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Arbor Care Centers-Countryside LLC

703 North Main Street, Madison, NE 68748 · Government - City · 70 certified beds · (402) 454-3373 Medicare & Medicaid certified

Call the home — (402) 454-3373 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0606) — cited Dec 20241 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$26,750 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0606), cited Dec 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605, F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $26,750 in federal fines (most recent 2026-03-24)
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (64%) runs well above the national median (45%)

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

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

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 5 of 5

Worth a closer look. This home's quality-measure rating runs 3 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Pharmacy
201 S Main St · (402) 454-2525 · Call to confirm hours
Grocery
102 N Main St · (402) 454-2721 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.

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

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased13.9%19.0%15.4%better
Long-stay residents who lose too much weight0.0%5.1%5.4%check this — see note marked star below the table
Long-stay residents with a catheter left in their bladder0.7%1.4%0.9%better
Long-stay residents with a urinary tract infection1.6%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
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 injury3.9%4.5%3.3%worse
Long-stay residents whose ability to walk worsened19.4%18.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication16.1%19.3%18.9%better
Long-stay residents given the seasonal flu vaccine84.2%96.1%95.3%worse
Long-stay residents with pressure ulcers4.0%4.0%4.7%better
Long-stay residents with worsening bladder/bowel control32.1%25.9%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.4%20.7%17.1%better
Short-stay residents who newly got an antipsychotic medication4.1%2.0%1.4%worse
Short-stay residents given the seasonal flu vaccine27.3%75.9%79.4%worse
Long-stay hospitalizations per 1,000 resident days1.041.811.67better
Long-stay outpatient ER visits per 1,000 resident days0.591.921.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

39.9% 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 33 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

39.9%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
0.33U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.33 therapist hours per resident per day in 2026Q1 — more than 55% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF39.9%CMS range 28.0–54.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 7.4–17.210.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.2%CMS range 3.0–13.67.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.921.02Oct 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

RN hours/ resident / day
LPN hours/ resident / day
Aide hours/ resident / day
Total nurse hours/ resident / day
RN hoursweekends
64.1%
Total nursing turnover
87.5%
RN turnover

How full it usually is: this home is certified for 70 beds and averages 35.5 residents a day — about 51% occupied, or roughly 34 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.

Weekend coverage: total nurse staffing is 2.74 hrs/resident/day on weekends vs 3.20 on weekdays — 15% thinner on weekends. RN hours go from 0.71 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

9
deficiencies at the latest standard inspection (2025-12-18)
8
at the previous standard inspection (2024-12-05)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

32 citations, most serious first. The 12 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2026-03-24 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10(D)Based on record review and interview; the facility failed to ensure 1 resident (Resident 4) of 4 sampled was free of significant medication errors. The facility had a census of 36. Findings are:A. Review of the facility policy Medication Error dated September 2024 revealed a medication error was the preparation, provision, or administration of medications that was not in accordance with the following:-Physician Orders;-Manufacturer's specifications regarding the preparation or administration of the drug;-Accepted professional standards that apply to professionals providing services; and-The five rights which included the right resident, the right drug, the right dosage, the right route and the right time. B.Review of the facility policy Medication Administration dated September 2024 revealed medications were administered by licensed nurses, or other staff who were legally authorized as ordered by the physician and in accordance with standards of practice. Compliance…

    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 · Past Non-Compliance
  • Actual harm · G2023-09-27 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D2a Based on observations, interviews and record review, the facility failed to implement interventions to prevent Resident 1's pressure sore from developing and worsening and failed to implement interventions to prevent the potential development of a pressure sore for Resident 8. The sample size was 2. The facility census was 31. Findings are: A. Review of the facility policy Pressure Ulcer Prevention Plan dated 2/2020 revealed the following: -Identify high-risk residents by performing comprehensive skin assessments upon admission and re-admission. -Complete a Braden scale (an assessment tool used to determine a person's risk of developing a pressure ulcer) on admission, re-admission, and with a significant change of condition. -Complete daily skin checks by a licensed nurse for high-risk residents or a resident with a current pressure ulcer. -All residents will have a minimum of weekly skin checks by a licensed nurse with documentation on the Weekly Pressure Ulcer…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-06-15 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.05Based on record review and interview; the facility failed to follow 1 (Resident 1) of 4 sampled residents' consent to not publish photographs of the resident. The facility census was 32.Findings are:A. Review of the facility policy Resident Rights reviewed 3/20 revealed the following:- The facility would inform the resident both orally and in writing in a language that the resident understands his or her rights and regulations governing resident conduct and responsibilities during the stay in the facility.-The facility would provide the residents with prompt notice (if any) of changes in any State or Federal laws related to resident rights or facility rules during the resident's stay in the facility. Receipt of any information must be acknowledged in writing.-The resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident. B. Review of Resident 1's admission Agreement signed by the resident's legal representative on 12/9/25 revealed the following:-Attachment J, Consent to…

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

    Resident Rights Deficiencies · Past Non-Compliance
  • Potential for harm · D2026-03-24 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.12(D)(i)(2)Based on record review and interview; the facility failed to accurately account for narcotic medications. This had the potential to affect all residents receiving narcotic medications in the facility. The facility sample size was 4 and the census was 36.Findings are:A.Review of the facility policy Controlled Substance Administration and Accountability Policy dated April 2025 revealed the following:-It was the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility would have safeguards in place to prevent loss, diversion or accidental exposure of controlled substances.-Inventory verification for areas without automated dispensing systems would be completed by two licensed nurses accounting for all controlled substances and the nurses would exchange keys at the end of each shift.B.Review of the Controlled Drug-Count Record form (signatures verified that staff had counted the narcotics and the count had been…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-24 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted 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 12-006.10(A)(ii) Licensure Reference Number 175 NAC 12-006.10(A)(iii) Licensure Reference Number 175 12-006.10(C) Based on record review and interview; the facility failed to ensure 1 (Resident 4) of 4 sampled residents records had accurate documentation of medication administration. The facility census was 36. Findings are:A.Review of the facility policy Medication Administration dated September 2024 revealed medications were administered by licensed nurses, or other staff who were legally authorized as ordered by the physician and in accordance with standards of practice. Compliance Guidelines included:-Ensure the six rights of medication administration were followed which included the right resident, the right drug, the right dosage, the right route, the right time, and the right documentation;-Review the Medication Administration Record (MAR) to identify the medication to be administered;-Compare the medication with the MAR to verify the resident name, medication form, dose,…

    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 · E2025-12-18 · tag F0628 — pattern
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09G and 175 NAC 12-006.02(A) Based on record review and interview, the facility failed to complete the required discharge notifications to the State Ombudsman when residents were transferred or discharged from the facility and complete discharge summaries for Residents 37 and 39. The sample size was 2 and the facility census was 38. Findings are: A. Review of Resident 37's Care Plan dated 10/10/25 revealed the resident was admitted to the facility with pneumonia and pancreatic cancer. Review of Resident 37's Progress Notes revealed the following: -On 10/10/25 at 7:14 PM the resident was admitted to the facility from a hospital on with increased weakness, a cancer diagnosis and the resident's family was in hopes the resident could have Physical Therapy and return home. -On 10/12/25 at 8:22 AM revealed, the resident was sent to the Emergency Room. -On 10/12/25 at 1:00 PM the resident's family reported the resident would most likely not return to the facility and 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 Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-12-18 · 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)(D) Based on observation, record review and interview; the facility failed to implement Enhanced Barrier Precaution (EBP-involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug resistant organism (MDRO-bacteria that have become resistant to certain antibiotics) as well as those at increased risk for MDRO, residents with wounds or indwelling medical devices) during toileting assistance for Resident 2, catheter cares for Resident 10 and wound care for Resident 7; failed to provide cleaning of resident care equipment to prevent cross-contamination and or potential infections for Resident 10 and failed to complete gloving and hand hygiene at appropriate intervals during the provision of care for Residents 1,7,10 and 41. The sample size was 13 and the facility census was 38.Findings are: A. Review of the facility policy Enhanced Barrier Precautions revised May 20, 2024, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-12-18 · tag F0940 — failed to train staff — pattern
    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 review and interview; the facility failed to ensure 4 out of 5 staff had the required initial training within 2 weeks of employment which included resident rights, emergency preparedness, abuse and neglect and dementia care. This had the potential to affect all residents of the facility. The facility census was 38.Findings are:Review of the Abuse, Neglect, and Exploitation Policy dated September 2024 revealed new employees would be educated on abuse, exploitation (treating someone unfairly) and misappropriation (unauthorized use of someone's property) of resident property during initial orientation. Training topics would include: prohibiting all forms of abuse, neglect, misappropriation of resident property and exploitation; identifying what constituted as abuse; recognizing signs of abuse; the reporting process; and understanding behavioral symptoms that may increase the risk of abuse. Review of the Nursing Assistant (NA)-Q's file revealed a hire date of 11/3/25. There was no evidence the initial training had been…

    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 · Dcited before2025-12-18 · 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

    Licensure Reference Number 175 NAC 12-006.05(21)Based on observation, record review and interview; the facility failed to ensure Resident 10's dignity by not covering the urinary drainage bag. The sample size was 3 and the facility census was 38.Findings are:A. Review of the facility policy titled Catheter Care dated September 2024 revealed the following:- It was the policy of this facility to ensure that residents with indwelling catheters received appropriate care and maintained dignity and privacy when indwelling catheters were in use. - Privacy bags would be available and catheter drainage bags would always be covered while in use. B. Review of Resident 10's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 12/13/25 revealed the resident had an indwelling catheter. Review of Resident 10's Care Plan dated 11/29/25 revealed Resident 10 had an indwelling catheter and the urinary catheter bag and tubing was to be placed away from the entrance of the door to the room. The following observations revealed Resident 10's urinary…

    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 · D2025-12-18 · tag F0552 — isolated
    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 12-006.12Based on record review and interview; Residents 8 and 9 did not have the required consent for the use of psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety and hypnotics). The sample size was 13 and the facility census was 38.Findings are:A. Review of the facility policy Use of Psychoactive Drugs with a review date of 2/2020 revealed the following:-Residents and their representatives should be educated on the risk and benefits of drug use as well as alternative treatments and non-pharmacological interventions. B. Review of Resident 8's Medication Administration Record (MAR) for the month of December 2025 revealed the resident received Sertraline (antidepressant) 100 milligrams (mg) daily for Depressive Disorder.Review of Resident 8's Minimum Data Set (MDS-federally mandated comprehensive…

    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 · D2025-12-18 · 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

    Licensure Reference Number 175 NAC 12-006.05(G)Based on record review and interview, the facility failed to ensure Resident 25 received the required face to face physician evaluations to continue the use of PRN (as needed) antipsychotic (used to treat psychotic disorders/symptoms) medications. The sample size was 5 and the facility census was 38. Findings are: Review of the facility policy Use of Psychoactive Drugs dated 2/2020 revealed the following: -Residents were not given psychotropic (mind altering) drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -A psychotropic drug was any drug that affected brain activities associated with mental processes and behavior. Psychotropic drugs included but were not limited to the following categories: antipsychotics, antidepressants, anti-anxiety and hypnotics. -The indications for use of any psychotropic drug were documented 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-18 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on record review and interview, the facility failed to provide bathing assistance to Resident 45 at intervals to meet the resident's needs. The sample size was 13 and the facility census was 38. Findings are: Review of the undated facility Bathing Policy Statement revealed the facility provided each resident with bathing services at a frequency that met the residents' individual needs and preferences. Additional baths were provided as needed for incontinent episodes, skin care needs, or physician's orders Review of Resident 45's Care Plan dated 9/28/25 revealed the resident was admitted on [DATE], had dementia, bladder incontinence and self-care deficits related to a recent hip fracture, infections, and dementia. The resident was unable to bear weight on the left leg and staff were to provide the resident with assistance with Activities of Daily Living (ADL's) including bathing. Review of Resident 45's Bathing Records revealed bathing occurred on 10/10…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-12-18 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09Based on observation, record review and interview; the facility failed to provide evidence of follow up evaluations and condition assessments to identify potential complications following a fall for Resident 10 and failed to follow physician's orders for treatment of a foot ulcer for Resident 7. The sample size was 13 and the facility census was 38. Findings are:A. Review of the facility policy Fall Prevention Program dated September 2024 revealed the following:-Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. -When any resident experiences a fall, the facility would complete the following:A. Assess the resident.B. Complete a post-fall assessment.C. Complete an incident report.D. Notify physicians and family.E. Review the resident's care plan and update as indicated.F. Document all assessments and actions.G. Obtain witness statements in the case of an injury. B. Record review of nursing documentation for Resident 10 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-18 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY License Reference Number 175 NAC 12-006.18(A)Based on record review and interview; the facility failed to have evidence Resident 4 and 7 were up to date and/or offered/given pneumococcal vaccinations. The sample size was 5 and the facility census was 38. Findings are:A. Review of the facility policy Vaccination dated September 2024 revealed each nursing facility would annually, no later than October 1, offer onsite vaccinations for pneumococcal to all residents. B. Review of Resident 4's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 10/1/25 revealed the resident was admitted [DATE] with diagnoses of Heart Failure, High Blood Pressure, and Kidney Disease; had moderate cognitive impairment; and their pneumococcal vaccination was not up to date and it was not offered. Review of Resident 4's Medical Record revealed no evidence the resident had been offered or received/declined the pneumococcal vaccination. C. Review of Resident 7's MDS dated [DATE] revealed the resident was…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-05 · tag F0727 — failed to provide required RN coverage — pattern
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    What the surveyor found here — the official record, unedited, may be distressing

    Licensure Reference Number 175 NAC 12-006.04(F) Based on record review and interview the facility failed to provide the required 8 hours of Registered Nurse (RN) coverage daily. The sample size was 14 and the facility census was 34. Findings are: A. Based on record review of the nurse's schedule for November 2024 there was not any RN coverage on 11/1/24, 11/2/24 and 11/3/24. During an interview on 12/5/24 at 10:00 AM with the Director of Nursing (DON) the DON confirmed that there was not any RN coverage on 11/1/24, 11/2/24 and 11/3/24.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-05 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 12-006.12(A)(vi) Based on record review and interview; the facility failed to follow the pharmacist's recommendations to address irregularities in medication regimens for Resident's 1 and 27. The sample size was 5 and the facility census was 34. Findings are: Review of the undated facility policy Medication Regimen Review (MMR) revealed the following: -The MMR was a thorough process of review and assessment conducted by a Consultant Pharmacist of the medications ordered for each resident, with a goal of promoting positive outcomes and minimizing adverse consequences associated with medications. -The MMR occurred monthly for each resident and recommendations were reported to the Administrator, Director of Nursing, attending physicians, and the Medical Director as it applied. -The Consultant Pharmacist utilized federally mandated standards of care, in addition to other applicable standards. -The Consultant Pharmacist provided reporting each month including documented concerns,…

    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 · Ecited before2024-12-05 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, record review, and interview the facility failed to implement Enhanced Barrier Precautions (EBP-an infection control interventions designed to reduce transmission of Multi-Drug-Resistant Organisms (MRDO's) that employed targeted gown and glove use during high contact resident care activities) during the provision of care for Residents 20 and 25 and failed to maintain ongoing evidence of antibiotic surveillance in the facility. Findings are: A. Review of the facility policy Enhanced Barrier Precautions dated [DATE] revealed the following: -It was the policy of the facility to implement enhanced barrier precautions for the prevention of transmission of MRDO's. -EBP referred to controlled interventions designed to reduce the transmission of MRDO's that employed gown and glove use during high contact resident care activities. -When EBP were implemented, the facility made gowns and gloves available immediately near or outside the resident's room.…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-05 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, record review and interview; the facility failed to implement interventions to prevent potential falls for Resident 27. The total sample size was 3 and the facility census was 34. Findings are: A. Review of the facility Fall Prevention and Fall Leaf Program with a revised date of 2/2020 revealed the following fall prevention procedure: Fall Prevention Procedure: - A fall risk care plan (a written document that outlines the care and support a person needs based on their health needs) would be developed for all residents as deemed appropriate by the Care Plan Coordinator. - If a resident had a fall a Fall Incident & Investigation report would be completed. The report would be reviewed at the next Clinical Team Meeting to determine what interventions would be added to prevent further falls. B. Review of Resident 27's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/21/24 revealed diagnoses of Non-Traumatic Brain Dysfunction, Dementia, Anxiety and Depression 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.

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

    Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview; the facility failed to ensure Resident 1's long term use of an antibiotic had a clinical rationale for continued use or an ordered duration of use. The sample size was 5 and the facility census was 34. Findings are: Review of the facility policy Antibiotic Stewardship Program (ASP) with a revision date of 3/2023 revealed the following: -The facility implemented an ASP as part of the overall infection prevention and control program and the purpose was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. -The Infection Preventionist (IP), with oversight from the Director of Nursing (DON) served as the leader of the ASP. -The Medical Director, Consultant Pharmacist, and attending Physicians supported the program through active participation in the development, promotion, and implementation of a facility wide system for monitoring the use of antibiotics. -All prescriptions for antibiotic included a specific dose, duration, and indication for use. 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 · D2024-12-05 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.18 Based on record review and interview; the facility failed to follow the facility Antibiotic Stewardship Policy for Resident 1 to ensure all antibiotics ordered had stop dates and or documented clinical rationale for ongoing use. Findings are: Review of the facility policy Antibiotic Stewardship Program (ASP) with a revision date of 3/2023 revealed the following: -The facility implemented an ASP as part of the overall infection prevention and control program and the purpose was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. -The Infection Preventionist (IP), with oversight from the Director of Nursing (DON) served as the leader of the ASP. -The Medical Director, Consultant Pharmacist, and attending Physicians supported the program through active participation in the development, promotion, and implementation of a facility wide system for monitoring the use of antibiotics. -All prescriptions for antibiotic included a specific dose, duration, and indication for use. Review of 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 date of correction
  • Potential for harm · D2024-08-22 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview: the facility failed to investigate an allegation of potential abuse/misappropriation/exploitation for Resident 2 and then to submit the results of the investigation to the State Agency. The sample size was 4 and the facility census was 39. Findings are: A. Review of the facility policy Abuse, Neglect, Exploitation, Mistreatment and Misappropriation dated [DATE] revealed the following; -The facility encouraged and supported all residents, staff, families, visitors, volunteers, and resident representatives to report suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation of resident property. -Neglect is the failure of the facility, it's employees or service providers to provide services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary…

    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 · Ecited before2023-11-14 · 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 12-006.09D7 Based on observation, record review and interview; the facility failed to implement fall interventions for Residents 3 and 16, to assess causal factors and to develop new interventions and/or revise current interventions to prevent ongoing falls for Resident's 3, 14, 15, and 16. The sample size was 4 and the facility census was 32. Findings are: A. Review of the facility policy Fall Prevention and Fall Leaf Program with a revision date of 2/2023 revealed the following; -The purpose was to ensure fall risks were identified and interventions were implemented to prevent falls, as possible, and to maintain a safe environment for each resident of the facility. -Fall Risk Evaluations were to be completed at admission, quarterly and with a significant change. If a risk score was 10 or more a fall leaf program was initiated. -A fall risk Care Plan was developed for all residents as deemed appropriate by the Care Plan Coordinator. -A fall leaf was placed on 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-14 · 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 (21) Based on interview and record review; the facility failed to address Resident 85's anxiety, health concerns and behaviors in a manner to promote and maintain the resident's dignity. The sample size was 3 and the census was 32. Findings are: Review of Resident 85's Minimum Data Set (MDS-a comprehensive assessment used to develop a resident's care plan) dated 8/21/23 revealed the resident was admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, cancer, emphysema, heart failure, respiratory failure, anxiety, pain and altered mental status. The following was assessed regarding Resident 85: -cognitively intact; -behaviors which included; delusions, verbal behaviors directed at others, other behavioral symptoms (hitting, scratching self and verbal/vocal symptoms like screaming or making disruptive sounds) not directed at others and rejection of cares; -need for extensive staff assistance with transfers, bed mobility, toileting, dressing and personal…

    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 · D2023-11-14 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — the official record, unedited, may be distressing

    Licensure Reference Number 175 NAC 12-006.051 Based on record review and interview, the facility failed to provide the required advance notifications prior to discharge from Medicare services for 2 (Resident 4 and 185) of 3 sampled residents. The facility census was 32. Findings are: A. Review of Resident 4's Skilled Nursing Facility Protection Notification Review revealed no evidence the Advance Beneficiary Notice of Non-coverage (ABN) was provided to the resident/representative prior to the resident's Medicare skilled services ending on 10/2/23. B. Review of Resident 185's Skilled Nursing Facility Protection Notification Review revealed no evidence the ABN and Notice of Medicare Non-coverage was provided to the resident/representative prior to the resident's Medicare skilled services ending on 6/13/23. C. An interview with the Social Services Director on 11/8/23 at 12:55 PM confirmed there was no evidence written notification was provided to the residents/representatives prior to the residents Medicare skilled services ending on 10/2/23 for Resident 4 and 6/13/23 for Resident 185.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-14 · tag F0606 — failed to not employ staff found guilty of abuse — isolated
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.04A3b Based on record review and interview, the facility failed to ensure background checks through the State Nurse Aide (NA) registry were completed on 5 of 7 employees. The facility census was 32. Findings are: A. Review of the Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property policy with a revised date of 10/19 revealed, the facility would conduct background checks and not knowingly employ or otherwise engage any individual who: -had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; -had a negative finding in the State Nurse Aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; and/or -a disciplinary action in effect against his or her professional license by a state licensure body because of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. B. Review of 7 employee files on 11/13/23 revealed no evidence Licensed…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-14 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide 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 Licensure Reference Number 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to provide assistance with shaving, oral hygiene and nail care for Resident 15, who required assistance with activities of daily living. The sample size was 3 and the facility census was 32. Findings are: Review of Resident 15's Minimum Data Set (MDS- a federally mandated assessment tool used for care planning) dated 8/24/23 revealed Resident 15 was admitted [DATE] with diagnoses of Alzheimer's disease, anxiety, post traumatic stress disorder and non-traumatic brain dysfunction. The following was assessed regarding Resident 15: -short- and long-term memory loss with severely impaired decision-making skills; -behaviors which included resistance with cares, verbal and physical behaviors directed at others, wandering and delusions; -required extensive staff assistance with dressing and personal hygiene; and -frequently incontinent of bowel and bladder. Review of the resident's current Care Plan…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on observation, interview, and record review; the facility failed to follow physician's orders related to surgical wound care for 1 (Resident 17) of 3 sampled residents. The facility identified a census of 32 at the time of survey. Findings are: Review of Resident 17's Minimum Data Set (MDS-a comprehensive assessment tool used to develop a resident's care plan) dated 8/24/23 revealed the resident was admitted [DATE] with diagnoses of down's syndrome, respiratory failure and morbid obesity. The resident's cognition was severely impaired, and the resident required extensive to total staff assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. In addition, the resident had areas of moisture associated skin damage with application of ointments and dressings other than to the resident's feet. Review of the resident's undated current Care Plan revealed the resident was at risk for impaired skin integrity related to excoriation and skin…

    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 · D2023-11-14 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review; the facility failed to prevent potential COVID-19 infection as the facility failed to provide evidence that a COVID-19 vaccination was offered and refused, and that education was provided for the refusal of the COVID-19 vaccine for 1 (Resident 17) of 5 sampled residents. The facility census was 32. The findings are: A. Review of the facility's COVID-19 Vaccination Policy (dated 10/21) revealed it was the policy of the facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering residents and staff the COVID-19 vaccine. The following was identified: -COVID-19 vaccinations were to be offered to residents and staff when supplies were available unless medically contraindicated, the resident had already received the vaccination during the time period or if the resident refused to receive the vaccine; -residents and staff were to be screened for suspected COVID-19, previous allergic reactions and administration 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-09-27 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09D Based on observations, interview and record review, the facility failed to ensure physician's orders were followed for 2 residents (Resident 8 and 12) related to Resident 8's pressure relief cushion and Resident 12's nutritional supplement. The total sample size was 13 and the facility census was 31. Findings are: A. Review of Resident 8's plan of care with a printed date of 9/27/23 revealed the resident had the potential for skin breakdown related to limited mobility and frequent bowel and bladder incontinence. In addition, the resident had been assessed as a high risk to develop pressure ulcers with the following interventions; use a pressure relieving mattress on the bed, a Roho cushion (a high quality seat cushion that provides pressure relief for persons at risk of pressure sores) on the chair and to keep [gender] heels off the mattress and foot rest. Review of Resident 8's Treatment Administration Record dated 9/1/23 to 9/30/23 revealed the resident had a physician order for a Low profile Roho cushion to the recliner and staff were…

    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 · D2023-09-27 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.12E7 Based on observations, interview and record review, the facility failed to ensure multiuse medications were dated when opened for 2 residents (Resident 7 and 13). The total sample size was 13. The facility census was 31. Findings are: A. Review of the facility policy Administering Medications dated 3/2023, revealed the following: -medications are administered in a safe and timely manner, and as prescribed; and -the expiration/beyond-use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. B. An observation of the facility's medication cart on 9/27/23 at 12:10 PM, revealed the following: -Resident 7 had an order for Artificial Tears Solution 1 %, 2 drops in both eyes two times a day for age related macular degneration and dry eyes. There was an opened bottle that had been used and no date was recorded on the container when the bottle was initially opened. -Resident 13 had an order for Flonase Allergy Relief Nasal Suspension 50 micrograms (mcg),…

    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
  • No harm found · Ccited before2024-12-05 · tag F0606 — failed to not employ staff found guilty of abuse — widespread
    Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
    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 12-006.04(A)(iii)(3)(c) Based on record review and interview the facility failed to evaluate adverse finding regarding criminal background checks for 3 of 5 sampled staff to protect residents from potential abuse. The facility census was 34. Findings are: Review of the facility policy Abuse Neglect and Exploitation dated [DATE] revealed the following: -The facility provided protections for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibited and prevented abuse, neglect, exploitation and misappropriation of resident property. -Developed policies and procedures to investigate any allegations. -Provided ongoing oversight and supervision of staff to assure policies were implemented. -Screened all potential employees for a history of abuse, neglect, exploitation or misappropriation including background, reference, and credential checks, and documented proof of the screening that occurred. -New employees were…

    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
  • No harm found · C2024-12-05 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview; the facility failed to complete the required staff posting of nursing hours. This had the potential to affect all facility residents. The facility census was 34. Findings are: Review of the facility Nurse-Staffing-Posting-Information Policy with a date of January 2024 revealed the following guidelines for posting nursing hours: The Nurse Staffing Sheet would be posted daily containing the following information: -facility's name -date -facility's census -The total actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. -The facility would post the Nurse Staffing Sheet at the beginning of each day. -The information would be posted in a prominent place readily accessible to residents and visitors. During observation on 12/2/24 and 12/3/24 there was no staff posting observed throughout the facility. Based on record review the facility had no evidence of staff postings from 12/2/24- 12/3/24 and no evidence staff postings had been completed over the past 30 days. During an interview with…

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

    Nursing and Physician Services 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

$26,750 in federal fines across 2 penalties.

  • $12,735 — penalty dated 2026-03-24
  • $14,015 — penalty dated 2026-03-24

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
ARBOR CARE CENTERS LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/23/2025
KLAASMEYER, AARONIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020
KLAASMEYER, JESSICAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2023
KLAASMEYER, KENNETHIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020
KLAASMEYER, LINDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020
MCNEILL, TRISHTIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/06/2024
MCWHORTER, EVERETTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020
SPANEL, ALANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2020

CMS files one row per role, so the 16 rows in the source record cover these 8 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.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

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

$3.9M
Net patient revenuemost recent cost report
-19.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 39%Medicare 6%Other / private 56%

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

$341per resident / day
operating cost
$10,364per month
≈ monthly operating cost
$286per 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 285207. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-18, 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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