Cycle 1
Health 2026-01-20 · Fire 2026-01-20
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Kearney, NE
Mt Carmel Home - Keens Memorial
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
412 West 18th Street, Kearney, NE
(308) 237-2287
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-12-01
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
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
4.50
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
6.16
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
5.40
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
6.74
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,515
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9926
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.03
Baseline 19.92% · Performance 20.49% · Measure score 2.03 · Achievement 2.03 · Improvement 0
Healthcare-associated infections
0.75
Baseline 6.51% · Performance 7.61% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Total nurse turnover
3.60
Baseline 54.43% · Performance 48.98% · Measure score 3.60 · Achievement 3.60 · Improvement 1.34
Adjusted total nurse staffing
9.47
Baseline 4.94 hours · Performance 5.77 hours · Measure score 9.47 · Achievement 9.47 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.85% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 7.96% · Lower 95% interval 6.57% |
| Discharge to community | 43.07% |
50.57%
7.5 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 37.78% · Lower 95% interval 34.46% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.47% |
95.27%
2.2 pts better
|
Numerator 77 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 53.23% |
53.69%
0.5 pts worse
|
Numerator 33 · Denominator 62 |
| Discharge mobility score | 64.52% |
50.94%
13.6 pts better
|
Numerator 40 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 2.53% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 79 · Adjusted rate 2.89% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 9.09% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 142 |
| Staff flu vaccination coverage | 83.71% |
42%
41.7 pts better
|
Numerator 149 · Denominator 178 |
| Discharge function score | 56.45% |
56.45%
About the same
|
Numerator 35 · Denominator 62 |
| 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 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
92.8%
6.7 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
4.5%
2.1 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.0% · Q3 3.8% · Q4 2.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.4%
3.4 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.3%
2.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 2.4% · Q4 4.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.9% |
19.5%
4.6 pts better
|
19.6%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 9.5% · Q3 11.4% · Q4 11.4% · 4Q avg 14.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.3% |
21.6%
2.7 pts worse
|
16.7%
7.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 23.5% · Q3 27.0% · Q4 25.7% · 4Q avg 24.3% · 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 | 23.7% |
20.4%
3.3 pts worse
|
16.3%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q4 17.0% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.5% |
19.9%
0.4 pts better
|
14.9%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 23.7% · Q3 7.5% · Q4 20.0% · 4Q avg 19.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.6%
1.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
2.9%
2.2 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.2% · Q3 8.2% · Q4 2.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.6% |
26.6%
8 pts worse
|
19.8%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 45.4% · Q3 29.9% · Q4 29.0% · 4Q avg 34.6% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.3%
0.1 pts worse
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 3.8% · Q3 1.6% · Q4 3.6% · 4Q avg 4.4% · 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 | 10.6% |
11.6%
1 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 9.3% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
2.4%
0.3 pts better
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.4% |
75.9%
21.5 pts better
|
79.7%
17.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.9% |
20.9%
4 pts better
|
23.9%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 13.0% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-13 · Fire 2024-11-13
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-11-16 · Fire 2023-11-16
1 health deficiencies
Top issue: Infection Control (1 deficiency)
7 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
2026-01-20
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2026-01-30
F · Potential for more than minimal harm
2026-01-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-30
F · Potential for more than minimal harm
2026-01-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-30
E · Potential for more than minimal harm
2026-01-20
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2026-01-30
E · Potential for more than minimal harm
2026-01-20
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2026-01-30
F · Potential for more than minimal harm
2024-11-13
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-11-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-11-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-11-13
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 2024-12-31
E · Potential for more than minimal harm
2024-11-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-31
F · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-20
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-30
D · Potential for more than minimal harm
2026-01-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-01-30
D · Potential for more than minimal harm
2026-01-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-23
D · Potential for more than minimal harm
2026-01-20
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 2026-01-21
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
Penalties and ownership
What sits behind the stars
Ownership
Blavet, Mary
5% Or Greater Direct Ownership Interest · Individual
Banda, Tracy
Operational/Managerial Control · Individual
Banda, Tracy
Corporate Officer · Individual
Banda, Tracy
W-2 Managing Employee · Individual
Birdsley, Emily
Corporate Officer · Individual
Birdsley, Emily
Contracted Managing Employee · Individual
Blavet, Mary
Corporate Officer · Individual
Johnson, Katherine
Corporate Director · Individual
Messbarger, Robert
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Mother Hull Home
Kearney, NE
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society - St John's
Kearney, NE
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Brookestone Gardens
Kearney, NE
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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