Cycle 1
Health 2025-05-01 · Fire 2025-05-01
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fremont, NE
Dunklau Gardens
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
450 East 23rd Street, Fremont, NE
(402) 721-1610
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
81
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-05-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
1.10
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.35
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.26
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.93
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.28
CMS adjusted RN staffing hours
Adjusted total hours
5.50
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,296
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0131
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.54
Baseline 19.15% · Performance 19.79% · Measure score 3.54 · Achievement 3.54 · Improvement 0
Healthcare-associated infections
7.54
Baseline 5.32% · Performance 5.58% · Measure score 7.54 · Achievement 7.54 · Improvement 0
Total nurse turnover
4.76
Baseline 39.06% · Performance 44.23% · Measure score 4.76 · Achievement 4.76 · Improvement 0
Adjusted total nurse staffing
7.32
Baseline 3.46 hours · Performance 5.16 hours · Measure score 7.32 · Achievement 7.32 · Improvement 6.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.02% |
10.72%
2.7 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 3.11% · Lower 95% interval 5.74% |
| Discharge to community | 58.54% |
50.57%
8 pts better
|
Better than the National Rate · Eligible stays 148 · Observed rate 57.43% · Lower 95% interval 51.93% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.85% |
95.27%
1.6 pts better
|
Numerator 123 · Denominator 127 |
| Falls with major injury | 0.79% |
0.77%
About the same
|
Numerator 1 · Denominator 127 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 38 · Denominator 95 |
| Discharge mobility score | 28.42% |
50.94%
22.5 pts worse
|
Numerator 27 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 127 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.58% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 1.87% · Lower 95% interval 3.04% |
| Staff COVID-19 vaccination coverage | 3.47% |
8.2%
4.7 pts worse
|
Numerator 5 · Denominator 144 |
| Staff flu vaccination coverage | 53.57% |
42%
11.6 pts better
|
Numerator 60 · Denominator 112 |
| Discharge function score | 42.11% |
56.45%
14.3 pts worse
|
Numerator 40 · Denominator 95 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 33.9% |
25.2%
8.7 pts better
|
Numerator 20 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
96.1%
2.7 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.6% |
4.5%
3.1 pts worse
|
3.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.7% · Q3 8.8% · Q4 9.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.4%
3.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.3%
1.2 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.5% · Q3 8.3% · Q4 7.4% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.5%
4.1 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 18.8% · Q3 14.8% · Q4 11.1% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
21.6%
0.4 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 20.4% · Q3 25.5% · Q4 22.9% · 4Q avg 22.0% · 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 | 17.2% |
20.4%
3.2 pts better
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 28.4% · Q3 6.7% · Q4 3.8% · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
19.9%
1.3 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 21.3% · Q3 24.1% · Q4 14.8% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.6%
0.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.6% · Q3 1.3% · Q4 1.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.9%
2.2 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
26.6%
8.7 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 24.3% · Q3 24.9% · Q4 10.2% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.3%
0.5 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.1% · Q3 4.9% · Q4 4.6% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.5%
19.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.2% |
11.6%
8.6 pts worse
|
12.0%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 16.7% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.4%
1.7 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
75.9%
24.1 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
20.9%
5.6 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 20.0% · Expected 18.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-23 · Fire 2024-04-23
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2023-06-08
0 health deficiencies
No concentrated health issue counts in this cycle.
19 fire-safety deficiencies
Top issue: Egress (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-24
F · Potential for more than minimal harm
2025-05-01
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-24
E · Potential for more than minimal harm
2025-05-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-24
F · Potential for more than minimal harm
2024-04-23
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-23
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-23
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-04-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-30
F · Potential for more than minimal harm
2023-06-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-11
F · Potential for more than minimal harm
2023-06-08
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-08-08
F · Potential for more than minimal harm
2023-06-08
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-06-08
K251 · Egress Deficiencies
Fire Safety
Conform to length requirements for dead end corridors.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-06-08
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-06-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-06-08
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-14
F · Potential for more than minimal harm
2023-06-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-27
F · Potential for more than minimal harm
2023-06-08
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-06-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-06-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-06-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-06-28
F · Potential for more than minimal harm
2023-06-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-08
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-06-09
E · Potential for more than minimal harm
2023-06-08
K321 · Smoke Deficiencies
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 2023-08-18
E · Potential for more than minimal harm
2023-06-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-24
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-24
F · Potential for more than minimal harm
2024-04-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-17
Penalties and ownership
What sits behind the stars
Ownership
Beebe, Kenneth
Corporate Director · Individual
Bixby, Jennifer
Corporate Director · Individual
Brown, Jayma
Operational/Managerial Control · Individual
Deemer, Tammy
Operational/Managerial Control · Individual
Emanuel, Linda
Corporate Director · Individual
Francis, Jeffrey
Corporate Director · Individual
Francis, Jeffrey
Corporate Officer · Individual
Goeser, Stephen
Corporate Director · Individual
Goeser, Stephen
Corporate Officer · Individual
Horner, Jody
Corporate Director · Individual
Jirka, Tyler
Operational/Managerial Control · Individual
Lamprecht, Adam
Corporate Director · Individual
Navarrette, Steven
Corporate Director · Individual
Nebraska Methodist Health System Inc
Operational/Managerial Control · Organization
Sellon, Monty
Corporate Director · Individual
Stanley, Kylee
Operational/Managerial Control · Individual
Vobejda, William
Operational/Managerial Control · Individual
Wagner Dix, Nicole
Corporate Director · Individual
Waring, Fred
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Nye Legacy Health & Rehabilitation Center
Fremont, NE
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Nye Pointe Health & Rehab Ctr
Fremont, NE
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Arbor Care Center-Valhaven, LLC
Valley, NE
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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