Nye Summit
410 West 5th Street, Louisville, NE 68037 · For profit - Corporation · 61 certified beds · (402) 234-2125 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- a high number of inspection citations overall (15) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $23,595 in federal fines (most recent 2024-10-17)
- its payroll-based staffing rating is low (1/5)
- its facility-reported quality-measure rating is low (2/5)
- nursing-staff turnover (80%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
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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 | 2 of 5 |
| Long-stay residentspeople who live here | 1 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 35.5% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.8% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.4% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.1% | 2.8% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 8.5% | 4.3% | 6.5% | worse |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 6.1% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 25.3% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 13.1% | 19.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 82.2% | 96.1% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 6.0% | 4.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.1% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.2% | 20.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 8.5% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 14.3% | 75.9% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 10.0% | 20.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 2.8% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.02 | 1.81 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 1.79 | 1.92 | 1.80 | typical |
‡ 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.
46.5% 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 56 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.4% 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 27 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 0.44 therapist hours per resident per day in 2026Q1 — more than 74% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 46.5%CMS range 33.3–59.9 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.0%CMS range 6.3–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 44.4% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 40.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 44.4% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 94.3% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.7% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.9% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 5.0–15.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.78 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 61 beds and averages 41.8 residents a day — about 69% occupied, or roughly 19 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.30 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 4.02 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.69 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 80% 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
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.
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.
15 citations, most serious first — scroll within the box to see all.
- Actual harm · Gcited before2024-10-17 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 178 NAC 12-006.09(I) Based on interview, observation, and record review, the facility staff failed to evaluate and implement interventions to prevent elopement for 2 (Resident 1 and 4) of 4 residents sampled. The facility identified a census of 44. Findings are: Record review of Facility policy dated 10/2024 revealed the following: -Elopement is a situation where an unsupervised resident is found outside of the facility. Staff is unaware of the resident's departure (did not visually see the resident leave). -Policy -It is the policy of the facility to take proper preventative measures to prevent episodes of resident wandering from the facility and to locate resident in an expedient and timely manner. -Procedure-Elopement I. Preventative measures will be taken by the facility to prevent residents from elopement. A. Assessing all residents upon admission for the potential of exit seeking. An Elopement Risk Assessment will be completed on each resident on pre-admission/admission,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · Gcited before2024-07-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, record review and interview; the facility failed to evaluate Resident 1's risk for hot liquid burns which resulted in a burn from a hot coffee spill. A total of 3 residents were reviewed for burn risk. The facility census was 38. Findings are: Record review of a facility policy entitled Hot Liquid Safety dated 6/2024 revealed the following: -Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. -Definitions: - Proper (safe and appetizing) temperature: means both appetizing to the resident and minimize the risk for scalding burns. - Scalding is a burn caused by spills, immersion, splashes, or contact with hot water, food and hot beverages, or steam. 1. Hot Liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed and the duration of the exposure. Refer to the table attached to this policy for an illustration of the time required for a burn to occur at various temperatures. 2. The temperature of the hot…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2026-06-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure staff performed handwashing before donning (putting on) and after removing gloves, all kitchen equipment was maintained in a clean and sanitary manner, and staff sanitized the food temperature (temp) probe before, during, and after use, all to prevent cross contamination. The facility failed to ensure all food in the facility's freezers were not expired, the bread was not expired, all recipes were followed, and all food temps were taken prior to serving the residents, all to prevent foodborne illness. This had the potential to affect all residents except one that resided at the facility. The total facility census was 40. Findings are:A.A record review of the facility's undated Proper Hand Washing and Glove Use policy revealed that staff should have washed hands between all tasks, before and after handling food, after touching any part of the uniform, face, and hair. Hands were to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-17 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 NAC 12-006.09(H)(iv)5 Based on record review and interview, the facility failed to ensure 1 resident (Resident 6) of 1 sampled resident received bowel care interventions for constipation (constipation - having infrequent bowel movements (fewer than three per week) or experiencing difficulty passing stool) for 4 days. The facility had a census of 39. Findings are:A record review of the facility's Bowel Management Guideline implemented 2024 revealed the following:Guideline:All residents are monitored for bowel movements daily; residents may be asked by staff who are able to manage this independently.Compliance Guidelines:Residents who have not had a bowel movement (BM) after 1 day may be offered prune juice 4-8oz as tolerated on day 2. If no BM noted after 2 days resident may be offered 30cc of Milk of Magnesia on day 3.If no BM noted after 3 days resident may be offered a Dulcolax suppository (a fast-acting stimulant laxative) on day 4.If no BM is noted after 4 days, nursing staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.11(E) Based on observations and interview, the facility failed to label and date opened packages of food and failed to dispose of expired food from the walk-in refrigerator and walk in freezer to prevent the potential for food borne illness. This had the potential to affect 47 residents that consumed food from the kitchen. Findings are: An initial observation on 1/6/25 at 8:15 AM of the walk in refrigerator in the kitchen revealed: - an undated zip lock bag of lettuce, - an undated zip lock bag of cut up celery. - a container of cooked vegetables dated 12/26/24, which indicated the food was expired, - an undated open package of turkey slices exposed to the air, - an undated zip lock bag of unknown meat, - 2 packages of undated white cheese packages, - an undated package of American cheese. An observation on 1/6/25 at 8:25 AM of the walk-in freezer in the kitchen revealed: - an undated open bag of French fries exposed to the air, -an undated zip lock bag of an unidentified white shredded substance, - an undated zip lock bag of an unidentified…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-01-13 · tag F0692 — failed to prevent malnutrition and dehydration — patternProvide enough food/fluids to maintain a resident's health.
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(J)(i)(1) Based on record reviews and interviews, the facility failed to obtain resident weights for 3 residents (Resident 32, Resident 3, and Resident 42) of 4 sampled for potential nutritional problems. The facility census was 48. Findings are: A record review of the facility's Resident Weights policy with effective date 11/10 revealed that residents with potential nutritional problems would be monitored by the dietitian on a weekly basis to determine if the resident had experienced a weight loss or gain that that equal or exceeds 5% in 1 month. 7.5% in 3 months, or 10% in 180 days. A. A record review of Resident 32's admission Record printed 01/06/2025 revealed the resident was admitted on [DATE] and had diagnoses of adult failure to thrive (a state of decline that shows up as weight loss, decreased appetite, poor nutrition, and inactivity), a stage 4 (full thickness) pressure injury (an injury to the skin caused by prolonged pressure) to the sacrum (bony area 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.
- Potential for harm · E2025-01-13 · tag F0923 — patternHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-007.04(D) Based on observation and interview, the facility failed to ensure that the ventilation system was operational in 14 occupied rooms (Rooms 201,202,203,204,205,206,208,209,210,211,212,213,214, and 215). This affected 14 bathrooms used by 20 residents. This had the potential to affect odor control in the facility. The facility census was 48. Findings are: An observation on 1/6/25 at 9:30 AM revealed that bathrooms in rooms 203, 204 and 206 did not have functional ventilation as tested with 1 ply square of toilet paper held flat against the ventilation cover that did not hold the paper which indicated that there was no air draw, and the ventilation system did not work. An observation on 1/13/25 at 1:30 PM with the Maintenance Director (MD) revealed that bathrooms in rooms 201,202,203,204,205,206,208,209,210,211,212,213,214, and 215 did not have functional ventilation as tested with 1 ply square of toilet paper held flat against the ventilation cover in the resident bathroom that did not hold the paper which indicated that there was no air…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-01-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to ensure interventions were implemented to protect 1 (Resident 11) of 2 sampled residents from elopement (when a resident leaves a facility without authorization or supervision, and may be a threat to their health or safety). The facility census was 48. Findings are: A record review of the facility's Elopement (when a resident leaves a medical facility without being noticed or supervised) policy with a last revision date of 10/2024 revealed the facility would do risk assessment on admission, quarterly, and with a change of condition. Wander bracelets would be placed on resident's identified as exit seekers and interventions would be placed in the care plan. A record review of Resident 11's Clinical Census dated 01/11/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 11's Medical Diagnosis dated 01/11/2025 revealed the resident had diagnoses of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-13 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
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)(vi)(3)(a) Based on observation, interview, and record review, the facility failed to provide cares for 1 (Resident 40) of 1 sampled resident's with a gastrostomy tube (G-tube, a tube inserted in the stomach to provide food, water, and medications). The facility census was 48. Findings are: A record review of the facility's Wound Care policy with a last revision date of 1/2024 revealed the facility was to cleanse the G-Tube area of insertion site by dabbing area with sterile water and gauze or per providers orders; noting area of breakdown, drainage, skin color, etc. Apply a clean, dry dressing such as gauze square around insertion site, may secure with paper tape. A record review of Resident 40's Clinical Census dated 01/08/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 40's Medical Diagnosis dated 01/11/2025 revealed the resident had diagnoses of Gastrointestinal Hemorrhage (digestive tract bleeding) Gastrostomy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-13 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) Based on record reviews and interviews, the facility failed to have a diagnosis in place to support the use of an antipsychotic (drugs that affect behavior, mood, thoughts, perception, and are used to manage psychotic disorders, which make it difficult to distinguish what is real from what is not) medication. This affected 2 residents (Resident 32 and Resident 7) of 5 residents sampled for unnecessary medication use. The facility census was 48. Findings are: A record review of the facility's Psychotropic [medications used to treat the symptoms of mental disorders] Medication Use policy with effective date 11/2023 revealed: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and, The indications for use of any psychotropic drug shall be documented in the medical record. A. A record review of Resident 32's admission Record printed 01/06/2025 revealed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-04 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview; the facility failed to submit an investigation to the state agency within the required five working days for 3 (Residents 1, 2, and 3) of 3 sampled residents. The facility census was 40. Findings are: A. Review of Resident 2's Progress Note dated 1/25/24 at 10:51 PM revealed: at 6:00 PM the writer saw two residents hitting at each other. When asked what happened, resident (Resident 2) stated the other resident (Resident 1) came over and hit [gender] on the face. Resident (Resident 2) retaliated and started hitting back. The resident was unable to say why or what happened. Resident 1 was at resident's (Resident 2) table. No injury noted at this time. Both residents were separated. Resident 1 was moved to [gender] table. Both POAs (power of attorney) called. PCP (primary care physician) and supervisor notified. APS (Adult Protective Services) called. Review of the facility reportable investigations in the last two months revealed no investigation was completed for Resident 1 and Resident 2. Interview on 3/4/24 at 11:22 AM, the Director of Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-12-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure 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
175 NAC 12.00611D Based on observation, interview and record review the facility failed to prepare food according to the recipe to conserve the nutritional value of the meal. This affects all residents that eat from the facility kitchen. The facility census was 38. Findings are: Record Review of the DiningRD.com recipe for Baked Macaroni and Cheese revealed that the ingredients for the meals was as follows: -Pasta, Elbow Macaroni, Dry -1 pound. -Water, boiling -4 quarts -Margarine solids -4 and 1/2 ounces -Flour, all purpose- 1/2 cup -Salt, iodized- 1teaspoon and 1/8 teaspoon -Mustard, dry -3/4 teaspoon -Cheese, Cheddar, Shredded 1 pound 11 ounces -Cracker crumbs 2 and 1/4 cups -Margarine solids, melted 1 and 1/4 ounces An observation on 12/07/2023 at 9:50 AM of the preparation of the baked macaroni and cheese revealed the Dietary Manager (DM) making cheese sauce. The DM had a pan on the stove top with milk and butter in it. The DM used a gloved hand and added 2 handfuls (unmeasured amount) of cheese to the pan and whisked it into the mixture then again with gloved hand added 2 more…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-12-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
175 NAC 12.00611E Based on observation, interview and record review the facility failed to ensure holding temperatures of hot foods was at or above 135 degrees Fahrenheit, failed to use the correct sanitization solution to disinfect surfaces, failed to use hair restraints for facial hair and failed to perform hand hygiene in a manner to prevent cross contamination. This had the potential to affect 38 of 38 residents who eat out of the facility kitchen. The facility census was 38. Findings are: A. Record Review of the Nebraska Food Code 2022 Section 3-5, Limitation of Growth of Organisms of Public Health Concern Sub Part 3-501 under Section 81-2,272.01 Time/Temperature Control for Safety of Food, Hot and Cold Holding (Replaces 2017 Food Code 3-501.16) states the following: (1) Except during preparation, cooking, or cooling, time/temperature control for safety food shall be maintained: (a) At 135 degrees Fahrenheit (F) or above. An observation on 12/11/23 at 12:40 PM revealed [NAME] C using the facility thermometer was taking the temperatures of food on the steam table after meal the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-12-12 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 175 NAC 12.006.09D1c Based on observation, interview and record review the facility failed to provide hair care for 2 (Resident 30 and Resident 22) of 4 sampled residents. Facility census was 38. Findings are: A. Record Review of Resident 22's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents), dated 5/02/2023 revealed Resident 22 had a Brief Interview of Mental Status (BIMS) score of 8. According to the MDS [NAME] as score of 8 to 12 indicates moderately impaired cognition. Record Review of Resident 22's care plan dated 10/16/2023 revealed Resident 22 needed extensive assistance of 1 staff member with all Activities of Daily Living (ADLs). An observation on 12/11/2023 at 12:10 PM revealed Resident 22 sitting in a wheelchair in the dining room eating lunch with other residents. Further observation on 12/11/2023 at 12:10 PM revealed Resident 22 hair was sticking up in the back and was uncombed. An interview on 12/11/2023 at 12:10 PM with Nursing Assistant…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-12-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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
175 NAC 12.006.09D7 Based on observation, interview and record review the facility failed to ensure fall interventions were in place for 1(Resident 30) of 7 sampled residents. The facility staff identified a census of 38. Findings are: Record Review of Resident 30's care plan dated 9/21/2023 revealed Resident 30 had a Morse Fall Scale (MFS, a rapid and simple method of assessing a patient's likelihood of falling) score of 75 indicating Resident 30 was at high risk of falling. Record Review of Resident 30's care plan dated 9-20-2023 revealed Resident 30 had the potential for falls. The goal for Resident 30 was not to have significant injuries from falls and and the risk of falls would be decreased. According to Resident 30's care plan dated 9/20/2023 Resident 30 occasionally transferred from the bed in a low position to a mat that was to be placed next to the bed. An observation on 12/06/2023 at 11:57 AM revealed Resident 30 was lying in bed. The fall mat was beside the bed and the call light was out of reach. An observation on 12/11/2023 at 9:41 AM revealed Resident 30 was lying 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.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$23,595 in federal fines across 1 penalty.
- $23,595 — penalty dated 2024-10-17
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 / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — 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.
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 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285267. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-06-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.