Linden Court
4000 West Philip Avenue, North Platte, NE 69101 · Non profit - Corporation · 135 certified beds · (308) 532-5774 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a high payroll-based staffing rating (4/5)
- it has an abuse, neglect, or exploitation citation (F0602), cited Nov 2025
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $14,017 in federal fines (most recent 2025-05-01)
- its payroll-based staffing score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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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 | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 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 4 to 3 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 | 23.1% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.4% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.8% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 2.2% | 4.3% | 6.5% | better |
| 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 | 6.2% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 14.5% | 18.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 9.3% | 19.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.6% | 4.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 30.9% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.9% | 20.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 91.5% | 75.9% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.2% | 20.7% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 8.2% | 11.4% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.67 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.72 | 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.
41.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 189 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 59.8% 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 107 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 0.36 therapist hours per resident per day in 2026Q1 — more than 61% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% 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 | 41.8%CMS range 35.7–49.9 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.0%CMS range 6.9–12.7 | 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 | 59.8% | 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 | 48.6% | 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 | 42.1% | 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 | 100.0% | 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 | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this 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 | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.7% | 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 | 6.6% | 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 | 7.5%CMS range 4.5–11.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.21 | 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 135 beds and averages 106.3 residents a day — about 79% occupied, or roughly 29 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.90 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.18 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 3.33 hrs/resident/day on weekends vs 4.13 on weekdays — 19% thinner on weekends. RN hours go from 0.90 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 39% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Immediate jeopardy · Kcited before2025-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure 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 observations, interviews and record reviews, the facility failed to provide a safe environment when residents have been identified at risk for elopement. This affected 10 (Residents 1, 4, 5, 7, 8, 9, 10, 11, 12, and 13) of 12 sampled residents. The facility census was 105. The facility Administrator (ADM) was notified on 04/30/2025 at 6:00 PM of an Immediate Jeopardy (IJ) which began on 04/20/2025. The IJ was removed on 04/30/2025, as confirmed by surveyor onsite verification. Findings are: A record review of a policy titled Elopement Prevention and Management dated 3/2024 revealed: Key elements: -Every building must have a current Elopement Risk Manual, located at the nurse's station. It includes the Missing Resident Identification Form for those at risk for elopement. -Every facility should be doing elopement drills quarterly and as needed. -Elopement Prevention Audit per the QAPI Audit schedule Resident Risk Assessment: -All residents will be evaluated…
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 before2026-04-16 · 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, interviews and record review, the facility failed to ensure outdated food items were not available for use, opened items were dated, and failed to do to complete hand hygiene and change gloves while preparing food to prevent potential cross contamination and food-borne illness. The facility identified a census of 113. This had the potential to affect all residents who ate out of the kitchen.Findings are: A. During the initial tour on 4/13/2026 from 11:21 AM until 12:00 PM, the following concerns were identified: -Walk-in refrigerated was found to have a half gallon bottle of buttermilk dated best by 4/11/2026. A tray of hamburger on the top shelf with a pan of cheesecake below it that had saran wrap loosely on top of it, not sealed.-Walk-in freezer was found to have box of hamburger patties opened in package and not sealed.-In dry storage, a bottle Coffee Mate hazelnut liquid creamer found with the lid caved in and available for use.-Opened package of penne and rotini pasta opened, resealed, but no date…
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 before2026-04-16 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 1-005.06(E&F), 12-006.18(B), and 1-005.06(D) Based on record review, interview, and observation, the facility failed to change their personal protective equipment when transitioning from infectious rooms to non-infectious rooms, failed to perform hand hygiene, and failed to ensure housekeeping services were provided to non-infectious rooms prior to infectious rooms. This had the potential to affect all residents residing within the facility. The facility census was 113. Findings Are: A. A record review of the Nebraska Infection Control Assessment and Promotion Program (ICAP) Nebraska Medicine 2026 website revealed a hyperlink in the COVID-19 Resources for Healthcare Settings section. The hyperlink was https://www.cdc.gov/covid/hcp/infection-control/. A record review of the CDC Infection Control Guidance: SARS-CoV-2 (COVID-19) document found at https://www.cdc.gov/covid/hcp/infection-control/ and dated 6/24/2024 revealed the guidance applied to all United States settings where…
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 · D2026-04-16 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to notify the ombudsman of 2 (Residents 116 and 118) of 3 sampled residents' discharge from the facility. The facility census was 113.Findings Are: A. A record review of Resident 116's admission Record dated 4/15/2026 revealed the resident was admitted to the facility on [DATE]. The document revealed the resident was discharged from the facility on 3/17/2026. A record review of a fax sent to the ombudsman by the Social Services Supervisor (SSS) on 4/1/2026 revealed no evidence of the ombudsman being notified of Resident 116's discharge from the facility. An interview on 04/14/2026 at 2:22 PM with the Administrator confirmed the ombudsman had not been notified of Resident 116's discharge from the facility. B.A record review of Resident 118's admission Record dated 4/15/2026 revealed the resident was admitted to the facility on [DATE]. The document revealed the resident was discharged from the facility 3/13/2026. A record review of a fax sent to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) was coded accurately for Resident 3's medication and Resident 5's Pre-admission Screening and Resident Review (PASRR, a process which requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have Serious Mental Illness or Intellectual Disability). The sample size was 23 and the facility census was 113.Findings Are: A.A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities) dated October 2025 revealed in Chapter 3,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-04-16 · 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 1-009.02(F)Based on observation, interview, and record review the facility failed to provide an environment free of accident hazards related to chemicals in the resident bathrooms for 3 residents (Resident 18, 92, 113) of 8 residents sampled. The facility census was 113. Findings are:An observation on 4/13/26 at 3:08 PM in the bathroom for Resident 92 revealed a cylindrical container titled, Micro-Kill D1 Germicidal Wipes sitting on the toilet tank. The container had a wipe hanging out of the lid of the container at the time.An interview with Resident 92 on 4/13/26 at 3:08 PM about the Micro-Kill D1 Germicidal Wipes in the bathroom revealed the resident smiling stating not knowing anything about it.An interview on 4/13/26 at 3:10 PM with Registered Nurse (RN)-V revealed the Micro-Kill D1 Germicidal Wipes are used for residents that occupy bathrooms with transmissible bacteria. RN-V further revealed Resident 92 has Extended-Spectrum Beta-Lactamase (ESBL; an enzyme produced by certain bacteria, that make them resistant to many common antibiotics 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.
- Potential for harm · D2026-04-16 · tag F0881 — failed to use antibiotics responsibly — isolatedImplement 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 1-005.06(C)Based on record review and interviews, the facility failed to ensure a stop date for the use of antibiotics medication. This affected 1 (Residents 15) ) of 5 sampled residents. The facility census was 113. Findings are: Record review of Resident 15's undated care plan revealed an admission date of 4/12/2021 with the following diagnoses: -FREQUENCY OF MICTURITION-AUDITORY HALLUCINATIONS-UNSPECIFIED URINARY INCONTINENCE -COGNITIVE COMMUNICATION DEFICIT-LONG TERM (CURRENT) USE OF ANTIBIOTICS -UNSPECIFIED DEMENTIA, SEVERE, WITH OTHER BEHAVIORAL DISTURBANCE-UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITH OTHER BEHAVIORAL -DISTURBANCEA record review of Resident 15's orders revealed an order dated 1/24/2025 with an order summary stating Bactrim Tablet 400-80 Milligrams (mg). Give 1 tablet by mouth one time a day related to long term use of antibiotics, continue this order. Leave as prescribed. There was no stop date identified for the use of the antibiotic medication. A record review of a document The core elements of Antibiotic Stewardship…
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 · D2025-11-25 · tag F0602 — failed to protect residents from theft of their belongings — isolatedProtect each resident from the wrongful use of the resident's belongings or money.
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 reviews and interviews, the facility failed to conduct and document a thorough investigation of misappropriation of resident property for 1 (Resident 3) of 3 sampled residents. The facility identified a census of 104. Findings are:A record review of the facility's policy, Abuse and Neglect Prevention Standard dated 3/2017, under Section V. Investigation, revealed all allegations of abuse or neglect would be investigated and interview investigations would be completed and documented. All investigation results would be maintained in a confidential file by the Administrator. A record review of an admission Record revealed the facility admitted Resident 3 on 7/12/2022. A record review of Resident 3's Inventory of Personal Effects (dated 9/10/2022), under Items of Specific Value revealed a wedding ring, a mother's ring, and a [NAME] ring. A record review of an Investigation Report (dated 10/8/2025) revealed on 10/3/2025, the facility received an email…
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 before2025-05-01 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number: 175 NAC 12-006.09(D) Based on record review, and interview, the facility failed to accurately code comprehensive assessments for 2 of 4 sampled residents (Resident #7 and Resident #14) and failed to accurately complete care area assessment summaries for 2 of 4 sampled residents (Resident #5 and Resident #14). The facility census was 105. Findings are: A. Record review of Resident #7's Quarterly Minimum Data Set (MDS - a federally mandated assessment used to develop resident care plans) dated 04/23/2025 revealed an anticoagulant medication (medication used to prevent blood clots) and antidepressant medication (medication used to treat symptoms of depression) was used during the last 7 days. Record review of Resident #7's MAR (medication administration record) showed no anticoagulant or antidepressant medication in use during the MDS observation period. An interview on 05/01/2025 at 1:45 PM with MDS Coordinator RN-A and MDS Coordinator LPN-B revealed that medications anticoagulant and antidepressant should not have been on the MDS because Resident #7 is no…
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 before2025-05-01 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number: 175 NAC 12-006.09(F) Based on record review and interview, the facility failed to update resident care plans to reflect resident care needs for 1 resident (Resident #7). The facility census was 105. Findings are: A record review of Resident #7's Care Plan (CP - an individual plan for caring for each resident that can be updated daily, and as needed between quarterly care plan assessments) last updated on 04/30/2025 revealed Resident #7 is taking an anticoagulant medication (medication used to prevent blood clots) and psychoactive medications; an antianxiety (medication used to treat symptoms of anxiety) and an antidepressant (medication used to treat symptoms of depression). Record review of Resident #7's MAR (medication administration record) showed no anticoagulant or antidepressant medication in use during the MDS observation period. Record review of Resident #7's last Quarterly Minimum Data Set (MDS - a federally mandated assessment used to develop resident care plans) was dated 04/23/2025. A record review of a Comprehensive Care Plan Policy dated…
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 before2025-01-30 · 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 NAC 175 12-006.11E Based on observations, interviews, and record review, the facility failed to perform hand hygiene as required after handling uncooked meat and failed to wear hair restraints in the kitchen as required to prevent the potential for food-borne illness. This had the potential to affect all 104 residents who resided within the facility and were served out of the kitchen. Findings are: A. Record review of an undated facility policy titled, Hand Washing Importance and Technique, revealed that hand washing was indicated after handling uncooked foods including raw meat, fish, poultry, and produce. An observation on 1/28/25 at 7:37 AM revealed Culinary Lead-B (CL-B) was preparing the ingredients for meat loaf. The observation revealed CL-B performed the following: -CL-B completed hand hygiene prior to food preparation using soap and water. -CL-B opened a 10-pound tube of uncooked ground beef while wearing gloves and emptied it into a bowl. -CL-B removed their gloves, then discarded their gloves and packaging at the same time. -CL-B entered 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.
Show the remaining 6 citations
- Potential for harm · Fcited before2025-01-30 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 1-005.06(D) Based on observations and interviews, the facility failed to follow infection control practices during environmental cleaning, disinfection, and with the application of Personal Protection Equipment (PPE). This had the potential to affect all the residents. The facility identified a census of 104. Findings Are: A continuous observation on 1/28/25 from 10:20 AM to 10:45 AM of the 100 Hall revealed at 10:22 AM a housekeeping staff (HSK-H) coming out of a residents' room with gloves on both hands. HSK-H was then observed renewing supplies at the housekeeping cart and returning to a different room with the same gloves on. HSK-H was observed using this technique to clean three resident rooms. At 10:40 AM a Nurses Assistant (NA-I) was observed applying PPE to enter an Enhanced Barrier Precautions room (EBP). NA-I was observed applying gown to shoulder length without tying it up to the neck before entering the room. An interview on 1/28/25 at 10:35 AM with HSK-H confirmed that the observed technique was not the facility policy and that HSK-H should…
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 · D2025-01-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference 175 NAC 12-006.09(E)(iii) Based on record reviews and interviews, the facility failed to develop comprehensive care plans (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) that reflected Resident 97's dialysis treatment and Resident 99's anticoagulant use. This affected 2 (Resident 97 and 99) of 21 sampled residents. The facility identified a census of 104. Findings are: A record review of a facility policy, Comprehensive Care Plans with a date implemented of 11/28/2016, indicated that is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that includes measurable objectives and timeframes to meet each resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The CCP will include…
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 before2025-01-30 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 12.006.04(F) Based on observation, interview, and record review; the facility failed to ensure that 1 (Resident 94) of 21 sampled residents care plan was reviewed and revised to reflect significant weight loss. The facility identified a census of 104. The findings are: A record review of a Comprehensive Care Plan Policy dated 11/28/2016 revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, quarterly MDS (MDS- a Federally mandated tool for implementing standardized assessment and for facilitating care management in nursing homes) assessment, and as needed. A record review of Resident 94's admission face sheet revealed an admission date of 10/4/24. A record review of Resident 94's diagnoses included pneumonia (an inflammation of the lungs that causes the air sacs (alveoli) to fill with fluid or pus), altered mental status (a change in a person's level of consciousness, awareness, and cognitive function), and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-30 · tag F0661 — isolatedEnsure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference 175 NAC 12-006.09(G)(i) Based on record reviews and interview, the facility failed to develop and provide a discharge summary (a detailed document with individualized care instructions to ensure continuity of care and a safe return home for the resident) that included a recapitulation of stay; information regarding the resident's physical functioning and assistance level needs, continence, and skin condition; and a reconciliation of the resident's medications as required for 1 (Resident 102) of 1 sampled resident. The facility identified a census of 104. Findings are: A record review of an admission Record indicated the facility discharge Resident 102 on 10/31/2024 at 2:00 PM. Resident 102 had diagnoses of a history of a right femur (thigh bone) fracture with surgical correction and high blood pressure. A record review of Resident 102's Discharge Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-29 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.12E8 Based on interview and record review, the facility failed to ensure 1 (Resident 76) of 5 sampled resident's Fentanyl Duragesic patch (a topical pain medication patch) destruction was witnessed by 2 credentialied individuals. The facility census was 98. Findings are: A record review of the facility's VSL ([NAME] Senior Living) Medication Destruction/Disposal Policy and Procedure dated 02/2020 revealed removed topical patches should have been disposed in the medication disposal system and 2 staff members needed to observe the disposal of a used Fentanyl patch. Ideally 2 nurses would observe the disposal of a removed Fentanyl patch. If 2 nurses were not available at least 1 staff member must be a nurse and the second may be a MA. Each person would initial witnessing the disposal on the Medication Administration Record (MAR). A record review of Resident 76's admission Record dated 02/27/2024 revealed the resident was admitted to the facility on [DATE]. A record review…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.006.17D Based on observation, interview, and record review, the facility failed to ensure that 1 (Resident 151) of 2 sampled resident's indwelling urinary catheter (a tube inserted in the bladder to drain urine) bag was kept off the floor and failed to ensure a clean barrier was used during tracheostomy (trach)(a breathing tube placed in the neck) care for 1 (Resident 58) of 1 sampled resident to prevent the potential for cross contamination, and failed to ensure handwashing was completed for at least 20 seconds during trach care for 1 (Resident 58) of 1 sampled resident. The facility census was 98. Findings are: A. A record review of the facility's Indwelling Urinary Catheter (Foley) Care and Management policy dated 12/11/2023 revealed the staff should not place the urinary catheter drainage bag on the floor to reduce the risk of contamination and subsequent Community Acquired Urinary Tract Infection (CAUTI). A record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$14,017 in federal fines across 1 penalty.
- $14,017 — penalty dated 2025-05-01
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.
Part of a chain
This home belongs to VETTER SENIOR LIVING — 22 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 4.2 | -2.2 vs chain |
| Health inspection | 2 of 5 | 3.9 | -1.9 vs chain |
| Staffing | 4 of 5 | 4.3 | -0.3 vs chain |
| Quality measures | 3 of 5 | 3.8 | -0.8 vs chain |
The other 21 homes this chain runs (chain average 4.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| VETTER SENIOR LIVING | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 12/23/2016 |
| BACKER, WINSOME | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/06/2021 |
| RUBENTHALER-BRUNKHARDT, KALI | Individual | CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL | — | since 12/02/2019 |
| STUHR, BRIAN | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VANEKEREN, GLENN | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VETTER, ELDORA | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VETTER, JACK | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 06/15/2017 |
| VSL VETTER HEALTH SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 07/01/2017 |
CMS files one row per role, so the 19 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners 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.
This home reported $691K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285083. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-16, 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.