Chadron, NE
1-star overall rating with 1-star inspections with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
420 Gordon Avenue, Chadron, NE
(308) 432-3355
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
70
Certified beds
Average residents
30
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lantis Enterprises
Operator or chain grouping
Approved since
1994-06-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
1.08
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.21
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.91
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.22
CMS adjusted RN staffing hours
Adjusted total hours
4.42
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
12,057
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 55.17% · Performance 62.22% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.82
Baseline 3.37 hours · Performance 3.88 hours · Measure score 2.82 · Achievement 2.82 · Improvement 1.61
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 2.08% · Lower 95% interval 6.2% |
| Discharge to community | 40.42% |
50.57%
10.1 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 35.9% · Lower 95% interval 28.27% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 93.75% |
95.27%
1.5 pts worse
|
Numerator 30 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 32 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 37 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 57 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.0
0.3 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 1.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
92.8%
9.9 pts worse
|
93.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 84.0% · Q3 77.8% · Q4 71.4% · 4Q avg 82.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.8% |
96.1%
15.3 pts worse
|
95.5%
14.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
4.5%
1.2 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 4.0% · Q3 3.7% · Q4 3.6% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
4.4%
2.6 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 13.6% · Q3 3.7% · Q4 7.4% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 13.9% |
5.3%
8.6 pts worse
|
5.4%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 33.3% · Q3 15.4% · Q4 7.4% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.9% |
19.5%
6.6 pts better
|
19.6%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 12.5% · Q3 7.7% · Q4 7.4% · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
21.6%
3.4 pts better
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q3 12.5% · Q4 25.0% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.5% |
20.4%
10.1 pts worse
|
16.3%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.9% |
19.9%
11 pts worse
|
14.9%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 45.8% · Q3 29.2% · Q4 28.0% · 4Q avg 30.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.9%
1.9 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.6% |
26.6%
11 pts worse
|
19.8%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.7% · Q2 31.4% · Q3 16.5% · Q4 57.8% · 4Q avg 37.6% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
4.3%
6.3 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 12.7% · Q3 12.6% · Q4 10.5% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.2% |
80.5%
49.3 pts worse
|
81.7%
50.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 23.1% · Q3 32.0% · Q4 54.5% · 4Q avg 31.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.7% |
11.6%
15.1 pts worse
|
12.0%
14.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.7% · Observed 25.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 10.0% |
2.4%
7.6 pts worse
|
1.6%
8.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.5% |
75.9%
37.4 pts worse
|
79.7%
41.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.6% |
20.9%
10.3 pts better
|
23.9%
13.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 10.0% · Expected 22.4% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-01-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-22
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-22
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2026-01-22
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2026-01-22
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-01-22
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-07
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-07
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-07
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-07
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-07
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-09-09
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-09
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-09
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-09
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-09-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-09
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-22
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2026-01-22
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2026-01-22
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-22
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-22
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-22
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-22
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-22
Health
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.
Corrected 2026-01-22
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-01-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-07
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-07
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-10-07
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-07
Health
Implement 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.
Corrected 2024-10-07
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-10-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-07
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-10-07
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-07
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-10-07
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-17
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-09-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-09
Penalties and ownership
Payment Denial · denial start 2026-01-06 · 17 days
17 day denial
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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