Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Falls City, NE
Falls City Nursing and Rehabilitation Center
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1720 Burton Drive, Falls City, NE
(402) 245-4466
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
63
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1979-03-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,456
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 24.04% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.59
Performance 6.76% · Measure score 3.59 · Achievement 3.59 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.27
Baseline 70.21% · Performance 62.16% · Measure score 1.27 · Achievement 0 · Improvement 1.27
Adjusted total nurse staffing
0
Baseline 3.50 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 7.64% |
| Discharge to community | 37.34% |
50.57%
13.2 pts worse
|
Worse than the National Rate · Eligible stays 54 · Observed rate 31.48% · Lower 95% interval 28.65% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 64 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 20 · Denominator 56 |
| Discharge mobility score | 32.14% |
50.94%
18.8 pts worse
|
Numerator 18 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 3 · Denominator 66 · Adjusted rate 4.52% |
| Healthcare-associated infections requiring hospitalization | 6.76% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 3.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 58 |
| Staff flu vaccination coverage | 61.18% |
42%
19.2 pts better
|
Numerator 52 · Denominator 85 |
| Discharge function score | 44.64% |
56.45%
11.8 pts worse
|
Numerator 25 · Denominator 56 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.59% |
25.2%
11.4 pts better
|
Numerator 15 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.0 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
2.0
1.4 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
92.8%
3.9 pts worse
|
93.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 95.0% · Q3 84.6% · Q4 80.0% · 4Q avg 88.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
96.1%
3.2 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
4.5%
3.2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 60.2% |
4.4%
55.8 pts worse
|
11.4%
48.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 65.6% · Q2 53.1% · Q3 58.3% · Q4 63.6% · 4Q avg 60.2% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
5.3%
2.3 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 13.9% · Q4 8.8% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
19.5%
2.4 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 13.9% · Q3 19.4% · Q4 18.9% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.4% |
21.6%
14.8 pts worse
|
16.7%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.2% · Q2 33.3% · Q3 32.1% · Q4 34.6% · 4Q avg 36.4% · 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 | 10.0% |
20.4%
10.4 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.5% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
19.9%
3.7 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 33.3% · Q3 2.9% · Q4 8.6% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
1.6%
1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.5% |
26.6%
4.9 pts worse
|
19.8%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.0% · Q2 34.5% · Q3 24.3% · Q4 23.4% · 4Q avg 31.5% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
4.3%
1.1 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.5% · Q3 6.4% · Q4 2.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.2% |
80.5%
1.3 pts worse
|
81.7%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 88.6% · Q3 75.9% · Q4 51.7% · 4Q avg 79.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
11.6%
3.4 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 8.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
2.4%
1.3 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
75.9%
4.1 pts better
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.5% |
20.9%
3.6 pts worse
|
23.9%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 24.5% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2023-08-23 · Fire 2023-08-23
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-14
F · Potential for more than minimal harm
2025-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-14
F · Potential for more than minimal harm
2025-07-31
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-14
E · Potential for more than minimal harm
2025-07-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-09-14
E · Potential for more than minimal harm
2025-07-31
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 2025-09-14
E · Potential for more than minimal harm
2025-07-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-14
E · Potential for more than minimal harm
2025-07-31
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-09-14
E · Potential for more than minimal harm
2025-07-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-14
F · Potential for more than minimal harm
2024-07-11
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-23
F · Potential for more than minimal harm
2023-08-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-13
F · Potential for more than minimal harm
2023-08-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-23
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 2023-09-13
E · Potential for more than minimal harm
2023-08-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-13
E · Potential for more than minimal harm
2023-08-23
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-09-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-31
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 2025-09-14
D · Potential for more than minimal harm
2025-07-31
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-09-14
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-14
F · Potential for more than minimal harm
2025-03-25
F761 · Pharmacy Service Deficiencies
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 2025-05-16
E · Potential for more than minimal harm
2024-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-23
Penalties and ownership
What sits behind the stars
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Alliance Medical Staffing Inc
Operational/Managerial Control · Organization
Burnam, Soon
Corporate Officer · Individual
Helenthal, Tara
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Morris, Spencer
Operational/Managerial Control · Individual
Onshift Inc
Operational/Managerial Control · Organization
Sato, Ami
Corporate Officer · Individual
Westengaard, Justin
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Falls City Care Center
Falls City, NE
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Maple Heights Nursing & Rehabilitative Center
Hiawatha, KS
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Apostolic Christian Home
Sabetha, KS
3-star overall rating with 2-star inspections with $43,403 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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