6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
19 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Deshler, NE
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
1203 4th Street, Deshler, NE
(402) 365-7237
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
49
Certified beds
Average residents
25
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-06-01
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
RN hours / resident day
0.90
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
523
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.31
Composite VBP score used to determine payment impact.
Payment multiplier
1.0215
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
10
Baseline 30.00% · Performance 24.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.66
Performance 4.12 hours · Measure score 3.66 · Achievement 3.66 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.33% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 6.56% |
| Discharge to community | 29.31% |
50.57%
21.3 pts worse
|
Worse than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 19.68% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 7 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 46 |
| Staff flu vaccination coverage | 47.83% |
42%
5.8 pts better
|
Numerator 22 · Denominator 46 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.7 |
2.0
1.7 pts worse
|
1.8
1.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
92.8%
5 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.0% · Q4 95.5% · 4Q avg 97.8% |
| 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 | 9.0% |
4.5%
4.5 pts worse
|
3.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.0% · Q3 12.0% · Q4 4.5% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
4.4%
1 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 4.2% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.3%
5.3 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
19.5%
9.1 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 42.9% |
21.6%
21.3 pts worse
|
16.7%
26.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.9% · 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 | 30.3% |
20.4%
9.9 pts worse
|
16.3%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.2% |
19.9%
2.3 pts worse
|
14.9%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.1% |
1.6%
3.5 pts worse
|
1.0%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q3 4.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.9%
0.5 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 8.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.6% |
26.6%
4 pts worse
|
19.8%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 21.7% · 4Q avg 30.6% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.3%
1.5 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
80.5%
1.3 pts better
|
81.7%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 81.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 22.7% |
2.4%
20.3 pts worse
|
1.6%
21.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 22.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (2 deficiencies)
19 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-06-19
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 2025-06-19
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-19
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 2025-06-19
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-06
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-19
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-06-19
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-19
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-19
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-19
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-19
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-06-19
Fire Safety
Use approved construction type or materials.
Corrected 2025-06-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-19
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-06-19
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-19
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-06-19
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-10
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 2024-07-10
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-01
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-01
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-01
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-01
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 2023-09-01
Inspection history
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-06
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-04
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-06-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-19
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2025-06-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-10
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-10
Health
Assess the resident when there is a significant change in condition
Corrected 2023-09-10
Penalties and ownership
Payment Denial · denial start 2025-06-20 · 16 days
16 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Security Interest · Organization
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
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