Cycle 1
Health 2025-04-22 · Fire 2025-04-22
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fremont, NE
Nye Legacy Health & Rehabilitation Center
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3210 N Clarkson, Fremont, NE
(402) 721-9300
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-12-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
1.09
Registered nurse staffing
LPN hours / resident day
0.63
Licensed practical nurse staffing
Aide hours / resident day
2.88
Nurse aide staffing
Weekend hours
3.97
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
1.8
1.6 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.0
0.7 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 69.8% |
92.8%
23 pts worse
|
93.4%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.5% |
96.1%
17.6 pts worse
|
95.5%
17 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
4.5%
1.1 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.4%
3.9 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.0% |
5.3%
1.3 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.1% |
19.5%
2.6 pts worse
|
19.6%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
21.6%
5.7 pts better
|
16.7%
0.8 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 | 39.2% |
20.4%
18.8 pts worse
|
16.3%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.5% |
19.9%
4.6 pts worse
|
14.9%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.6%
0.7 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 12.1% |
2.9%
9.2 pts worse
|
1.7%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.0% |
26.6%
7.4 pts worse
|
19.8%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.3%
About the same
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.7% |
80.5%
4.8 pts worse
|
81.7%
6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.6% |
11.6%
5 pts worse
|
12.0%
4.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
2.4%
1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.5% |
75.9%
2.4 pts worse
|
79.7%
6.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
20.9%
2.2 pts worse
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-14 · Fire 2024-05-14
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-21 · Fire 2023-06-21
4 health deficiencies
Top issue: Infection Control (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-22
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 2025-06-06
E · Potential for more than minimal harm
2025-04-22
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-06-06
F · Potential for more than minimal harm
2024-05-14
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-14
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 2024-06-28
E · Potential for more than minimal harm
2024-05-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-06-28
F · Potential for more than minimal harm
2023-06-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
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 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-05
F · Potential for more than minimal harm
2023-06-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-05
E · Potential for more than minimal harm
2023-06-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-05
E · Potential for more than minimal harm
2023-06-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-08-05
E · Potential for more than minimal harm
2023-06-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-05
D · Potential for more than minimal harm
2023-06-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-05
D · Potential for more than minimal harm
2023-06-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-22
F758 · Pharmacy Service Deficiencies
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 2025-06-06
F · Potential for more than minimal harm
2024-05-14
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 2024-06-28
E · Potential for more than minimal harm
2024-05-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-14
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 2024-06-28
D · Potential for more than minimal harm
2024-05-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
D · Potential for more than minimal harm
2023-06-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-14
Penalties and ownership
What sits behind the stars
Ownership
Peterson, Jennifer
5% Or Greater Direct Ownership Interest · Individual
Peterson, Russell
5% Or Greater Direct Ownership Interest · Individual
Paragon Management Services Inc
Operational/Managerial Control · Organization
Sweeney, Daniel
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Fremont, NE
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 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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