-006.18 & (B) & 1-005.06 The facility failed to ensure hand hygiene was performed to prevent the potential for cross contamination during medication administration for 7 Residents (5, 25, 26, 32, 39, 40, and 43) of 7 residents medications administered. The facility showed a census of 39.Findings areRecord review of a facility policy 'Hand Hygiene' dated 2/27/23 revealed information that reads: Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . The relevant situations are as follows:-Before and after coming into direct contact with residents-Before preparing or handling mediations- After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident-After removing glovesContinuous observations made from 7:13 AM until 8:30 AM on 6/24/26 with Medication Aid (MA)B revealed the following:-At 7:13 AM MA-B began preparing medications for Resident…

    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 plan of correction
  • Potential for harm · D2026-06-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05(S) Based on observations, interview, and record review; the facility failed to preserve 1 (Resident 27) of 1 sampled resident's dignity by ensuring their catheter bag was concealed when in view of other residents. The facility identified a census of 39.Findings Are: A record review of facility policy Resident Dignity Policy with a review date of 5/15/26 revealed the facility would maintain an environment that preserved each resident's dignity. A record review of Resident 27's Continuity of Care Document dated 6/23/2026 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 27's undated Care Plan revealed the resident required an indwelling urinary catheter related to urinary retention. This section of the Care Plan contained an intervention stating, store collection bag inside a protective, dignity pouch. An observation on 06/23/2026 at 8:15 AM revealed Resident 27 walking out of the dining room and down the 100 hallway. Their…

    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 plan of correction
  • Potential for harm · D2026-06-25 · 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 review and interview, the facility failed to ensure 1 (Resident 1) of 5 sampled residents did not suffer adverse consequences from their psychotropic medication as evidenced by increasing Abnormal Involuntary Movement Scale (AIMS, a brief, 12-item clinician-rated examination used to detect and measure the severity of tardive dyskinesia (TD, a neurological movement disorder that causes uncontrollable, repetitive muscle movements, usually in the face, lips, jaw, and tongue)) assessment scores. The facility census was 39.Findings Are: An interview on 6/23/26 at 1:20 PM with the facility administrator revealed the facility did not have any policies specific to the use or monitoring of psychotropic medications. The administrator also revealed the facility performed AIMS assessments on all residents that were taking psychotropic medications. A record review of Resident 1's Continuity of Care Document dated 6/24/2026 revealed the resident was admitted 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-06-25 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the Ombudsman (a state official who works with nursing home and assisted living residents who helps answer resident concerns and complaints and advocates for resident rights and their well-being) of 1 (Resident 47) of 1 sampled resident's discharge from the facility. The facility census was 39.Findings Are: A record review of Resident 47's Interdisciplinary Discharge Summary revealed the resident was admitted to the facility on [DATE] following a right hip fracture. The document revealed the resident was later discharged from the facility on 4/1/2026 to their family home. A record review of Resident 47's medical records revealed no evidence of the Ombudsman being notified of their discharge from the facility. An interview on 6/24/26 at 2:45 PM with the facility Administrator confirmed the facility had not notified the Ombudsman of Resident 47's discharge. Per the administrator, the facility only notified the Ombudsman of facility-initiated…

    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 plan of correction
  • Potential for harm · Dcited before2026-06-25 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure an antibiotic was clinically indicated for 1 (Resident 42) of 1 sampled resident. The facility identified a census of 39.Findings Are: A record review of facility policy Antibiotic Stewardship Program with a review date of 2/14/19 revealed the facility's antibiotic stewardship program promotes the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. In the procedure section it states that the physician will be notified of results of diagnostics to ensure resident is taking the appropriate antibiotic or if antibiotic needs to be discontinued or changed. A record review of Resident 42's Continuity of Care Document dated 6/24/2026 revealed the resident…

    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 plan of correction
  • Potential for harm · Ecited before2025-08-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(G) Licensure Reference Number 175 NAC 12-006.09(I) Based on record reviews and interviews, the facility failed to determine the root cause of every fall incident, implement interventions that prevented recurrence of falls related to the identified causes, and develop and implement new interventions after subsequent falls occurred for 3 (Residents 1, 2, and 3) of 3 sampled residents. The facility identified a census of 38. Findings are: An interview on 8/27/2025 at 10:25 AM with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that the facility's process following a resident fall includes the nurse completing an incident report, noting what was happening before the fall. The facility holds a Utilization Review (UR) meeting daily (except Thursdays and weekends) to discuss falls and assign interventions. The interdisciplinary team (IDT) determines if interventions are appropriate based on the cause of the fall. The DON gave an example that if 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-21 · tag F0607 — failed to have anti-abuse policies — widespread
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04(A)(iii) Based on record reviews and interviews, the facility failed to implement their policies and procedures related to screening potential employees prior to employment for 3 [Housekeeper (HSKPG) - U, Actvities Supervisor (AS) - S, and Dietary Aide (DA) - T] of 5 sampled employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 39. Findings are: A record review of a facility policy Abuse Prohibition Policies and Procedures with a last revised date of 1/11/2017 revealed all potential employees will be screened for a history of abuse, neglect or mistreatment of residents by checking criminal prosecution history by: 1) reviewing the Nebraska License Information System for Disciplinary Action and License Status - for all nursing staff holding licenses or certifications, 2) checking the Nebraska Adult Abuse Registry and Child Abuse Registry (APS/CAN), 3) checking a criminal history and 4) checking the Nebraska State Patrol Sex Offender Registry. There was no evidence of the…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · F2025-04-21 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and interviews, the facility failed to ensure 5 [Nurse Aide (NA) - P, NA-L, NA-O, NA-N, and NA-K] of 5 sampled nurse aides (NA) had completed at least 12 hours of ongoing training annually based upon their employment date as required. This had the potential to affect all residents who reside within the facility. The facility identified a census of 39. Findings are: A record review of the facility's Facility Assessment with a date of 4/1/2025 revealed all staff would have training on resident transfers, infection control, disaster/emergency preparedness, resident rights, abuse and neglect, dementia, oxygen, Activities of Daily Living, and Hospice/Comfort Care. There was no evidence that nurse aides would complete at least 12 hours of ongoing education based upon their employment date. A record review of an undated facility-provided list of staff names, dates of hire, their department, and job title revealed the following: - NA-P was hired on 3/19/2024. - NA-L was hired on 12/8/2023. - NA-O was hired on…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-21 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number NAC 175 12.006.18 Based on observations and interviews the facility failed to develop Enhanced Barrier Precautions (EBP) policies and procedures and implement EBP for Residents 10, 21, and 27. The facility identified a census of 39. Findings are: A record review of Resident 21's Minimum Data Set (MDS- a federally mandated assessment tool used in Long Term Care) dated 4/10/25 revealed in Section H that Resident 21 had an indwelling catheter. A record review of Resident 27's MDS dated [DATE] revealed in Section M that Resident 27 had unresolved wounds. A record review of Resident 10's MDS dated [DATE] revealed in Section M that Resident 10 had one unresolved stage III pressure ulcer. An observation on 4/14/25 at 9:45 AM in the hallway outside Resident 21's room revealed no sign on Resident 21's door or any other indicator to staff that Resident 21 required the use of personal protective equipment (PPE) for high-contact care. An observation on 4/14/25 at 11:00 AM in the hallway outside…

    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 · F2025-04-21 · tag F0940 — failed to train staff — widespread
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04(B)(i) Based on record reviews and interviews, the facility failed to ensure each employee received initial orientation within 2 weeks after beginning employment on topics of resident rights, emergency procedures, adult abuse/neglect and training on medical emergency directives and dementia for nursing staff as required for 11 [Nurse Aide (NA) - Q, NA-R, Housekeeper (HSKPG) - U, Activities Supervisor (AS) - S, NA-D, NA-E, NA-F, NA-G, NA-H, and NA-I] of 12 sample employees. This had the potential to affect all residents residing within the facility. The facility identified a census of 39. Findings are: A record review of the facility's Facility Assessment with a date of 4/1/2025 revealed all staff would have training on Emergency Preparedness, Resident Rights, and Abuse and Neglect. There was no evidence that the facility provides training on medical emergency directives. A record review of the Fusion Workforce Solutions Compliance Requirements with a date of 11/20/2024 revealed the facility required training on Elder Abuse. A record review…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-04-21 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04(B)(ii) Based on record reviews and interview, the facility failed to ensure nurse aides had completed at least 4 hours of dementia training annually as required for 5 [Nurse Aide (NA) - K, NA-O, NA-P, NA-L, and NA-N] of 5 sample employees. This had the potential to affect all residents who reside within the facility. The facility identified a census of 39. Findings are: A record review of a Facility Assessment with a date of 4/1/2025 revealed all staff would have training on dementia. There was no evidence that nurse aides would complete at least 4 hours of dementia training as required. A record review of an undated facility-provided list of staff names, dates of hire, their department, and job title revealed the following: - NA-K was hired on 1/15/2015. - NA-O was hired on 3/31/2021. - NA-P was hired on 3/19/2024. - NA-L was hired on 12/8/2023. - NA-N was hired on 5/23/2023. A record review of NA-K's Relias Transcript as of 4/15/2025 revealed no evidence NA-K had completed any dementia training between 1/15/2024 and 1/15/2025. A record…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.02(H) Nebraska Revised Statute 28-372 Based on record review and interview, the facility failed to A) immediately investigate and report an allegation of staff-to-resident abuse within 24 hours of the allegation being made and B) submit an investigation to the State Agency (SA) within 5 working days of the incident for 1 (Resident 39) of 1 sample resident. The facility identified a census of 39. Findings are: A record review of a facility policy Abuse Prohibition Policies and Procedures, with a last revised date of 1/11/2017, revealed an allegation of abuse will be reported within 24 hours to the SA and a copy of the written investigation report will be submitted to the SA within five working days of the alleged incident. A. A record review of Resident 39's Progress Note from 4/11/2025 at 9:24 AM written by Licensed Practical Nurse (LPN) - A revealed Resident 39 had been upset when LPN-A was assessing the resident. Resident 39 kept repeating that the guy/girls from last night were hitting them. LPN-A explained to Resident 39 that it was 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop 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

    Licensure Reference 175 NAC 12-006.09(E) The facility failed to develop a 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 (CCP) regarding Resident 16's primary diagnoses and high-risk medications and develop and implement a Comprehensive Care Plan including non-pharmacological interventions related to Resident 25's behavioral and emotional well-being. This affected 2 of 12 sampled residents. The facility identified a census of 39. Findings are: A. Record review of Resident 25's electronic medical record revealed Resident 25 had medical diagnoses including Parkinson's disease (a movement disorder that affects the nervous system and worsens over time), dementia (a usually progressive condition marked by the development of multiple cognitive deficits), and anxiety disorder (anxiety is an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-21 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    LICENSURE REFERENCE NUMBER 175-12 006.09(G)(i) Based on record review and interviews, the facility failed to document a recapitulation (a complete summary of resident stay in nursing facility from admittance to discharge) for a resident-initiated discharge for one (Resident 40) of one sampled resident. The facility identified a census of 39. Findings are: A record review on 04/14/2025 of a Discharge and Transfer Policy last revised on 02/27/2023 revealed no documented evidence requiring a recapitulation of stay as part of the discharge process. A record review of a progress note dated 02/21/2025 at 2:30 PM revealed a summary of care conference meeting note and detailed that Resident 40's goals to be discharged home had been met. No other documentation of a complete summary of the residents stay noted in the residents' chart. An interview with the Social Service Director (SSD) on 04/14/2025 at 2:30 PM revealed the facility has not ever done a recapitulation upon discharge, only an Interdisciplinary discharge planning summary which just indicates the Resident met their goals to return…

    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 · D2025-04-21 · tag F0700 — isolated
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    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 and interviews, the facility failed to attempt the use of appropriate alternatives prior to the installation of bed rails (adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Synonymous terms are side rails, bed side rails, and safety rails) as required for 1 (Resident 39) of 1 sample resident. The facility identified a census of 39. Findings are: A record review of a facility policy Side Rails with a date of 2/27/2023 revealed bed rails may be used by a resident if a bed rail request form and a bed rail decision making tree has been filled out. This will be reviewed quarterly. There was no evidence that the use of appropriate alternatives prior to the installation of bed rails was required. A record review of the Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term…

    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 · D2025-04-21 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement 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

    Licensure Reference 175 NAC 12-006.09(H) Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for psychotropic medications for 1 (Resident 25) of 5 sampled residents. The facility identified a census of 39. Findings are: Record review of Resident 25's electronic medical record revealed Resident 25 had medical diagnoses including Parkinson's disease (a movement disorder that affects the nervous system and worsens over time), dementia (a usually progressive condition marked by the development of multiple cognitive deficits), and anxiety disorder (anxiety is an abnormal and overwhelming sense of apprehension and fear often marked by physical signs, by doubt concerning the reality and nature of the threat, and by self-doubt about one's capacity to cope with it). Record review of a Brief Interview for Mental Status (BIMS, a brief screening tool that aids in detecting cognitive impairment) completed on 2/4/25 revealed Resident 25 had a score of 0 out of 15, which indicated the resident had severely impaired cognition. Record review…

    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 · Fcited before2024-05-07 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference 175 NAC 12-006.11E Based on observations, interviews, and record reviews, the facility kitchen staff failed to utilize handwashing and gloving techniques to prevent the potential for cross contamination during meal preparation. This had the potential to affect all 41 residents who ate from the kitchen. The facility census was 41. Findings are: A record review of a facility policy Personal Sanitation for Dietary Employees with a last revised date of 11/2023 revealed hands should washed frequently including before starting work, after touching anything contaminated, before putting on gloves, after the removal of gloves, and upon entrance to the kitchen. A record review of a facility policy Wearing Protective/Disposable Gloves by Dietary Employees with a last revised date of 11/2023 revealed to change gloves as necessary to maintain cleanliness. An observation on 5/6/2024 at 2:47 PM revealed Dietary Staff (DS)-B had entered the kitchen to begin food preparation and did not complete hand hygiene upon entrance to the kitchen, obtained a box of buttermilk biscuit mix,…

    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 before2024-05-07 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12-006.17D. Based on observations, record review and interviews, the facility failed to implement hand hygiene during the distribution of resident laundry and during medication administration. This had the potential to affect all residents. The facility census was 41. The Findings Are: A. An observation on 5/6/2024 from 7:23 AM through 7:35 AM revealed Laundry Aide (LA)-G distributing personal laundry to resident rooms. LA-G pushed a rolling cart to room [ROOM NUMBER], took folded laundry from the basket section of the cart and knocked on the door of room [ROOM NUMBER]. The resident told LA-G to come back later, so LA-G took the laundry back to the cart. LA-G then pushed the cart up the hallway and then removed hanging shirts from the cart. LA-G knocked on the door of room [ROOM NUMBER], entered the room, hung up the shirts in the closet and removed an empty hanger from the closet and hung the hanger on the rolling cart. LA-G then pushed the laundry cart to the 400 hallway and stopped…

    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 · F2024-05-07 · tag F0881 — failed to use antibiotics responsibly — widespread
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 172 NAC 12-006.17A(3) Based on record review and interviews, the facility failed to implement an antibiotic stewardship program. This had the potential to affect all residents who resided within the facility. The facility census was 41. The Findings Are: A record review of facility policy Antibiotic Stewardship Program with last review date of 2/27/23, revealed in the Procedure section #5 If indicated, based upon criteria, an antibiotic is ordered, the practitioner will identify the diagnosis/indication, the appropriate antibiotic, proper dose, duration and route. The policy also revealed in #10. Nursing will track antibiotic use and monitor adherence to evidence-based criteria including: a. Documentation related to antibiotic selection and use, b. Tracking antibiotics used to review patterns of use and determination of the impact of the antibiotic stewardship interventions, c. Monitoring for clinical outcomes such as rates of C. difficile infections, antibiotic-resistant organisms or adverse drug events, d. Reporting of communicable disease is done by 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-05-07 · tag F0757 — failed to avoid unnecessary drugs — pattern
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to obtain an end date or obtain rationale for the continued use of antibiotics for Urinary Tract Infections (UTIs) for Resident 8 and 28 and for history of eye infections for Resident 39. This affected 3 (Resident 8, 28, and 39) of 3 sampled residents. The facility census was 41. Findings are: A record review of Center for Disease Control (CDC) document The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use revealed Surveys of antibiotic use have shown that UTI prophylaxis accounts for a significant proportion of antibiotic prescriptions. Very few studies support antibiotic use for UTI prophylaxis, especially in older adults, and many studies have shown this antibiotic exposure increases risk of side effects and resistant organisms. Therefore, efforts to educate providers on the potential harm of antibiotics for UTI prophylaxis could reduce unnecessary antibiotic exposure 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-05-07 · 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 175 NAC 12-006.10D Based on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was less than 5% for 4 (Residents 5, 29, 32 and 38) of 8 sampled residents. Observations of 27 medication administered revealed 4 errors resulting in an error rate of 14.81%. The facility census was 41. Findings are: A record review of facility policy Medication Administration with a last revised date of 2/23/2010 revealed the following: - Medications are matched to the Medication Administration Record to check the correct resident, medication, dose, time, route, and documentation. -Medications will be passed in a timely manner, within the time frame of 60 minutes prior and 60 minutes after the prescribed time frame. A record review of Resident 29's Medication Administration Record revealed an order for levothyroxine with an administration time of 6:00 AM. An observation on 5/6/2024 at 7:13 AM revealed LPN-C had administered Resident 29's levothyroxine. A record review of Resident 38's Medication Administration Record revealed an order…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-07 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, the facility failed to ensure 1 (Resident 39) of 3 sampled residents' advance directive was added to their electronic health record. The facility census was 41. The Findings Are: A record review of Resident 39's paper medical chart, located in a room next to the nurse's station, revealed the resident had an advance directive indicating they did not want resuscitation (DNR). A record review of Resident 39's Electronic Health Record (EHR) revealed the statement no advanced directive on file for this resident. An interview on 5/2/2024 at 10:40 AM with Nurse Aide (NA)-E confirmed the staff would look at the resident's MAR (medication administration record), which was located in the EHR, to find out whether the resident was a DNR. An interview on 5/2/2024 at 10:41 AM with LPN-C confirmed they would look in the resident's EHR first to find the resident's code status (whether or not they were a DNR). An interview on 5/2/2024 at 11:10 AM with the Assistant Director of Nursing (ADON) confirmed Resident 39's advance directive was not in the resident's…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12-006.09D7 Based on observations, interviews and record reviews, the facility failed to ensure the use of two-persons while utilizing a Hoyer lift for 1( Resident 8) and failed to ensure the oxygen concentrator was turned off when not in use for 1( Resident 35) of 5 sampled residents . The facility census was 41. Findings are: A. Record review of a Face Sheet indicated the facility admitted Resident 8 on 1/18/2019 with diagnoses of Dementia, Type 2 Diabetes Mellitus, Chronic Kidney Disease, difficulty in walking, and lack of coordination. A record review quarterly Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 3/21/2024, revealed Resident 8 had severe cognitive impairment. Further review of Resident 8's MDS dated [DATE] revealed Resident 8 was dependent for all cares and transfers. A record review of Resident 8's Care Plan revealed Resident 8 required assist of 2 for bed mobility, dressing, incontinence care and to use a Hoyer lift (type of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    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

    Licensure Reference 175 NAC 12-006.09D6 Based on observation, record review, and interview the facility failed to ensure oxygen was administered per the physician's orders for 2 (Residents 13 and 35) of 3 sampled residents. The facility census was 41. The findings are: A. A record review of the facility policy Oxygen Administration with review date of 2/20/24 revealed oxygen would be administered to residents as ordered by the physician. A record review of Resident 13's Care Plan revealed the resident was at risk for respiratory distress/failure related to COPD (Chronic Obstructive Pulmonary Disease) and that they were to have oxygen via nasal cannula per provider orders. A record review of Resident 13's physician's orders revealed an order for continuous O2 (oxygen) 1-2 Liters Per Minute (LPM) to keep saturations above 90%. The order was to be documented on twice a day indicating the oxygen flow rate. A record review of Resident 13's vital signs documentation revealed the following: -4/25/2024 at 4:17 PM Oxygen Saturation: 97%, Oxygen Use Liter Flow: 3. -4/22/2024 at 10:20 AM…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-07 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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 and interview, the facility failed to provide a pneumococcal immunization for 1 (Resident 35) of 5 sampled residents. The facility census was 41. The Findings Are: A record review of facility policy Influenza & Pneumococcal Vaccines dated 2/23/23 revealed in the Procedure section, #1. On admission, residents will be interviewed as to immunization status. If pneumococcal vaccine has not been given, the resident/resident representative will be instructed as to the advisability of vaccination, and vaccination shall be given with an order from the physician and resident/resident representative permission, unless contraindicated. #3. If the history of pneumonia or influenza immunization status is unknown, Social Services/Nursing will contact the physician clinic for further records prior to giving the immunization. A record review of Resident 35's medical records revealed a signed pneumococcal vaccine consent form dated 7/5/2023 which indicated the resident had received a pneumococcal vaccine but there was not a date or…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-07 · tag F0887 — isolated
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, the facility failed to provide a COVID-19 immunization for 1 (Resident 38) of 5 sampled residents. The facility census was 41. The findings are: A record review of Resident 38's medical records revealed a COVID-19 vaccine consent form, dated 12/11/2023, which the resident had signed acknowledging they wanted to receive the COVID-19 vaccine. A record review conducted on 5/6/2024 of Resident 38's immunization records revealed no evidence that the resident had received a COVID-19 vaccine. An interview on 5/6/24 at 2:25 PM with the Assistant Director of Nursing (ADON) revealed that Social Services (SS)-D was responsible for entering resident immunization data into the medical records and for scheduling resident immunizations. An interview on 5/6/2024 at 3:00 PM with SS-D revealed Resident 38 had not yet been scheduled to receive the COVID-19 vaccine.

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$27,606 in federal fines across 1 penalty.

  • $27,606 — penalty dated 2025-04-21

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
ANDERSON, TREVORIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 02/01/2024
AUTREY, JORDANIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2022
HICKMAN, DAWNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 11/01/2019
MORITZ, JOHNIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2023
NEWELL, SHEILAIndividualMANAGING CONTROL - GOVERNING BODY; TRUSTEE OF THE SNFsince 01/01/2023
STULL, SARAHIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
OTT, JESSICAIndividualADP OF THE SNFsince 05/28/2025

CMS files one row per role, so the 14 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
-8.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 55%Medicare 8%Other / private 37%

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

$330per resident / day
operating cost
$10,036per month
≈ monthly operating cost
$305per 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 285256. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-25, 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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