4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Norfolk, NE
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1203 North 13th Street, Norfolk, NE
(402) 371-4991
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
108
Certified beds
Average residents
99
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Vetter Senior Living
Operator or chain grouping
Approved since
1989-05-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
0.73
Licensed practical nurse staffing
Aide hours / resident day
2.76
Nurse aide staffing
Weekend hours
3.38
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.0
1.5 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
96.1%
2.9 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
4.5%
0.6 pts better
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.4%
4.1 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.3%
1.9 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
19.5%
2.5 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
21.6%
17.2 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.3% |
20.4%
5.1 pts better
|
16.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
19.9%
10.2 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.9%
2.1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
26.6%
3.3 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.3%
3.3 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
80.5%
19 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
11.6%
4.9 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.4%
0.8 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
75.9%
20.3 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 9.3% |
20.9%
11.6 pts better
|
23.9%
14.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-08
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-09
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-21
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-08
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-08
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-08
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-06
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-06
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-22
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-08-22
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-22
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Contracted Managing Employee · Individual
Nearby options
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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