Gold Crest Retirement Center
200 Levi Lane, Adams, NE 68301 · Gage County · (402) 988-7115
52 certified beds, about 37 residents a day · Non profit - Other · Medicare and Medicaid since 1984
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
4 of 5
Staffing
1 of 5
CMS note: This facility reported a high number of days without a registered nurse onsite.
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 285065 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 12, 2025, inspectors cited 3 health deficiencies (the Nebraska average is 7.4, the national average 9.2).
None of its 12 health citations since May 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 0.64 hours per resident per day, against 3.98 across Nebraska and 3.86 nationally. Registered nurses accounted for 0.00 of those hours.
66.7% of nursing staff left within the year CMS measured (Nebraska average 48.7%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
305/23
110/23
504/24
303/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
6E
0F
Potential for minimal harm
0A
0B
0C
March 12, 2025Standard inspection · 3 citations
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(i)(3) Based on record review, observations, and interviews, the facility failed to provide oral cares for 4 (Residents 4, 18, 2, and 6) of 16 residents sampled. The facility census was 41 at the time of survey.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.12(D)(i) Based on interview, observation, and record review the facility failed to secure all medications in a locked storage area and to limit access only to authorized personnel. The facility identified a census of 41 Observation on 3/06/25 at 8:40AM revealed the treatment cart sitting in hallway in front of open door stating Drug on it. Treatment Cart was open and able to view insulin supplies in second drawer. Stood at side of Treatment Cart and open door for 6 minutes. Director of Nursing (DON) walked to treatment cart and open door marked Drug. Interview on 3/06/25 at 8:48 AM with DON stated, the Treatment Cart and the door marked Drug should be locked. Observation on 3/06/25 at 8:52 AM revealed Registered Nurse (RN-F) walked to the treatment cart from the 100 hall. [...]
- E Provide and implement an infection prevention and control program.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 1-005.06(D) Based on observations, interviews and record reviews the facility failed to ensure that staff follow principles of infection control and prevention through hand hygiene, glove use, use of personal protection equipment (PPE) and cleaning of equipment between residents. This affected 7 (Residents 1,8,9,16,27,35,39) out of 8 residents sampled. The facility identified a census of 41.
April 2, 2024Standard inspection · 5 citations
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09C1c Based on observations, interviews, and record reviews, the facility failed to revise the Care Plan ( written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) regarding a CPAP (Continuous Positive Airway Pressure -- a treatment that uses mild air pressure to keep your breathing airways open) for Resident 10, a pressure injury (injuries to the skin and the tissue below the skin that are due to pressure on the skin for along time) for Resident 4, and falls for Resident 21. This affected 3 of 12 residents reviewed for care plan revision. The facility census was 42.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04C3a(6) Based on record reviews and interviews, the facility failed to notify Resident 4's physician of a deterioration in condition of a pressure injury (localized damage to the skin and underlying tissue due to prolonged pressure to the area.) This affected 1 of 3 residents sampled for pressure injuries. The facility census was 42.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interviews, the facility failed to ensure the accuracy of the Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities) regarding oxygen for Resident 4 and falls for Resident 21. The affected 2 of 12 residents reviewed for MDS accuracy. The facility census was 42.
- D Ensure a qualified health professional conducts resident assessments.
Inspectors wroteBased on record review and interview, the facility failed to ensure that a Discharge Minimum Data Set (MDS- a comprehensive assessment of each resident's functional capabilities. A Discharge MDS is a subset of information completed when a resident is discharged from a facility) was certified as complete for Resident 41 upon discharge from the facility. This affected 1 of 13 residents reviewed for MDS completion. The facility census was 42.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D6 Based on observation, record review, and interviews, the facility failed to ensure oxygen tubing was changed as required and stored in a manner to prevent cross-contamination for Resident 4. This affected 1 of 1 residents reviewed for oxygen. The facility census was 42.
October 23, 2023Complaint inspection · 1 citation
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.02 Based on record review and interview, the facility failed to report an elopement of 1 (Resident 1) of 1 sampled resident. The facility identified a census was 46.
May 25, 2023Standard inspection · 3 citations
- E Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(5) Based on record reviews and interviews, the facility failed to provide written notice of transfer to the resident and/or resident representative upon transfer to the hospital for Residents 10, 20 and 39. This affected 3 of 3 residents sampled for hospitalization. The facility census was 39.
- E Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference 175 NAC 12-006.17D Based on observation, record review, and interviews, the facility failed to prevent the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) during medication pass for 1 Resident (5) of 6 observed for medication pass, during catheter care and perineal (peri) care (cleaning the private areas of a resident) for 1 Resident (10) of 2 sampled for catheters, and during wound care for 1 Resident (20) of 4 sampled for wound care. The facility census was 39.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04C3a(6) Based on record review and interview the facility failed to notify the resident representative and physician of a change in condition for 1 of 1 sampled residents (Resident 20). The facility identified a census of 39. Findings Are: Interview on 5/22/23 at 2:12 PM with Resident 20's representative stated it was reported that on 5/13/23 night, Resident 20 went unresponsive for 40 minutes and Resident 20's representative was not notified from the facility and had found out from Resident 20's represenative newphew's wife. Resident 20's representative voiced that this had happened another 2 times and the representative had not been notified until this time. [...]
Fire safety inspections
19 fire safety citations on file: 7 on March 12, 2025, 6 on April 2, 2024, 6 on May 25, 2023.
Every fire safety citation19 citations
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- F Meet other general requirements that are deficient.
- F Have simulated fire drills held at unexpected times.
- F Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- F Ensure that testing and maintenance of electrical equipment is performed.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- F Meet other general requirements that are deficient.
- F Have simulated fire drills held at unexpected times.
- F Ensure proper usage of power strips and extension cords.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- F Implement emergency and standby power systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Install corridor and hallway doors that block smoke.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure proper usage of power strips and extension cords.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Nebraska | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 0.64 | 3.98 | 3.86 |
| Registered nurses | 0.00 | 0.67 | 0.69 |
| All nursing staff on weekends | 0.68 | 3.48 | 3.42 |
| Nurse aides | 0.58 | ||
| Licensed practical nurses | 0.06 | ||
| Nursing staff turnover (share who left in a year) | 66.7% | 48.7% | 45.8% |
| Registered nurse turnover | 50.0% | 44.1% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.24 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 0.63 on weekdays and 0.68 on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 100.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.61 in April to June 2025 to 0.64 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 0.64 | 0.00 | 0.63 | 0.68 | 100.0% | 90 of 90 | 37 |
| Oct to Dec 2025 | 4.51 | 1.03 | 4.72 | 3.98 | 7.5% | 1 of 92 | 33 |
| Jul to Sep 2025 | 4.01 | 0.86 | 4.22 | 3.47 | 13.1% | 0 of 92 | 36 |
| Apr to Jun 2025 | 3.61 | 0.71 | 3.85 | 3.01 | 18.9% | 0 of 91 | 37 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Nebraska, Jan to Mar 2026 | 4.01 | 0.66 | 4.21 | 3.53 | 7.1% | 1.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Nebraska | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 17.8 | 19.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.7 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 5.5 | 2.8 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.3 | 4.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 4.9 | 2.0 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 28.9 | 18.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.5 | 4.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 9.9 | 20.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 17.0 | 20.7 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 0.0 | 11.4 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.9 | 1.8 |
Owners and operators
Legal business name: COFFMAN-LEVI CHARITABLE TRUST, INC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Fritzen, Jeffrey | W-2 managing employee | Individual | 03/06/2010 | |
| Fritzen, Jeffrey | Corporate director | Individual | 03/06/2010 | |
| Gramann, Henry | Corporate director | Individual | 10/30/2009 | |
| Gramann, Henry | Corporate officer | Individual | 01/01/1996 | |
| Hershberger, Susan | Corporate officer | Individual | 01/01/2007 | |
| Siefkes, Wes | Corporate officer | Individual | 02/04/2013 | |
| Sutter, Ronald | Corporate officer | Individual | 05/07/1984 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on April 2, 2024: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 3 problems in this area, most recently on April 2, 2024: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 2 problems in this area, most recently on March 12, 2025: "Provide care and assistance to perform activities of daily living for any resident who is unable."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on March 12, 2025: "Provide and implement an infection prevention and control program."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 0.68 hours per resident per day, below the Nebraska average of 3.48.
Other nursing homes nearby
- Beatrice Health and Rehabilitation Beatrice, 16.3 mi · 5 of 5 stars · 10 citations
- Good Samaritan Society - Beatrice Beatrice, 16.9 mi · 3 of 5 stars · 14 citations
- Southlake Village Rehabilitation & Care Center Lincoln, 19.6 mi · 5 of 5 stars · 6 citations
- Eventide Williamsburg Lincoln, 22.1 mi · 5 of 5 stars · 8 citations
- Emerald Nursing & Rehab Brookside LLC Lincoln, 22.6 mi · 1 of 5 stars · 44 citations
- Hillcrest Firethorn Lincoln, 22.7 mi · 4 of 5 stars · 12 citations
- Good Samaritan Society - Syracuse Syracuse, 22.9 mi · 4 of 5 stars · 9 citations
- Heartland Ridge Care Center Lincoln, 23 mi · 2 of 5 stars · 21 citations
Nebraska contacts for a concern about a nursing home
These are the official offices in Nebraska. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Nebraska Department of Health and Human Services, Licensure Unit, Long Term Care Facilities, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Nebraska Long-Term Care Ombudsman Program, (800) 942-7830. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
Common questions
- What is Gold Crest Retirement Center's Medicare star rating?
- CMS rates Gold Crest Retirement Center 3 out of 5 stars overall, with 4 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Gold Crest Retirement Center get at its last inspection?
- 3 health deficiencies at the standard inspection on March 12, 2025. The Nebraska average is 7.4.
- Has Gold Crest Retirement Center been fined?
- CMS lists no fines in the last three years.
- Does Gold Crest Retirement Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Gold Crest Retirement Center?
- CMS lists 7 owners and managers. Legal business name: COFFMAN-LEVI CHARITABLE TRUST, INC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.