Emerald Nursing & Rehab Legacy Pointe llc
3110 Scott Circle, Omaha, NE 68112 · For profit - Limited Liability company · 108 certified beds · (402) 455-6636 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- CMS lists it as a Special Focus candidate — not on the watch list itself, but among the homes CMS is watching because of its recent inspection history
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors cited 1 immediate-jeopardy problem — the most serious level
- a high number of inspection citations overall (35) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $68,086 in federal fines (most recent 2026-06-09)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- about 26% of its spending goes to commonly-owned related companies
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 | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its 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 |
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 improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 10.1% | 19.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.6% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 3.0% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 4.3% | 6.5% | check this* — see note marked star below the table |
| 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 | 4.2% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 15.5% | 18.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 23.1% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 88.9% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.7% | 4.0% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 31.7% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 29.4% | 20.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 65.2% | 75.9% | 79.4% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.76 | 1.81 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.06 | 1.92 | 1.80 | better |
* 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.
35.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 30 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.18 therapist hours per resident per day in 2026Q1 — more than 19% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 52% of this home’s weekday level — it runs therapy at close to weekday levels right through the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 35.5%CMS range 20.4–52.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 11.8%CMS range 7.2–17.4 | 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 | not 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 discharge | not 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 discharge | not 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 identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not 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 worsened | not 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 hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.83 | 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 108 beds and averages 60.5 residents a day — about 56% occupied, or roughly 48 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.45 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.37 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.01 hrs/resident/day on weekends vs 3.62 on weekdays — 17% thinner on weekends. RN hours go from 0.76 to 0.52 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 53% 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.
35 citations, most serious first. The 11 most serious are shown; the remaining 24 are one tap away and print in full.
- Immediate jeopardy · J2026-06-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I) and 12-006.09(I)(i)(1,2,3 and 4). Based on observation, record reviews and interviews; the facility failed to ensure residents that were identified as an elopement risk were supervised when leaving the facility for 1 (Resident 1) of 3 residents sampled, failed to ensure prompt follow-up after a resident's whereabouts were unknown for 1 (Resident 2) of 3 residents sampled, failed to identify and implement interventions to prevent elopements and falls and failed to monitor for neurological changes after unwitnessed falls or falls with head injuries for 1 (Resident 1) of 3 residents on sample. The facility staff identified a census of 65.The facility Administrator (ADM) was notified on 6/8/26 at 5:25 PM of an Immediate Jeopardy (IJ) which began on 6/8/26. The IJ was removed on 6/8/26, as confirmed by surveyor onsite verification. The findings are: A. Record review of the facility's policy titled Elopement, Risk reduction strategies and management of missing residents…
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 · F2026-06-09 · tag F0835 — failed to run the facility competently — widespreadAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.02 Based on observations, record reviews and interviews; the facility management failed to utilize its resources to attain or maintain the highest practicable physical and psychosocial well-being of each resident as identified by the deficient practices cited. The facility staff identified a census of 65. Findings are: -F689: The facility failed to ensure residents that were identified as an elopement risk were supervised when leaving the facility, failed to ensure prompt follow-up after a resident's whereabouts were unknown, failed to identify and implement interventions to prevent elopements and falls and failed to monitor for neurological changes after unwitnessed falls or falls with head injuries. These findings placed the facility in a substandard level of care requiring an extended survey. -F725: The facility failed to ensure competency testing for 12 of 12 employees sampled. -843: The facility failed to obtain a transfer agreement with a local hospital.-867: The facility failed to ensure the QAPI program identified and addressed…
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 · F2026-06-09 · tag F0843 — widespreadHave an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview; the facility staff failed to have a transfer agreement between the facility and hospital. This had the potential to effect all residents in the facility. The facility staff identified a census of 65. Findings are: Record review of the facility agreements revealed there was no evidence of a transfer agreement between the facility and the hospital.Interview on 06/09/2026 at 1:50 PM with the Administrator (ADM) revealed the facility did not have a hospital transfer agreement.
- Potential for harm · F2026-06-09 · tag F0867 — failed to act on quality-improvement findings — widespreadSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure reference Number 175 NAC 12-006.07(C)Based on observation, interview, and record review, the facility failed to ensure the QAPI program identified and addressed concerns related to deficient practice for elopement and falls prior to a complaint survey. This had the potential to affect all residents in the facility. The facility identified a census of 65.Findings are:A.Record review of a facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership with a revision date of 1/2024 revealed the following:Policy: the Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI committee, which reports its findings, actions and results to the Administrator and the governing body.Policy Interpretation and Implementation1. The Administrator, whether a member of the QAPI Committee or not, is ultimately responsible for the QAPI Program, and for interpreting its results and findings to the governing body.2. The governing body is responsible for ensuring that the QAPI Program:a. Is implemented 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 · E2026-06-09 · tag F0725 — failed to have enough nursing staff — patternProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(B)(ii)Based on record review and interview, the facility failed to ensure competencies were completed on 12 (Nurse Aide(NA) A,NA B, NA C, NA D, NA E ,Medication Aide (MA F, MA G, MA H, MA I, MA J), Licensed Practical Nurse (LPN) K and Registered Nurse (RN) L) of 12 staff reviewed. The facility identified a census of 65.Findings are:Record review of Nurse A (NA) revealed a hire date of 2/24/2026, further review revealed they had not had competencies completed since the hire date.Record review of NA B revealed a hire date of 3/18/2026 further review revealed they had not had competencies completed since the hire date.Record review of NA C revealed a hire date of 1/13/2026 further review revealed they had not had competencies completed since the hire date.Record review of NA D revealed a hire date of 4/15/2026 further review revealed they had not had competencies completed since the hire date.Record review of NA E revealed a hire date of 4/7/2026 further review revealed they had not had competencies completed since the hire date.Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-06-09 · tag F0947 — failed to train nurse aides adequately — patternEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.04(B)(ii)(1), Licensure Reference Number 175 NAC 12.006.04 (B)(iii) Based on record review and interview, the facility failed to ensure 12 hours of yearly training for 5 of 5 nurse aide/medication aids sampled and failed to ensure 5(MA F, MA G, MA H, MA I, MA J) of 5 medication aides had the required number of hours for dementia training. The facility identified a census of 65.Findings are:Record review of Medication Aid F revealed a hire date of 7/30/2020 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid F revealed they had attended dementia training with no amount of time specified.Record review of Medication Aid G revealed a hire date of 3/24/2021 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid G revealed they had attended dementia training with no amount of time specified.Record review of Medication Aid H revealed a hire date of 11/16/2021 revealed they did not have 12 hours of training in the last year. Further review of Medication Aid H…
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 before2025-11-20 · 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 12-006.18Based on observation, interview and record review, the facility failed to ensure staff followed hand hygiene procedures during the provision of peri-care (the process of washing the genitals and anal area to maintain hygiene, prevent infection and prevent skin breakdown) for 2 residents (Residents 1 and 2) of 3 residents surveyed. The facility identified a census of 68.Findings are:A record review of the facility's undated Hand Hygiene Policy revealed all staff are responsible for following hand hygiene procedures. - before and after having direct contact with a residents intact skin.- after contact with blood, body fluids or excretions, mucous membranes (a tissue that secretes mucus), non-intact skin, or wound dressings.- when hands move from a contaminated-body site to a clean body site during resident care.- before and after wearing gloves.A record review of the Infection Control Standard Precautions dated 3-20, 2024 revealed Hand Hygiene is performed 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 · Dcited before2025-11-18 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09 Based on interview and record review the facility failed to update the resident's healthcare practitioner of chest x-ray results for 1 (Resident 1) of 4 residents sampled, resulting in a delay of treatment. The facility census was 69. The findings are:Record review of Resident 1's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-25-2025 revealed the facility staff assessed the following about the resident:-was rarely able to make themselves understood. -required total assistance with toileting, bathing, transfers, dressing, bed mobility, eating and hygiene. Record review of Resident 1's progress notes dated 09-06-2025 revealed Resident 1 had audible moist sounding wheezes while breathing, had green nasal drainage and eyes were glassy. Furthermore, the note revealed the healthcare practitioner was called and an order for a chest x-ray was obtained. Record review of Resident 1's telephone orders revealed an order dated 09-06-2025 for a portable chest x-ray, 2 views STAT (urgent). 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.
- Potential for harm · Fcited before2025-07-22 · 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 12-006.18, 12-006.18 (C)Based on observation, interview, record review, the facility failed to implement a plan to mitigate the potential growth of Legionella, and failed to implement Enhanced Barrier Precautions (EBP) for Residents 8 and 61. Findings are: A. An interview on 07/22/2025 10:15 AM with the Maintenance Director (MD) confirmed no documentation of flushing holding tanks or areas that have the potential for stagnant water which could promote potential growth of Legionella. Record review of the facility policy titled “Environmental-Infection Control-Legionella Surveillance & Detection”, dated 1/2024. Legionella Surveillance and Detection Policy Statement: Our facility is committed to prevention, detection, and control of water-borne contaminants, including Legionella. Legionnaire’s disease will be included as part of our infection surveillance activities. Legionella Water Management Program Policy Interpretation: Our facility is committed to the prevention, detection,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-22 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.11(A)Based on observations, record review and interview, the facility kitchen staff failed to follow the menu serving sizes for 48 resident who have a regular textured diet. The facility staff identified a census of 63. Findings are: Record review of a undated Menu at a Glance revealed the lunch meal for 7-17-2025 was as follows:-BBQ meat balls-Smashed red potatoes-Green Beans-Corm bread with margarine-BeverageRecord review of of the Diet Spreadsheet for the 7-17-2025 noon meal revealed the following information:-Regular texture portion sizes:-BBQ meatballs, 3- 1 ounce (oz) size meat balls.-Smashed Red Potatoes, #8 scoop size.-Green Beans #8 scoop size.-Cornbread with margarine, 1 each.Observations on 7-17-2025 at 11:56 AM revealed Dietary Assistant (DA) E began serving and setting up room trays to be given to resident in their rooms or secured unit dinning room. Further observations on 7-17-2025 revealed DA E did not use dietary card (informational cards that identify diet type, portion, consistency of foods, food preferences 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 · E2025-07-22 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews; the facility kitchen staff failed to ensure foods were at temperatures that was appetizing and palatable. The deficient practice had the potential to effect all residents who eat food from the kitchen. The facility staff identified a census of 63. Findings are: Record review of the current Nebraska Food Code found at 81-2,272.01 for hot and cold holding temperatures revealed the following information:-1. Except during preparation, cooking or cooling or when time is used as a public health control, time/temperature control for safety shall be maintained.-a. At 135 degrees Fahrenheit or above, for hot foods.-41 degrees or less for cold food. Record review of of a facility grievance log from 1-1-2025 through 7-14-25 revealed the following information:-1-01-2025, Multiple Residents , resident not happy with choices for breakfast and complained of cold food.-2-17-2025, Multi resident reported food was cold when they received it in their rooms. -4-4-02-2025, resident unhappy with food. Stated it looked as if it was just thrown on the plate.-6-05-2025,…
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 24 citations
- Potential for harm · Dcited before2025-07-22 · tag F0561 — failed to honor residents' choices — isolatedHonor 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
Nebraska Licensure Reference 175 NAC 12-006.05(E)Based on interview and record review, the facility failed to evaluate resident food preferences related to religious beliefs for 1 (Resident 20) of 1 sampled resident. The facility staff identified a census of 63.The findings are:An interview on 7-16-2025 at 10:32 AM with Resident 20 revealed [gender] does not eat pork due to Seventh Day Adventist beliefs and revealed the facility staff offer meals containing pork.An interview on 7-17-2025 at 1:59 PM with the Food Services Director (FSD) revealed the facility performed a food preferences interview at the time of admission and the results of that interview are recorded on the resident's tray card. The FSD confirmed Resident 20's dietary preferences were not listed on the tray card.A record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified Resident 20 had diagnoses which included chronic obstructive pulmonary disease (COPD, pulmonary disease that is characterized by chronic typically irreversible airway…
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 before2025-07-22 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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(F)(i)(5)Based on record review and interview the facility failed to notify the resident's practitioner of omitting the administration of insulin for 3 (Residents 5, 31, and 39) of 3 residents sampled. The facility census was 63. The findings are: A. Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a score of 13 to 15 indicate a person is cognitively intact. -had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus. -was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood). -was receiving insulin injections. -required partial…
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 · D2025-07-22 · 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
Licensure Reference Number 175 NAC 12-006.05Based on record review and interview, the facility failed to provide notice of transfer in writing to the resident or resident's representative for 2 (Resident 20 & 64) of 4 residents sampled. The facility staff identified a census of 63.The findings are:Record review of facility policy entitled Transfer and Discharge from the Facility dated 1-2024 revealed: -The facility will provide proper and timely notice to a resident who will be discharged as required by regulations and laws. -C. Contents of the notice: -Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language in which is understood. -At a minimum the notice will include: -a. The reason for transfer/discharge -b. The effective date of the transfer/dischargeA.A record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified Resident 20 had diagnoses which included chronic obstructive pulmonary…
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 · D2025-07-22 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(H)(i)(3) Based on observation, interview and record review the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The facility census was 63. The findings are:Licensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation and interview the facility failed to ensure nails were trimmed for 1 (Resident 2) of 2 residents sampled. The facility census was 63. The findings are:Record review of Resident 2's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 06-11-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 4. According to the MDS Manual a BIMS score of 0-7 indicates severe cognitive impairment. -had quadriplegia (a condition characterized by paralysis of all 4 limbs and torso).-required total assistance with eating, hygiene, dressing, toileting, bathing, transfers and bed mobility. Record review of Resident 2's Comprehensive Care Plan (CCP) dated 03-06-2024 revealed 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.
- Potential for harm · D2025-07-22 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H)(vi)(2). Based on observation, interview and record review the facility failed to implement an individualized activity program for Resident 5. The findings are: Record review of Resident 5's Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident:-Brief Interview of Mental Status (BIMS) was scored as a 13. According to the MDS Manual a BIMS score of 13 to 15 indicates a person is cognitively intact. -had a diagnosis of End Stage Renal Disease (ESRD: a chronic condition where the kidneys have permanently lost most of their function and can no longer filter waste products from the blood) and Diabetes Mellitus. -was receiving hemodialysis (a treatment for ESRD that helps remove waste and excess fluid from the blood).-required partial assistance with toileting, bathing, dressing and transfers. An interview conducted on 07-16-2025 at 9:45 AM with Resident 5…
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 before2025-07-22 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Nebraska Licensure Reference 175 NAC 12-006.09(H)(iv)(5)Based on interview and record review, the facility failed to evaluate bowel function and failed to implement interventions to manage bowel function for 1 (Resident 8) of 5 sampled residents. The facility staff identified a census of 63.The findings are:Record review of Resident 8's admission Record printed 7-21-2025 revealed the facility admitted the resident on 6-21-2021 and identified Resident 8 had diagnoses which included dementia with behavioral disturbance (a usually progressive condition marked by the development of multiple cognitive deficits (such as memory impairment, aphasia [a language disorder that affects a person's ability to communicate], and the inability to plan and initiate complex behavior), hypertension (high blood pressure), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks and is accompanied by irritability, fatigue, poor concentration, sleep disturbances, weight gain or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-22 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Nebraska Licensure Reference Number 175 NAC 12-006.09(H)(v)Based on observation, interview, and record review; the facility failed to implement interventions to prevent further decrease in range of motion for 1 (Resident 20) of 1 resident sampled. The facility staff identified a census of 63.The findings are:Record review of a facility policy entitled Activities of Daily Living (ADLs) dated 1-2024 revealed: -The facility will ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. -2. The facility will provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. -Tips for improving or maintaining ADL skills: involvement of therapy or restorative nursing personnel to retrain resident.Record review of Resident 20's admission Record printed 7-17-2025 revealed the facility admitted the resident on 7-21-2021 and identified the resident had diagnoses which included pain, type 2 diabetes mellitus (a common form of diabetes mellitus that develops…
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 · D2025-07-22 · tag F0698 — failed to provide proper dialysis care — isolatedProvide safe, appropriate dialysis care/services for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09Based on record review and interview the facility failed to identify and implement a plan to manage medications for residents on dialysis services for 3 (Residents 5, 31 and 39) of 4 residents sampled. The facility census was 63. The findings are: A. Record review of the facility policy titled Special Needs dated 01-2024 revealed the following: -to address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician’s orders, the comprehensive person-centered care plan, and the resident’s goals and preferences. -this policy pertains to the following needs-dialysis -the facility will communicate relevant information with outside providers to ensure safe, continuous care of the resident. -medical conditions will be monitored and managed to prevent complications. -Registered Nurses (RN) and Licensed Practical Nurses (LPN) will participate…
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 before2025-07-22 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.10(D) Based observations, record reviews and interviews; the facility staff failed to ensure a medication error rate of less than 5%. Observations of 28 medications administered revealed 3 errors resulting in a medication error rate of 10.71%. The medication errors affected 3 (Resident 11, 22 and 37) of 7 sampled residents. The facility staff identified a census of 63. Findings are: A. Record review of a Order Summary Report (OSR) printed on 7-22-2025 revealed Resident 22's practitioner ordered a Advair Diskus inhaler (medication used to help with breathing) to be used every 12 hours on 7-14-2022. Instruction on the order was to inhale 1 puff and then to rinse the mouth after use.Observation on 7-17-2025 at 6:54 AM revealed Certified Medication Assistant (CMA) A obtained the Advair Diskus, a cup of water and went into the resident's room. CMA A handed the Advair Diskus to the resident and instructed Resident 22 to take a puff. Further observation on 7-17-2025 at 6:54 AM…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-22 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.15(A) & (B). Based on observation, interview and record review the facility failed to ensure dental services were provided for 2 (Resident 5 and 56) of 2 residents sampled. The facility census was 63. The findings are: A. Record review of the facility policy titled Dental Services Policy revealed the following: -it is the policy of this facility in order to meet the needs of the residents, to assist all residents in obtaining routine and emergency dental care to the extent covered under the State plan and 24-hour emergency dental care. -the facility will provide or obtain from an outside resource, routine and emergency dental services to meet the needs of each resident. -the facility will assist the resident with making dental appointments and arranging transportation to and from the dental service location. Record review of Resident 5’s Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 07-01-2025 revealed the facility staff assessed the following about the resident: -Brief Interview of Mental Status…
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 · D2024-11-19 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide 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 12-006.09(H)(iii)(1) Based on observations, record review and interview; the facility staff failed to implement interventions to prevent potential development of pressure ulcers for 1 (Resident 7) of 5 residents. The facility staff identified a census of 60. Findings are: Record review of a Order Summary Report (OSR) printed on 11-18-2024 revealed Resident 7 admitted to the facility on [DATE] with the diagnoses of, Pain, Hypertension and Hemiplegia (paralysis) and Hemiparesis weakness) related Cerebral Infarction (stroke) that effected the left side of the body. Further review of the OSR printed on 11-18-2024 revealed Resident 7's practitioner ordered a treatment to be completed to a wound on Resident 7's buttock/coccyx (tail bone area) three times a day. Record review of Resident 7's Minimum Data set (MDS, a federally mandated assessment tool used for care planning) dated 9-26-2024 revealed the facility staff assessed the following about the resident: -Brief interview 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 · Dcited before2024-11-19 · 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 12-006.18 Based on observations record review and interview; the facility staff failed to implement Enhanced Barrier Precaution (EBP,an infection control intervention designed to reduce transmission of resistant organisms that employs gown and glove use during high contact resident care activities) for 1(Resident 7) of 1 sampled resident. The facility staff identified a census of 60. Findings are: Record review of a Order Summary Report (OSR) printed on 11-18-2024 revealed Resident 7 admitted to the facility on [DATE] with the diagnoses of, Pain, Hypertension and Hemiplegia (paralysis) and Hemiparesis weakness) related to a Cerebral Infarction (stroke) that effected the left side of the body. Further review of the OSR printed on 11-18-2024 revealed Resident 7's practitioner ordered a treatment to be completed to a wound on Resident 7's buttock/coccyx (tail bone area) three times a day. In addition Resident 7's OSR revealed Resident 7 received tube feedings. 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.
- Potential for harm · E2024-05-23 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18B3 Based on observation and interview, the facility failed to maintain walls, floors, resident equipment, fixtures, air conditioning and ventilation covers in a clean, safe and functional manner in 7 rooms (116, 122, 123, 126, 127, 128 and 130) and in the east and west shower rooms, which had the potential to affect 55 of 64 residents that utilized those rooms. The total number occupied resident rooms was 42. The facility census was 64. Finding are: Observations on 05/20/24 between 7:30 AM and 12:30 PM revealed: - Multiple scrapes on the wall by the air conditioning unit in room [ROOM NUMBER] that has removed the painted surface leaving several dark marks. - A 1/2 inch irregular shaped opening (hole) around the air conditioner power intake cover for room [ROOM NUMBER]. - The ventilation covers in resident bathrooms were covered with a gray substance resembling dust in rooms 116,122, 123,126,127,and 128. - The left armrest on Resident 31's wheelchair was broken exposing…
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 · E2024-05-23 · tag F0761 — failed to label and store drugs safely — patternEnsure 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.12E1 Based on observations and interviews, the facility failed to ensure the east medication room was secure. This had the potential to affect 22 of 64 residents who were self-mobile and resided in the facility and 2 (Nursing Assistant A and B) of 3 unauthorized staff. Findings are: An observation on 05/23/2024 at 4:10 AM revealed the keys were in the lock of the medication storage room door on the east side of the building beside the nurses' station. The door was clearly visible by anyone who passed in the hallway. There were no staff present at the nurses' station at that time. An observation on 05/23/2024 at 4:10 AM revealed Registered Nurse (RN)-A at the end of the east hall outside room [ROOM NUMBER]. An observation on 05/23/2024 at 4:10 AM revealed Resident 27 was in a wheelchair beside the nurses' station. A record review of Resident 27's Electronic Health Record confirmed Resident 27 had a BIMS (Brief Interview of Mental Status - a federally mandated tool used 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.
- Potential for harm · D2024-05-23 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, the facility staff failed to investigate and submit their written investigation of alleged misappropriations to the state agency within 5 working days for 1 (Resident 31) of 3 residents reviewed. The facility identified a census of 64. Findings are: Record review of an Adult Protective Services (APS) report dated 1/2/24 revealed APS was notified Resident 31 alleged a family member had stolen Resident 31's Net Spend card (similar to a debit card). Record review of Resident 31's Progress Notes dated 1/02/2024 revealed the facility staff had notified APS at 11:57 AM of the allegation of Resident 31's Net Spend card being stolen. A interview on 5/22/2024 at 10:02 AM was conducted with the Director of Nursing (DON). During the interview the DON confirmed a investigation and the results of the investigation being sent to the required state agency had not been completed. Record review of a facility Policy dated 1/2024 titled Abuse Protection revealed the following information: -Misappropriation is defined as the deliberate misplacement, exploitation,…
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 · D2024-05-23 · tag F0699 — isolatedProvide care or services that was trauma informed and/or culturally competent.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.095D5 Based on interviews and record reviews, the facility failed to evaluate and implement interventions to manage triggers for 1 (Resident 7) of 1 resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). The facility staff identified a census of 64. Findings are: Record review of Resident 7's Census revealed Resident 7's admission date was 9/20/23. Record review of Resident 7's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 3/26/24 revealed Resident 7's Brief Interview of Mental Status (BIMS, a test to determine cognition) had a score of 15. According to the MDS manual a score of 13-15 indicated a person was cognitively intact. Further review of Resident 7's MDS revealed Resident 7 had the diagnosis of Post Traumatic Stress Disorder (PTSD). Record review of Resident 7's Comprehensive Care Plan (CCP) initiated on 9/20/23 revealed no indication of PTSD or interventions staff were to use to mitigate triggers for Resident 7's PTSD. Interview with Resident 7 on 5/20/24 at 9:43 AM, Resident 7…
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 before2024-01-03 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 12-006.04C3a(6) Based on record review and interview, the facility failed to ensure responsible party was notified of weight loss for 2 [Residents 1 and 3] of 4 sampled residents. The facility had a total census of 63 residents. Findings are: A. A review of Resident 1's admission record revealed Resident 1 was admitted to the facility on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage in hemisphere subcortical [stroke] and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side [paralysis on one side of the body following stroke]. Resident 1 has a legal guardian according to admission record. A review of Resident 1's admission MDS [Minimum Data Set; a comprehensive assessment used in care planning] dated 9/26/23 revealed a BIMS [Brief Interview for Mental Status] score of 9 indicating moderate cognitive impairment. A review of Resident 1's weights recorded in weight section of electronic medical record revealed a weight of 187 lbs.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-11-30 · tag F0561 — failed to honor residents' choices — isolatedHonor 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 12-006.05(4) Based on record review and interview, the facility failed to ensure baths were given according to preferences for 3 residents (Resident 57, 35 and 29) of 3 sampled residents. The facility census was 62. Findings are: A. Record review of Resident 57's Comprehensive Care Plan dated 8/14/23 revealed, Resident 57 had a functional deficit with activities of daily living (ADL) related to a femur fracture and required extensive assistance of one staff member for transfers out of the wheelchair. An interview on 11/27/23 at 11:05 AM with Resident 57 revealed, [gender] had not recieved a bath in 2 weeks. A record review of Resident 57's electronical health record (EHR) revealed, Resident 57 recieved a shower on 11/3 and a bed bath on 11/23/23. An interview on 11/30/23 at 9:35 AM with Resident 57 revealed, [gender] preferred to have a bath at least 2 times a week. A record review of Resident 57's EHR revealed, that Resident 57's daily preferences were not asessed or completed. An interview on 11/30/2023 at 4:00 PM with the facility Director 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 · Dcited before2023-11-30 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 12-006.04C3a(6) Based on record review and interview; the facility staff failed to notify the practitioner of an abnormal laboratory result for 1 (Resident 19) of 5 sampled residents. The facility staff identified a census of 62. Findings are: Record review of an Order Summary Report (OSR) printed on 11-30-2023 revealed Resident 19 was admitted to the facility on [DATE] with a diagnosis of Diabetes Mellitus. Record review of Resident 19's laboratory results dated [DATE] revealed Resident 19's A1C ( a blood test that measures your average blood sugar levels over the past 3 months) was 8.5 as compared to the reference range of 5.7 or less. Record review of Resident 19's electronical medical record revealed there was no indication Resident 19's practitioner had been notified the the laboratory results of the A1C dated 9-26-2023. On 11-30-2023 at 12:41 PM an interview was conducted with the Director of Nursing (DON) which revealed Resident 19's practitioner was not notified of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, observation and interview, the facility failed to obtain a rationale from the medical practitioner for the continued use of a psychotropic medication for 1( Resident 50) of 5 sampled residents. The facility identified a census of 62. Findings are: A record review of the Medication Regimen Review (MRR) for Resident 50 completed between 9/1/23 and 9/8/23 revealed, the facility Pharmacy Consultant gave a recommendation on 9/7/23 for the physician to give a clinical rationale to continue the use of lorazepam (a medication to treat anxiety) prn (as needed) for duration of six months. A record review of a MRR completed between 11/01/2023 and 11/8/2023 for Resident 50 revealed the Pharmacist Consultant gave a recommendation on 11/09/2023 for the physician to give a clinical rational to continue the use of as needed lorazepam. On 11/30/2023 at 12:20 PM an interview was conducted with the Director of Nursing (DON). During the interview review of the pharmacist recommendation dated 9/07/2023 and 11/09/2023 was completed with the DON. The DON confirmed during 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 before2023-11-30 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
LICENSURE REFERENCE NUMBER 175 NAC 12-006.10D Based on observation, record review and interview, the facility failed to ensure a medication error rate of less than 5%. Observation of 30 medications administered revealed 2 errors which resulted in an error rate of 6.67%. The errors affected 2 of 5 residents (Resident's 7 and 59) observed during medication administration. The facility identified a census of 62. Findings are: A. Observation on 11/30/2023 at 7:35 AM of a medication administration for Resident 7 revealed Certified Medication Assistant (CMA)-B prepared medications that included a Advair Diskus (bronchodilator) inhaler, 100/50 mcg 1 puff to be taken 2 times a day and for Resident 7 to rinse the mouth after use. CMA-B prepared the medication, including the Advair Diskus inhaler to be given to Resident 7. CMA-B after administering oral medication to Resident 7, primed and handed the Advair Diskus to Resident 7. Resident 7 inhaled the metered dose of the medication and handed the inhaler back to CMA-B. CMA-B did not have Resident 7 rinse the mouth after use. An interview 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.
- Potential for harm · D2023-11-30 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 12-007.01A Based on record review, observation and interview, the facility failed to date opened food items to prevent the potential for food borne illness. This had the potential to affect all residents in the building. The facility staff identified a census of 62. Findings are: A record review of an undated Facility Food safety Requirement policy revealed, the following; Paragraph b) #4, Proper labeling and dating of each item. An observation on 11/27/23 at 6:57 AM of 4 packages of Sysco drink mixes are open and placed in an open zip lock bag with no date of opening. 1) Sysco fruit punch drink mix, 2) Sysco Orange Drink Mix, 3) Sysco Lemonade drink Mix, 4) Sysco Grape Drink Mix. An observation on 11/29/23 at 6:05 AM of the Sysco fruit punch drink mix was open and dated 12/27/23 (a month later). Sysco orange drink mix was opened and dated 12/27/23. Malt O Meal (on spice rack) opened with no date. Hamburger buns opened and not dated. A interview on 11/29/23 at 6:10 AM with DM (Dietary Manager) revealed, that the packages were opened on 11/28/23.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-30 · tag F0847 — isolatedInform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
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(6) Based on record review and interview; the facility staff failed to ensure a Voluntary Arbitration Agreement ( According to www.alabar.org a Arbitration agreement requires that persons who signed them resolve any disputes by binding arbitration, rather than in court before a judge and/or jury) was explained and understood for 3( Resident 8, 57 and 58) of 3 sampled residents. The facility staff identified a census of 62. Findings are: A. Record review of Resident 58's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 8-20-2023 revealed Resident 58 admitted to the facility on [DATE]. Further review of Resident 58's MDS dated [DATE] revealed the facility staff assessed Resident 58 with a Brief Interview of Mental Status (BIMS) of a 7. According to the MDS [NAME] a BIMS of 0-7 indicates severe cognitive impairment. Record review of Resident 58's MDS dated [DATE] revealed the facility staff assessed Resident 58 with a BIMS of 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 before2023-11-30 · 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 12-006.17 Based on observations, record review and interview; the facility staff failed to implement interventions to prevent the spread of Covid-19 in the secured unit, this had the potential to effect 13 out of 17 residents in the secured unit), failed to sanitize a mechanical lift before resident use between 2 rooms and failed to utilize handwashing and gloving techniques to prevent the potential cross contamination from resident to resident. The facility staff identified a census of 62. Findings are; A. A record review of the list of residents who tested positive for Covid-19 revealed the following information: - Residents 24, 47 and 58, who resident on the secured unit, tested positive for Covid-19 on 11/27/2023. An observation on 11/28/2023 at 9:00 AM revealed Residents 24, and 58 have remained in their original rooms with their roommates who had tested negative for Covid-19. Observations of the dining room on 11/28/2023 at 11:15 AM revealed Resident 24 and 58 to be 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.
“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
$68,086 in federal fines across 9 penalties.
- $11,641 — penalty dated 2026-06-09
- $4,938 — penalty dated 2024-02-20
- $4,938 — penalty dated 2024-02-12
- $14,814 — penalty dated 2024-01-22
- $4,938 — penalty dated 2024-01-08
- $4,587 — penalty dated 2024-01-02
- $11,645 — penalty dated 2023-12-11
- $3,176 — penalty dated 2023-11-06
- $7,409 — penalty dated 2023-10-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to EMERALD HEALTHCARE — 14 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 | 1 of 5 | 1.3 | -0.3 vs chain |
| Health inspection | 1 of 5 | 1.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 1.8 | +1.2 vs chain |
| Quality measures | 3 of 5 | 2.0 | +1.0 vs chain |
The other 13 homes this chain runs (chain average 1.3★, 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 |
|---|---|---|---|---|
| EMERALD NURSING & REHAB LEGACY POINTE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 04/29/2022 |
| LEGACY POINTE OPCO HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 04/29/2022 |
| RUNYAN, CHERYL | Individual | W-2 MANAGING EMPLOYEE | — | since 04/29/2022 |
| CHAFETZ, YISROEL | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/29/2022 |
| WALDEN, JACOB | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | — | since 04/29/2022 |
CMS files one row per role, so the 7 rows in the source record cover these 5 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.
About 88% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.0M paid to related parties — landlords or management companies under common ownership — equal to about 26% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285239. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-22, 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.