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.
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 41 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
33D
3E
2F
Potential for minimal harm
0A
0B
1C
March 10, 2026Complaint inspection · 1 citation
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteBased on record review and interview, the facility failed to ensure discharge planning was completed for 1 resident (Resident 1) of 4 residents surveyed. The facility claimed a census of 44. A record review of the Facility Discharge Planning Process dated 5/6/2019 and revised 8/18/2022, revealed the following:The discharge planning process will address each resident's discharge goals and needs, including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan. ProcedureIdentify the resident's needs and goals regarding discharge upon or as soon as practicable after admission. The discharge plan is incorporated into the interdisciplinary care plan. [...]
November 19, 2025Complaint inspection · 2 citations
- G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09 (H)(iii)(2). Based on observation, interview and record review, the facility failed to implement treatment and interventions to promote healing and prevent new pressure ulcers for 1 (Resident 3) of 1 residents sampled. The facility census was 94.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(vi)(3) and 12-006.09(J). Based on observation, interview and record review the facility failed to ensure a tube feeding was running continuously for 1 (Resident 2) of 3 residents sampled and failed to provide treatment to a feeding tube insertion site according to the practitioner's orders for 1 (Resident 7) of 3 residents sampled. The facility census was 94.
September 15, 2025Standard inspection, Complaint inspection · 10 citations
- F
Post nurse staffing information every day.
Inspectors wroteBased on record review and interview, the facility failed to ensure that the posted nurse staffing information contained the required information related to the total number of actual hours worked per discipline. This had the potential to affect all residents that resided in the facility. The facility staff identified a census of 98. Record reviews of 30 days of past posted nurse staffing between 8/10/25 and 9/10/25 revealed the daily posted nurse staffing did not contain the total number of actual hours worked for the different types of staff. An interview on 9/15/25 at 1:02 PM with the facility Administrator confirmed the nurse staff posting information did not contain the total number of actual hours worked per discipline and that the hours had not been calculated or documented on the posted nurse staffing and should have been.
- E
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)Based on interview and record review, the facility failed to ensure behavior monitoring was completed for 1 (Resident 28) who received a psychotropic medications (drugs that alter mental processes, emotions, and behavior), failed to monitor for side effects for 1 (Resident 54) who received Depakote (a drug used to treat bipolar disorder, seizures, and prevent migraines) and Lexapro (a drug used to treat depression and anxiety), failed to ensure a sleep diary or test was completed for 1 (Resident 28) who received Zolpidem Tartrate (Ambien, a drug used to treat sleep disorders), failed to ensure as needed (PRN) antipsychotic medications (drugs used to treat mental health conditions) had a stop date of 14 days after first issuance for 1 (Resident 30), and failed to perform baseline and ongoing Abnormal Involuntary Movement Scale (AIMS) testing [...]
- D
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(G) Based on interview and record review, the facility failed to complete a discharge plan for 1 (Resident 102) of 2 sampled residents. The facility census was 98.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.06(A) Based on interview and record review, the facility failed to provide a bed hold policy to 3 (Residents 7, 100, and 111) of 3 sampled residents on hospital transfer and failed to notify the State Long term Care (LTC) Ombudsman (an official appointed to investigate individuals complaints) of a facility-initiated transfer on 3 (Residents 7, 100, and 111) of 3 sampled residents. The facility census was 98.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on observation, interview and record review the facility failed to accurately code the Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) for 1 (Resident 13) of 1 residents sampled. The facility census was 98.
- D
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 12-006.09(F)(iii)Based on record review and interview, the facility failed to revise the comprehensive care plan related to fluid restriction for 1 (Resident 1) of 22 residents sampled. The facility staff identified a census of 98.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview the facility failed to complete neurological evaluations after an unwitnessed fall for 1 (Resident 71) of 3 residents sampled. The facility census was 98.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent the potential for accidents on 2 (Residents 9 and 111) of 7 sampled residents. The facility census was 98.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to monitor lab values related to thyroid medication for 1 (Resident 30) of 5 residents sampled and failed to hold blood pressure medication when the blood pressure was outside of parameters for 1 (Resident 71) of 5 residents sampled. The facility census was 98.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of 5% or less as evidenced by 2 medication administration errors out of 25 opportunities for error, resulting in an error rate of 8%. The facility census was 98.
June 11, 2025Complaint inspection · 3 citations
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview the facility failed to provide a report to the receiving healthcare institution after an emergent transfer from the facility for 2 (Resident 1 and 3) of 4 residents sampled. The facility census was 95.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.04 Based on record review and interview the facility failed to train licensed staff on an external cardiac defibrillator, prior to providing care to 1 (Resident 1) of 1 residents sampled. The facility census was 95.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure Reference Number 175 NAC 1-005.06(E & F), 12-006.18(B) Based on observation, interview and record review the facility failed to utilize contact precautions for 1(Resident 2) of 3 residents sampled and failed to utilize enhanced barrier precautions for 2 (Resident 3 and 4) of 2 residents sampled. The facility census was 95.
March 17, 2025Complaint inspection · 3 citations
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wrote175 NAC 12-006.09(H)(vi)(3)(a) Based on observation, interview and record review the facility failed to administer enteral tube feedings and water flushes according to the practitioner's orders for 1 (Resident 5) of 1 residents sampled. The facility census was 99.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, interview and record review the facility failed to ensure a medication error rate of less than 5%. Observation of 29 medications administered revealed 3 errors resulting in a medication error rate of 10.34%. The medication errors affect 2 (Resident 2 and 3) of 4 residents. The facility census was 99.
- D
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 wrote175 NAC 12-006.12(D)(iii) Based on observation, interview and record review the facility failed to ensure 10 insulin pens were labeled with the date opened for Residents 5, 6 and 8 during an observation of 1 medication cart sampled. The facility census was 99.
October 29, 2024Complaint inspection · 3 citations
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(E) Based on record review and interview; the facility staff failed to include the resident/ family member in the quarter care planning process for 1 (Resident 2) of 3 sampled residents. The facility staff identified a census of 90.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure Refernce Number 175 NAC 12-006.09(l) Based on observations, record review and interview; the facility staff failed to implement assessed interventions to prevent accidents/falls for 3 (Resident 1,3 and 4) of 4 sampled residents. The facility staff identified a censu of 90.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observation, record review and interview; the facility staff failed to ensure a medication error rate of less than 5%. Observation of 34 medication revealed 4 errors resulting in an error rate of 11.76%. The medication errors effect 3 (Resident 10,11 and 13) of 5 sampled residents. The facility staff identified a census of 90.
July 23, 2024Standard inspection · 6 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a serious mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care, requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability, be offered the most appropriate setting for their needs, and receive the services they need in those settings) Level II was completed on a resident with a serious mental disorder for 1 of 1 resident's reviewed (Resident 6). The facility identified a census of 81.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview, the facility failed to complete a baseline care plan (a person-centered plan developed and implemented to meet the resident's needs) on admission for 1 (Resident 79) of 29 sampled residents. The facility identified a census of 81.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility staff failed to complete a Comprehensive Care Plan (CCP, the plan of care is developed from a comprehensive assessment to ensure the resident achieves optimal functional status.) for Resident 79 after the completion of the comprehensive assessment. This affected 1 (Resident 79) of 29 sampled residents. The facility identified a census of 81.
- D
Provide activities to meet all resident's needs.
Inspectors wroteLicensure reference: 175 NAC 006.09(H)(vi)(2) Based on observation, interview, and record review, the facility failed to ensure activities were provided to meet resident needs and interests for 1 [Resident 63] of 1 sampled resident. The facility had a total census of 81 residents.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure reference: 175 NAC 12-006.09(I) Based on observation, interview, and record review, the facility failed to ensure interventions to prevent potential falls were implemented for 1 [Resident 63] of 3 residents sampled for falls. The facility had a total census of 81 residents.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteLicensure reference: 175 NAC 12-006.09(H)(vi)(3) Based on observation, interview, and record review, the facility failed to ensure enteral feeding was provided in accordance with physician order for 1 [Resident 63] of 1 resident sampled for enteral feeding. The facility had a total census of 81 residents.
April 3, 2024Complaint inspection · 4 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteLicensure reference: 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to ensure monitoring of Wanderguard bracelet placement and function to prevent potential elopement from the facility for 1 [Resident 1] of 3 sampled residents at risk for elopement. The facility had a total census of 85.
- D
Respond appropriately to all alleged violations.
Inspectors wroteLicensure reference: 175 NAC 12-006.02 (8) Based on record review and interview, the facility failed to report to Adult Protective Service and submit investigation to state agency within 5 working days 2 elopements involving 1 [Resident 1] of 4 sampled residents. The facility had a total census of 85 residents.
- D
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteLicensure reference: 12-006.04B2a Based on record review and interview, the facility failed to ensure 2 [Nurse Aide C and D] of 5 sampled nurse aides had completed 12 hours of yearly in-service training and failed to complete dementia and abuse in-service training for 1[ Nurse Aide C] of 5 sampled nurse aides. The facility had a total census of 85 residents.
- C
Post nurse staffing information every day.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure posting of daily nursing staffing. The facility had a total census of 85 residents.
January 9, 2024Complaint inspection · 3 citations
- 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(8) Based on record review and interview; the facility staff failed to investigate and report within 5 working days of a potential allegation of neglect for 1 (Resident 1) of 3 sampled Resident. The facility staff identified a census of 90. Record review of the facility Abuse-Identification of Types policy and procedure dated 10-04-2022 and a policy review date of 7-18-2023 revealed the following: -Neglect: -Neglect is defined as a failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. a. neglect includes cases where the facility's indifference or disregard for the residents care, comfort or safety, result in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. [...]
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D4 Based on observation, record review and interview; the facility staff failed to ensure complete personal cares for 1 (Resident 3) of 4 sampled residents. The facility staff identified a census of 90.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D Based on observations, record review and interviews; the facility staff failed to implement pain management interventions for 1 (Resident 3) of 3 sampled residents. The facility staff identified a census of 90.
June 29, 2023Standard inspection · 6 citations
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Nebraska Food Code 4-602.13 Based on observation, interview and record review; the facility failed to maintain a fan, air conditioner units and ceiling ventilation covers in clean condition in the facility kitchen. This had the ability to affect 87 of 91 residents who ate food prepared in the facility kitchen. The facility census was 91.
- E
Honor 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.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on observation and interview, the facility failed to maintain walls, fixtures, ceiling tiles, outlets, baseboards and doors in 21 ( Rooms 100, 102, 105, 107, 200, 201, 204, 205, 303, 306, 402, 407, 409, 410, 505, 604, 605, 606, 700, 707, 708) of 101 occupied resident rooms. The facility census was 91.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteLicensure reference number 175 NAC 12-006.17D Based on record reviews, observations, and interviews, the facility failed to ensure hand hygiene was completed between glove changes for 2 residents (Resident 54 and 19) of 2 sampled residents, and failed to perform hand hygiene during catheter care for Resident 19. The facility staff identified a census of 91.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D1c Based on observations, interviews, and record review; the facility failed to provide nail care for a dependent resident for 1 (Resident 5) of 2 sampled residents. The facility census was 91.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteLicensure Reference 175 NAC 12-006.09D Based on record reviews and interviews, the facility failed to provide emergency care for Resident 13 as evidenced byt he facility contacting an ambulance transport company as opposedd to calling 911 for immediate transport for emergency services. This affected 1 of 5 sampled residents. The facility census was 91.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteLicensure reference number 175 NAC 12-006.09 Based on record review and interviews, the facility failed to monitor a hemodialysis access (is a way to reach the blood) site for 1 resident of 1 (Resident 8) sampled. The facility identified a census of 91.
Fire safety inspections
32 fire safety citations on file: 4 on July 23, 2024, 12 on June 29, 2023, 16 on March 29, 2022.
Every fire safety citation32 citations
- 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.
K 222 · July 23, 2024 · Waiver
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · July 23, 2024 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · July 23, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · July 23, 2024 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
K 354 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Have an externally vented heating system.
K 522 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Provide a written emergency evacuation plan.
K 711 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure proper usage of power strips and extension cords.
K 920 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
K 343 · June 29, 2023 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · June 29, 2023 · Corrected (the home has a date of correction)
- F
Implement emergency and standby power systems.
E 41 · March 29, 2022 · Corrected (the home has a date of correction)
- 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.
K 222 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Install corridor and hallway doors that block smoke.
K 363 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Have properly installed electrical wiring and gas equipment.
K 511 · March 29, 2022 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 29, 2022 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · March 29, 2022 · Corrected (the home has a date of correction)
- E
Meet other general requirements.
K 200 · March 29, 2022 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 29, 2022 · Corrected (the home has a date of correction)
- E
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 29, 2022 · Corrected (the home has a date of correction)
- E
Meet requirements for the use of electrical equipment.
K 919 · March 29, 2022 · Corrected (the home has a date of correction)
- E
Meet requirements for the use and maintenance of medical gas equipment.
K 922 · March 29, 2022 · Corrected (the home has a date of correction)