Cycle 1
Health 2025-11-25 · Fire 2025-11-25
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lincoln, NE
Southlake Village Rehabilitation & Care Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
9401 Andermatt Drive, Lincoln, NE
(402) 327-6300
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
120
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Vetter Senior Living
Operator or chain grouping
Approved since
1998-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
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
0.61
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.22
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
5.08
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
325
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.18
Composite VBP score used to determine payment impact.
Payment multiplier
1.0238
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 20.26% · Performance 16.27% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
5.89
Baseline 6.09% · Performance 6.08% · Measure score 5.89 · Achievement 5.89 · Improvement 0
Total nurse turnover
6.51
Baseline 46.90% · Performance 37.09% · Measure score 6.51 · Achievement 6.51 · Improvement 3.95
Adjusted total nurse staffing
6.88
Baseline 4.27 hours · Performance 5.03 hours · Measure score 6.88 · Achievement 6.88 · Improvement 4.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.93% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 572 · Observed rate 6.99% · Lower 95% interval 7.16% |
| Discharge to community | 65.72% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 548 · Observed rate 65.88% · Lower 95% interval 60.61% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 326 · Denominator 326 |
| Falls with major injury | 0.61% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 326 |
| Discharge self-care score | 39.15% |
53.69%
14.5 pts worse
|
Numerator 110 · Denominator 281 |
| Discharge mobility score | 28.47% |
50.94%
22.5 pts worse
|
Numerator 80 · Denominator 281 |
| Pressure ulcers or injuries, new or worsened | 1.53% |
2.29%
0.8 pts better
|
Numerator 5 · Denominator 326 · Adjusted rate 2.15% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 343 · Observed rate 4.37% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 3.07% |
8.2%
5.1 pts worse
|
Numerator 7 · Denominator 228 |
| Staff flu vaccination coverage | 45.16% |
42%
3.2 pts better
|
Numerator 112 · Denominator 248 |
| Discharge function score | 44.84% |
56.45%
11.6 pts worse
|
Numerator 126 · Denominator 281 |
| Transfer of health information to provider | 99.09% |
95.95%
3.1 pts better
|
Numerator 109 · Denominator 110 |
| Transfer of health information to patient | 99.39% |
96.28%
3.1 pts better
|
Numerator 164 · Denominator 165 |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 75 · Denominator 165 |
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 2.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
92.8%
6.9 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 2.3% |
4.5%
2.2 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.2% · Q3 2.2% · Q4 1.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
4.4%
3.8 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.2% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.3%
0.8 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 4.1% · Q3 3.9% · Q4 1.4% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
19.5%
1.4 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 24.3% · Q3 21.1% · Q4 14.7% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
21.6%
6.8 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 17.5% · Q3 12.5% · Q4 13.6% · 4Q avg 14.8% · 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 | 21.4% |
20.4%
1 pts worse
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 16.1% · Q3 17.8% · Q4 18.7% · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
19.9%
3.3 pts better
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 23.9% · Q3 12.2% · Q4 14.9% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.9%
1.4 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 1.1% · Q4 2.3% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
26.6%
3.6 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 34.6% · Q3 28.1% · Q4 26.8% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.3%
1.4 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.0% · Q3 1.0% · Q4 4.6% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
80.5%
18.7 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 99.1% · Q4 99.1% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
11.6%
5 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.4%
1.3 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 1.3% · Q4 2.4% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.7% |
75.9%
22.8 pts better
|
79.7%
19 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
20.9%
1.7 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 18.6% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-13 · Fire 2024-08-13
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-08-03 · Fire 2023-08-03
1 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-25
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 2025-12-10
F · Potential for more than minimal harm
2025-11-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-10
F · Potential for more than minimal harm
2025-11-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-10
F · Potential for more than minimal harm
2024-08-13
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 2024-09-01
F · Potential for more than minimal harm
2024-08-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-08-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-08-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-08-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-01
F · Potential for more than minimal harm
2024-08-13
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-08-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-09-01
F · Potential for more than minimal harm
2023-08-03
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-03
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-03
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-09-07
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-25
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-12-23
E · Potential for more than minimal harm
2025-11-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-11-25
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-11-25
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 2025-12-23
D · Potential for more than minimal harm
2025-11-25
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2025-12-23
D · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-01
Penalties and ownership
What sits behind the stars
Ownership
Vetter Senior Living
5% Or Greater Direct Ownership Interest · Organization
Bergmann, David
Operational/Managerial Control · Individual
Bergmann, David
Contracted Managing Employee · Individual
Stuhr, Brian
Operational/Managerial Control · Individual
Stuhr, Brian
Corporate Officer · Individual
Stuhr, Brian
Contracted Managing Employee · Individual
Triggs, Ted
Operational/Managerial Control · Individual
Triggs, Ted
Contracted Managing Employee · Individual
Vanekeren, Glenn
Operational/Managerial Control · Individual
Vanekeren, Glenn
Corporate Officer · Individual
Vanekeren, Glenn
Contracted Managing Employee · Individual
Vetter Senior Living
Operational/Managerial Control · Organization
Vetter, Eldora
Operational/Managerial Control · Individual
Vetter, Eldora
Corporate Officer · Individual
Vetter, Eldora
Contracted Managing Employee · Individual
Vetter, Jack
Operational/Managerial Control · Individual
Vetter, Jack
Corporate Officer · Individual
Vetter, Jack
Contracted Managing Employee · Individual
Vsl Vetter Health Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Hillcrest Firethorn
Lincoln, NE
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Emerald Nursing & Rehab Brookside LLC
Lincoln, NE
1-star overall rating with 1-star inspections with $53,267 in total fines with 15 recent health deficiencies with 27 fire-safety deficiencies in the latest cycle
#3
Tabitha At The Landing
Lincoln, NE
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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