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
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
1.09
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.88
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.61
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.49
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,747
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0091
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.91
Baseline 21.90% · Performance 18.78% · Measure score 5.91 · Achievement 5.72 · Improvement 5.91
Healthcare-associated infections
7.77
Baseline 7.69% · Performance 5.51% · Measure score 7.77 · Achievement 7.77 · Improvement 7.58
Total nurse turnover
2.72
Baseline 66.12% · Performance 52.85% · Measure score 2.72 · Achievement 2.65 · Improvement 2.72
Adjusted total nurse staffing
5.31
Baseline 4.39 hours · Performance 4.59 hours · Measure score 5.31 · Achievement 5.31 · Improvement 0.95
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.89% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 417 · Observed rate 9.11% · Lower 95% interval 7.92% |
| Discharge to community | 56.26% |
50.57%
5.7 pts better
|
Better than the National Rate · Eligible stays 381 · Observed rate 56.43% · Lower 95% interval 51.71% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 269 · Denominator 269 |
| Falls with major injury | 0.74% |
0.77%
About the same
|
Numerator 2 · Denominator 269 |
| Discharge self-care score | 61.99% |
53.69%
8.3 pts better
|
Numerator 137 · Denominator 221 |
| Discharge mobility score | 54.75% |
50.94%
3.8 pts better
|
Numerator 121 · Denominator 221 |
| Pressure ulcers or injuries, new or worsened | 2.97% |
2.29%
0.7 pts worse
|
Numerator 8 · Denominator 269 · Adjusted rate 3.6% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 252 · Observed rate 3.17% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 4.73% |
8.2%
3.5 pts worse
|
Numerator 8 · Denominator 169 |
| Staff flu vaccination coverage | 26.73% |
42%
15.3 pts worse
|
Numerator 58 · Denominator 217 |
| Discharge function score | 58.37% |
56.45%
1.9 pts better
|
Numerator 129 · Denominator 221 |
| Transfer of health information to provider | 99.12% |
95.95%
3.2 pts better
|
Numerator 113 · Denominator 114 |
| Transfer of health information to patient | 98.08% |
96.28%
1.8 pts better
|
Numerator 102 · Denominator 104 |
| Resident COVID-19 vaccinations up to date | 29.69% |
25.2%
4.5 pts better
|
Numerator 38 · Denominator 128 |
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 · Adjusted 3.4 · Observed 3.2 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 2.7 · Observed 2.7 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 68.4% · Q2 73.7% · Q3 73.7% · Q4 63.9% · 4Q avg 69.8% |
| 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 · 4Q avg 78.5% |
| 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 · Q1 3.5% · Q2 3.5% · Q3 3.5% · Q4 3.3% · 4Q avg 3.4% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% |
| 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 · Q1 2.3% · Q2 2.3% · Q3 9.5% · Q4 2.2% · 4Q avg 4.0% |
| 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 · Q1 23.4% · Q2 20.4% · Q3 25.5% · Q4 19.1% · 4Q avg 22.1% |
| 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 · Q1 18.9% · Q2 17.1% · Q3 14.3% · Q4 13.2% · 4Q avg 15.9% · 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 | 39.2% |
20.4%
18.8 pts worse
|
16.3%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 39.2% · Used in QM five-star |
| 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 · Q1 36.4% · Q2 20.8% · Q3 29.8% · Q4 11.1% · 4Q avg 24.5% · Used in QM five-star |
| 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 · Q1 7.4% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 7.7% · Q2 21.2% · Q3 15.4% · Q4 5.1% · 4Q avg 12.1% · Used in QM five-star |
| 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 · Q1 21.4% · Q2 41.6% · Q3 30.1% · Q4 42.0% · 4Q avg 34.0% |
| 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 · Q1 1.2% · Q2 4.5% · Q3 6.5% · Q4 4.9% · 4Q avg 4.3% · Used in QM five-star |
| 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 · Q1 54.4% · Q2 72.1% · Q3 90.2% · Q4 86.4% · 4Q avg 75.7% |
| 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 · Adjusted 16.6% · Observed 16.1% · Expected 10.8% · Used in QM five-star |
| 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 · Q1 2.1% · Q2 1.5% · Q3 0.7% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 73.5% |
| 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 · Adjusted 23.1% · Observed 20.7% · Expected 21.3% · Used in QM five-star |
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
#1
Dunklau Gardens
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
Jump out