Fremont, NE

Nye Pointe Health & Rehab Ctr

3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

2700 Laverna Street, Fremont, NE

(402) 727-4900

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

43

Certified beds

Average residents

39

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1998-11-06

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

0.71

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.24

Licensed practical nurse staffing · state 0.71 · national 0.87

Aide hours / resident day

2.66

Nurse aide staffing · state 2.76 · national 2.35

Total nurse hours

3.61

All reported nurse hours · state 4.17 · national 3.89

Licensed hours

0.95

RN + LPN hours · state 1.41 · national 1.54

Weekend hours

3.06

Weekend nurse staffing · state 3.61 · national 3.43

Weekend RN hours

0.42

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

0.74

CMS adjusted RN staffing hours

Adjusted total hours

3.78

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

43%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

65%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,914

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.65

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.85

Performance 21.04% · Measure score 0.85 · Achievement 0.85 · This facility did not have sufficient data to calculate a baseline period measure result.

Healthcare-associated infections

2.71

Performance 7.03% · Measure score 2.71 · Achievement 2.71 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

1.19

Baseline 47.37% · Performance 58.82% · Measure score 1.19 · Achievement 1.19 · Improvement 0

Adjusted total nurse staffing

2.71

Baseline 3.60 hours · Performance 3.85 hours · Measure score 2.71 · Achievement 2.71 · Improvement 0.65

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.68%	10.72% About the same	No Different than the National Rate · Eligible stays 70 · Observed rate 8.57% · Lower 95% interval 6.36%
Discharge to community	41.68%	50.57% 8.9 pts worse	No Different than the National Rate · Eligible stays 41 · Observed rate 36.59% · Lower 95% interval 31.41%
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 32 · Denominator 32
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 32
Discharge self-care score	25%	53.69% 28.7 pts worse	Numerator 6 · Denominator 24
Discharge mobility score	25%	50.94% 25.9 pts worse	Numerator 6 · Denominator 24
Pressure ulcers or injuries, new or worsened	6.25%	2.29% 4 pts worse	Numerator 2 · Denominator 32 · Adjusted rate 5.19%
Healthcare-associated infections requiring hospitalization	7.02%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.3%
Staff COVID-19 vaccination coverage	2.82%	8.2% 5.4 pts worse	Numerator 2 · Denominator 71
Staff flu vaccination coverage	12.5%	42% 29.5 pts worse	Numerator 8 · Denominator 64
Discharge function score	33.33%	56.45% 23.1 pts worse	Numerator 8 · Denominator 24
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	1.8 0.2 pts worse	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.6	2.0 1.6 pts worse	1.8 1.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.6 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	82.0%	92.8% 10.8 pts worse	93.4% 11.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 90.0% · Q3 64.5% · Q4 85.3% · 4Q avg 82.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.1%	96.1% 2 pts worse	95.5% 1.4 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of long-stay residents experiencing one or more falls with major injury	8.6%	4.5% 4.1 pts worse	3.3% 5.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.0% · Q3 9.7% · Q4 5.9% · 4Q avg 8.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	13.8%	4.4% 9.4 pts worse	11.4% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 0.0% · Q3 14.8% · Q4 22.6% · 4Q avg 13.8%
Percentage of long-stay residents who lose too much weight	2.8%	5.3% 2.5 pts better	5.4% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.8%	19.5% 0.7 pts better	19.6% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.5% · Q3 19.2% · Q4 20.7% · 4Q avg 18.8%
Percentage of long-stay residents who received an antipsychotic medication	16.5%	21.6% 5.1 pts better	16.7% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 10.0% · Q3 23.8% · Q4 21.7% · 4Q avg 16.5% · 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	24.3%	20.4% 3.9 pts worse	16.3% 8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 24.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	28.2%	19.9% 8.3 pts worse	14.9% 13.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 39.1% · Q3 25.0% · Q4 24.1% · 4Q avg 28.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.8%	1.6% 0.2 pts worse	1.0% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 4.2% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.8%	2.9% 1.9 pts worse	1.7% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 0.0% · Q3 3.3% · Q4 2.9% · 4Q avg 4.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	38.1%	26.6% 11.5 pts worse	19.8% 18.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 43.0% · Q2 28.9% · Q3 45.4% · Q4 34.6% · 4Q avg 38.1%
Percentage of long-stay residents with pressure ulcers	1.6%	4.3% 2.7 pts better	5.1% 3.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.2% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	67.7%	80.5% 12.8 pts worse	81.7% 14 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 58.8% · Q3 69.2% · Q4 79.3% · 4Q avg 67.7%
Percentage of short-stay residents who had an outpatient emergency department visit	19.9%	11.6% 8.3 pts worse	12.0% 7.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 23.1% · Expected 13.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.9%	2.4% 0.5 pts better	1.6% 0.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	84.8%	75.9% 8.9 pts better	79.7% 5.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	3.9%	20.9% 17 pts better	23.9% 20 pts better	Short Stay · 20240701-20250630 · Adjusted 3.9% · Observed 3.8% · Expected 23.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-21 · Fire 2025-08-21

3 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-07-23 · Fire 2024-07-23

4 health deficiencies

Top issue: Infection Control (1 deficiency)

18 fire-safety deficiencies

Top issue: Egress (4 deficiencies)

Cycle 3 Health 2023-08-15 · Fire 2023-08-15

0 health deficiencies

No concentrated health issue counts in this cycle.

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-08-21

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 2025-09-03

E · Potential for more than minimal harm 2025-08-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-09-03

F · Potential for more than minimal harm 2024-07-23

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

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 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

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 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-09-06

F · Potential for more than minimal harm 2024-07-23

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-07-23

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-07-23

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-07-23

K922 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use and maintenance of medical gas equipment.

Corrected 2024-09-06

E · Potential for more than minimal harm 2024-07-23

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-09-06

E · Potential for more than minimal harm 2023-08-15

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 2023-09-27

E · Potential for more than minimal harm 2023-08-15

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-09-27

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-08-21

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-08-21

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-08-22

D · Potential for more than minimal harm 2025-08-21

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-08-22

F · Potential for more than minimal harm 2024-07-23

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 2024-09-06

F · Potential for more than minimal harm 2024-07-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-07-23

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-09-06

D · Potential for more than minimal harm 2024-07-23

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 2024-09-06

Penalties and ownership