Wayne Countryview Care and Rehabilitation
811 East 14th Street, Wayne, NE 68787 · For profit - Limited Liability company · 60 certified beds · (402) 375-1922 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has a citation for mishandling residents’ money or property (F0565)
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure 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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 2 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 2 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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 | 12.8% | 19.0% | 15.4% | better |
| Long-stay residents who lose too much weight | 9.8% | 5.1% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.9% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.2% | 2.8% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 6.2% | 4.3% | 6.5% | typical |
| 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 | 2.9% | 4.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 16.0% | 18.2% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 20.8% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.2% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 28.1% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 32.3% | 20.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 5.7% | 2.0% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 44.4% | 75.9% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.5% | 20.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 13.2% | 11.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.62 | 1.81 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.89 | 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.
36.0% 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 34 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.45 therapist hours per resident per day in 2026Q1 — more than 76% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| 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 | 36.0%CMS range 22.3–52.5 | 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 | 11.0%CMS range 7.5–16.4 | 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 | 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 | 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 | 0.0% | 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 | 4.3% | 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 | 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 | 1.12 | 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 60 beds and averages 43.8 residents a day — about 73% occupied, or roughly 16 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 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.42 hrs/resident/day on weekends vs 3.98 on weekdays — 14% thinner on weekends. RN hours go from 0.36 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 10 most serious are shown; the remaining 13 are one tap away and print in full.
- Potential for harm · Ecited before2026-01-28 · 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, record review, and interviews; the facility failed to reassess and to put interventions in place to prevent potential elopement for 1 (Resident 33) and failed to prevent the potential for burns related to hot water temperatures in resident handwashing sinks. Six out of 35 facility resident rooms had water temperatures that exceeded 120 degrees. The sample size was 20 and the facility census was 41. Findings are: A. Review of the undated facility policy Water Temp revealed the facility tested water temperatures by letting the water run for 3-5 minutes and inserting a thermometer probe into the stream of running water all while holding the testers hand under the water to assess how the water felt on skin. Temperature checks were performed at various locations throughout the facility. There was no evidence at what temperature the water was considered acceptable or how often the temperature checks were performed. On 1/25/26 between 8:00 AM 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 · D2026-01-28 · 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 Licensure Reference Number 175 NAC 12-006.09(G)(ii)(iii)Based on record review and interviews, the facility failed to complete a comprehensive discharge summary including a recapitulation of care and reconciliation of medications for 1(Resident 43) and failed to notify the State Ombudsman of discharges for 2 (Resident's 43 and 45) of 4 sampled residents. The facility census was 41.0 Findings are: A. Review of the facility policy Criteria for Transfer and Discharge with a revision date of April 2025 revealed the following: -The facility would not transfer or discharge a resident unless appropriate criteria existed. -The transfer and/or discharge were documented in the resident record and appropriate information was communicated to the receiving provider. -The physician signed a discharge summary when a resident was discharged or transferred and the summary included a post discharge plan of care, indication of where the resident would reside, any arrangements for follow up care, and any post-discharge medical 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 · Dcited before2026-01-28 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(i)(3) Based on observations, record review, and interview; the facility failed to provide timely eating assistance for Residents 33 and 19. The sample size was 2 and the census was 41. Findings are: A. Review of Resident 33's Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 11/24/25 revealed the resident was admitted on [DATE] with diagnoses of Alzheimer's dementia, malnutrition, coronary artery disease, and high blood pressure. The assessment identified the following:-cognition was severely impaired;-partial/moderate assistance was provided by staff with dietary intakes; and-weight of 100 pounds (lbs.). During the breakfast meal service on 1/25/26 the following was observed related to Resident 33:-8:34 AM was seated at a table in the dining room for residents who required assistance with eating. The resident was served a glass of milk and juice, a bowl with hot cereal, and a plate with a biscuit and scrambled eggs. Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(J)(i) Based on observations, record review, and interview; the facility failed to implement weight loss interventions for Resident 33. The sample size was 4 and the facility census was 41. Findings are: A. Review of the facility policy Nutrition Status Management with a revision date of 4/2025 revealed it was the policy of the facility to assess each resident's status and needs, including medications and medical conditions to ensure that all residents maintained an acceptable parameter of nutritional status unless the resident's clinical condition demonstrated this was not possible. The following procedure was identified:-each resident's nutritional status was assessed at admission and at least quarterly afterwards.-dietary evaluations were to include determination of ideal body weight range, usual body weight, current diet, percentage of food eaten, possible dental problems, current illness, likes and dislikes, and any other change in medical condition that may impact weight loss.-if there was a significant change in the 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 · Dcited before2026-01-28 · 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 12-006.17Based on observations, record review, and interview; the facility failed to perform hand hygiene at appropriate intervals and to utilize the required Personal Protective Equipment (PPE) when providing management/care of Resident 39's catheter. The sample size was 2 and the facility census was 41.Findings are:A. Review of the Hand Hygiene policy with a revision date of 12/2025 revealed it was the policy of the facility to provide the necessary supplies, education, and oversight to ensure healthcare workers performed hand hygiene based on accepted standards. Hand hygiene was identified as one of the most effective measures to prevent the spread of infection. Staff were to perform hand hygiene when:-hands were visibly soiled.-before and after coming on duty.-before and after direct contact with residents.-before preparing or handling medications.-before and after handling an invasive device (urinary catheter).-before handling clean or soiled dressings, gauze pads.-before…
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 · F2024-10-16 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.04(B)(ii)(3) Based on record review and interview: the facility failed to employ a qualified Dietary Manager (DM). This had the potential to affect food service provided to all residents who were served food from the kitchen. The total sample size was 26 and the facility census was 34. Findings are: A. Review of the facility Job Description: Dietary Manager dated 12/27/2021 revealed the DM would direct the overall operation of the Dietary Department in accordance with current applicable federal, state, local standards, guidelines, and regulations, governing the facility. The DM was to assure that quality nutritional services would be provided daily, and the dietary department would be maintained in a clean, safe, and sanitary manner. Duties and Responsibilities of the DM included: -Plan, develop, organize, implement, evaluate, direct the dietary department, programs, and activities. -Coordinate dietary services and activities with other related departments -Receive scheduled consultations from a qualified dietitian/nutritional professional.…
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 · F2024-10-16 · 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 12-006.11E Based on observations, record review and interview; the facility failed to maintain the kitchen in a clean and sanitary manner and failed to maintain food temperatures to prevent the potential for food borne illness. This had the potential to effect all residents who ate food from the kitchen. The facility census was 34. Findings are: A. Review of the undated Monthly and Daily Cleaning Checklist for the cooks and aides revealed the Cooks and Aides had cleaning duties daily and monthly for day and night shift. B. The Dietary Safety and Sanitation Audit Completed by the Registered Dietitian, (RD), on 10/8/24, revealed the following: -Dry storage area floor was a bit dirty. -Spills were noted down the front and sides of the steam table. -The shelf below the steam table was dusty/dirty, containers were dirty inside and out. -Floors in the kitchen remained dirty throughout. C. An observation on 10/09/24 at 8:29 AM revealed the following: -Noted dried on foods to the side and front of the stove and dried on foods to the back wall behind 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 · Fcited before2024-10-16 · 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 12-006.18(B)(C)(D) Based on observation, interview, and record review; the facility failed to implement the required Personal Protective Equipment (PPE- items such as gowns, gloves, face shield that are worn to protect care givers during the provision of care and to protect other residents from being exposed to potential harmful communicable disease/s) during the provision of care for Residents 12 and 235, failed to implement a mitigation plan to prevent potential water borne illness, failed to place a protective barrier for medications taken to resident care areas and then returned to the medication cart after use for Resident 21, failed to complete hand hygiene during the administration of medications and the delivery of room trays, and failed to store oxygen equipment in a manner to prevent potential cross-contamination for Resident 85. Findings are: A. Review of the facility policy Infection Control Prevention and Control Program dated 9/2017 revealed the facility had a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-10-16 · 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 12-006.19(A) Based on observation and interview; the facility failed to ensure a clean, comfortable, and homelike environment. The facility census was 34. Findings are: During the course of the survey from 10/9/24 through 10/16/24 the following was observed: -on 10/9/24 at 12:30 PM multiple stained and sagging ceiling tiles were observed in the hallway entrance adjacent to the south side of the dining room. In addition, the same hallway had a 10-to-12-foot pitted and chipped line in the dry wall on the east wall. -on 10/10/24 at 9:10 AM the dry-wall adjacent to Resident 1's bed in room [ROOM NUMBER] was gouged open approximately 1 inch by 24 inches. -on 10/10/24 at 9:20 AM multiple rooms in the center hallway (hall 400) were noted to be soiled and have carpet stains in rooms [ROOM NUMBER]. The threshold to room [ROOM NUMBER] was taped down with a red colored industrial tape. During an environmental tour on 10/10/24 the following was noted: -Door frames throughout the facility…
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 · E2024-10-16 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 12-006.19 Based on observations, record review and interviews: the facility failed to maintain a pest free environment in Resident 235's Room and the facility kitchen. The total sample size was 26 and the facility census was 34. Findings are: A. Review of the facility Pest Control Policy dated 2007 revealed the facility had measures in place to maintain pest control in the facility and outer areas of the facility. The facility had a contract with a pest control company to do monthly scheduled inspection for pest and rodent control. B. During an interview with Resident 235 on 10/9/24 at 1:34 PM, resident stated there were tiny black bugs in the bathroom in the little basin by the sink. C. An observation on 10/9/24 at 1:37 PM revealed tiny black bugs were in resident 235 toothbrush basin, some of the bugs were moving around. An observation on 10/10/24 at 7:46 AM, noted a yellow basin in the bathroom with tiny black bugs, none of the bugs were moving. An observation on 10/10/24 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 13 citations
- Potential for harm · D2024-10-16 · tag F0554 — isolatedAllow residents to self-administer drugs if determined clinically appropriate.
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(A)(i) Based on observations, record review and interview; the facility staff failed to evaluate Resident 85 for the ability to self-administer medications and to ensure security of medications. The total sample size was 26 and the facility census 34. Findings are: A. Review of the facility policy Self-Administration of Medications with a revision date of 5/23 revealed it was the policy of the facility to respect the wished of alert, competent residents to self-administer prescribed medications as allowable under state regulations. The following procedures were to be followed: -upon admission, alert residents were to be informed of their right to self-administer medications. -if a resident would desire to participate in self-administration, the interdisciplinary team would then assess the resident and then periodically re-evaluate as needed. -if a resident is a candidate for self-administration of medications, this will be indicated in the resident's medical 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 · Dcited before2024-10-16 · 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)(1) Based on observations, record review and interview; the facility failed to provide toileting assistance and incontinence management for Resident 13 who required assistance with activities of daily living. The facility census was 34 and the sample size was 2. Findings are: A. Review of the facility policy Incontinent Care dated 5/2007 revealed it was the policy of the facility to provide a dry and odor free perennial care system. The policy indicated the residents were to be checked at least every 2-3 hours for incontinence. B. Review of Resident 13's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 9/10/24 revealed diagnosis of diabetes, anemia, non-Alzheimer's dementia, anxiety, and depression. The same assessment indicated the resident's cognition was severely impaired, the resident was dependent with toileting hygiene, transfers and personal hygiene and indicated the resident was always incontinent of bowel and bladder. Review of Resident 13's current Care Plan 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 · D2024-10-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on observations, interview, and record review; the facility failed to follow Resident 85's physician order regarding a fluid restriction. The sample size was 1 and the facility census was 34. The findings are: A. Review of the facility policy Fluid Restriction with a revised date of 5/2007 revealed it was the policy of the facility to provide fluids as specified by the physician order. The following procedures were identified: -nursing was to notify dietary department of the parameters ordered for the resident's fluid restriction to include the minimum and maximum allowance. -the Dietary Manager (DM) was to divide the allotted total fluid amount for dietary among the daily meal pattern and enter the specified amounts in the resident's diet card. -nursing was to document fluid restrictions with the resident's intake and outputs on the Medication Administration Record (MAR). -the resident was to be educated regarding benefits/risks of compliance/noncompliance 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 · D2024-10-16 · 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
LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview; the facility failed to monitor a dialysis (a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood) access site for 1 (Resident 85) of 1 resident. The facility staff identified a census of 34. Findings are: A. Review of the facility policy Renal Dialysis, Care of Resident with a revision date of 6/09 revealed the following guidelines in the care of the resident on renal dialysis. -access site to be checked for condition, bruit (whooshing sound heard near the site with a stethoscope) and thrill (a thrill or buzz like vibration caused by blood flowing through the fistula) every shift. -physician to be notified of any complications. -blood pressures and venous punctures not to be performed on the extremity with the access site. -staff to prevent, identify and manage potential complications. B. Review of the resident's admission orders dated 10/8/24 revealed the resident was to receive renal dialysis 3 times a week on Mondays, Wednesdays, 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 · D2024-10-16 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure insulin pens were dated when opened for Residents 5 and 21. The sample size was 5 and the facility census was 34. Findings are: Review of the facility policy Proper Insulin Pen Administration, undated revealed the following: -staff were to document an open date on the insulin pen, -a new safety pen needle would be screwed or clicked on, -the needle would be primed with 2 units of insulin to remove any air, -the dial would be turned to the number of insulin units needed, -the needle would be inserted into the skin and the button pressed to deliver the dose, -the pen would be held at the injection site for 10 seconds (allowing the full dose to be injected), then removed, and -the used pen needle would be removed for proper disposal in a sharp's container. Review of Resident 21's medication orders active as of 10/15/24 revealed an order for Basaglar (a long-acting insulin) at bedtime and Novolog (short-acting) insulin with meals (3 times per day) both…
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 · D2024-01-22 · 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 12-006.04C3a(6) Based on record review and interview; the facility failed to notify Resident 2's physician for an ongoing weight loss. The sample size was 3 residents. The facility census was 40. Findings are: Review of the facility policy Significant Weight Loss/Gain, undated revealed the facility would monitor resident's weights monthly, identify weight loss/gain or potential weight loss/gain and determine if interventions were necessary to avoid further weight loss/gain, the Dietary Manager would address significant weight changes with the stand-up team, and notify the physician with any recommendations. Review of the facility policy Notifications, Physician, or Responsible Parties, last revised 7/19 revealed that the facility would notify the resident's attending physician of changes in condition/status which included a significant change in the resident's physical, mental or psychosocial status, if there was a need to alter the resident's treatments significantly, when 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 · E2023-10-05 · tag F0565 — failed to support the resident council — patternHonor the resident's right to organize and participate in resident/family groups in the facility.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.06B Based on record review and interview; the facility failed to address food grievances to prevent sustained further resident concerns. The sample size was 16 and the facility census was 40. Review of the facility policy titled Grievances last revised 6/6/22 revealed the following: -the Grievance Official (GO) evaluated and investigated the concerns and would take immediate action to resolve the concern and prevent further potential violations of resident rights, -the Grievance Official or designee would respond to the individual expressing concern within 3 working days of the initial concern, and -the Grievance Official would take appropriate corrective action and contact all parties with the outcome. Review of the facility form titled Grievances revealed the following food concerns: January 2023: - 1/5/23: The resident stated they did not receive breakfast or lunch. The solution was that the resident's tray was made and was not delivered. The resident was encouraged to go to the dining room for meals and speak up if did not receive a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-10-05 · tag F0678 — failed to provide CPR when needed — patternProvide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
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 Based on interview and record review; the facility failed to have staff who were trained and certified in Cardiopulmonary Resuscitation (CPR-emergency procedures performed if a person stops breathing or their heart stops) for transportation of residents identified as having a full code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive) status. This had the potential to affect 3 (Residents 19, 33 and 2) sampled residents identified as having a full code. The facility census was 40. Findings are: A. Review of the facility policy Cardiopulmonary Resuscitation with a revision/review date of 1/22 revealed it was the policy of this facility to provide Basic Life Support (BLS) including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of advanced directives or a Do Not Resuscitate (DNR) order. Only staff members with current CPR…
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 · E2023-10-05 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11D Based on observation, record review, and interview; the facility failed to serve food at palatable temperatures. The sample size was 16 and the facility census was 40. Findings are: A. Review of the facility policy titled Food, Reheating and Cooling during Tray Line, last revised 2/15/17 revealed the temperature of the food when the resident received it is based on palatability and the goal was to serve cold food cold and hot food hot. The recommended temperature of food at delivery to the resident was to be at the following temperatures: -cold entrée: less than or equal to 50 degrees, -fruit or cold dessert: less than or equal to 50 degrees, -salads: less than or equal to 45 degrees, -hot entrée: greater than or equal to 120 degrees, -waffles/pancakes, french toast: greater than or equal to 120 degrees, -starch: greater than or equal to 120 degrees, and -vegetables: greater than or equal to 140 degrees. B. Review of the facility form Food Temperature Log from 9/23…
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 · Ecited before2023-10-05 · tag F0880 — failed to prevent and control infections — patternProvide 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 observation, record review, and interview the facility failed to ensure hand hygiene was completed to prevent the potential spread of infection for Residents 9,12,23, and 25, test Resident 17 when signs and symptoms of COVID-19 were present and failed to wear the appropriate Personal Protective Equipment (PPE) during care for Resident 9. The sample size was 14 and the facility census was 40. Findings are: A. Review of the facility policy Infection Prevention and Control Program with a revision date of 7/2023 revealed the following; -The infection prevention and control program was a facility wide effort involving all disciplines and individuals, and was an integral part of the quality assurance and performance improvement program, -The elements of the infection prevention and control program consisted of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health, -The program…
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 before2023-10-05 · 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 12-006.09D7(a) (b) Based on observation, interview and record review; the facility failed to implement interventions for the prevention of ongoing falls for Resident 26. The sample size was 5 and the facility census was 40. Findings are: A. Review of the facility policy Fall Prevention with a revision date of 5/23 revealed it was the policy of the facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls to minimize the potential for injury. B. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/15/23 revealed the resident was admitted [DATE] with diagnoses of Alzheimer, Non-Alzheimer's dementia, anxiety and depression. The assessment indicated the following regarding the resident; -severe cognitive impairment; -required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene;…
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 before2023-10-05 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-005.09D8b Based on observations, interview and record review; the facility failed to provide/implement interventions to prevent weight loss for 1 (Resident 26) of 1 sampled resident. The facility census was 40. Findings are: A. Review of a facility policy titled Nutrition Status Management with a revision date of 1/22 revealed the facility was to ensure all resident's maintained acceptable parameters of nutritional status. The facility staff were to define and implement measures to improve nutritional status. Staff were to monitor and evaluate the resident's responses or lack of response to revise or discontinue the approaches as appropriate or justify the continuation of current approaches. B. Review of Resident 26's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 8/15/23 revealed the resident was admitted [DATE] with diagnoses of Alzheimer, Non-Alzheimer's dementia, anxiety and depression. The assessment indicated 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 · D2023-10-05 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to attempt a gradual dose reduction of Resident 12's antipsychotic (medication used to treat a psychotic disorder) medication or have a documented contraindication, and failed to ensure Resident 34's as needed antianxiety medication was limited to 14 days or had renewed orders. The sample size was 5 and the facility census was 40. Findings are: A. Review of the facility policy Psychotropic Drug Use dated 8/2017 revealed the following; -It was the policy of the facility to ensure that residents who had not used psychotropic (drugs that affect a person's mental state) drugs were not given unless the medication was necessary to treat specific conditions as diagnosed and documented in the clinical record. -The facility would ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue those drugs. 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.
“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
No federal fines in the current CMS record.
Part of a chain
This home belongs to THE ENSIGN GROUP — 342 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 | 3 of 5 | 3.2 | -0.2 vs chain |
| Health inspection | 3 of 5 | 2.8 | +0.2 vs chain |
| Staffing | 2 of 5 | 2.7 | -0.7 vs chain |
| Quality measures | 2 of 5 | 4.4 | -2.4 vs chain |
The other 341 homes this chain runs (chain average 3.2★, per CMS)
Showing 40 of 341; lowest-rated first.
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 | Since |
|---|---|---|---|
| DOBBINS, MELISSA | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2017 |
| HELENTHAL, TARA | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/08/2018 |
| JORGENSEN, DAVID | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| BURNAM, SOON | Individual | CORPORATE OFFICER | since 07/18/2011 |
| KEETCH, CHAD | Individual | CORPORATE OFFICER | since 03/01/2011 |
| SATO, AMI | Individual | CORPORATE OFFICER | since 09/09/2024 |
| HELPING HANDS NURSING SOLUTION INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/18/2011 |
| ONSHIFT INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/18/2011 |
| TWOMAGNETS LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | since 07/18/2011 |
| PORT, BARRY | Individual | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | since 07/09/2025 |
| CARETRUST GP LLC | Organization | ADP OF THE SNF | since 07/18/2011 |
| CARETRUST REIT INC | Organization | ADP OF THE SNF | since 07/18/2011 |
| CTR PARTNERSHIP LP | Organization | ADP OF THE SNF | since 07/18/2011 |
| ENSIGN SERVICES INC | Organization | ADP OF THE SNF | since 06/01/2011 |
| WAYNE HEALTH HOLDINGS LLC | Organization | ADP OF THE SNF | since 07/18/2011 |
CMS files one row per role, so the 20 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
8 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 $495K 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 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 285135. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-28, 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.