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
Staffing
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
0.71
Licensed practical nurse staffing
Aide hours / resident day
1.99
Nurse aide staffing
Weekend hours
2.90
Weekend nurse staffing
RN turnover
20%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 30.3% |
20.4%
9.9 pts worse
|
16.3%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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