18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Grand Island, NE
1-star overall rating with 1-star inspections with $16,801 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
800 Stoeger Drive, Grand Island, NE
(308) 382-5440
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Beds
76
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avid Healthcare Group
Operator or chain grouping
Approved since
1998-05-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 2 overall / 2 health / 3 staffing / 2 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
RN hours / resident day
0.40
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.06
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.36
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.36
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
13,333
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
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
0
Baseline 61.70% · Performance 85.25% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.29
Baseline 3.59 hours · Performance 3.45 hours · Measure score 1.29 · Achievement 1.29 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 7.65% |
| Discharge to community | 55.04% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 46.67% · Lower 95% interval 41.55% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 35 · Denominator 35 |
| Falls with major injury | 2.86% |
0.77%
2.1 pts worse
|
Numerator 1 · Denominator 35 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 40.91% |
50.94%
10 pts worse
|
Numerator 9 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 8.57% |
2.29%
6.3 pts worse
|
Numerator 3 · Denominator 35 · Adjusted rate 8.01% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · 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 57 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 52 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 11 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 57.69% |
25.2%
32.5 pts better
|
Numerator 15 · Denominator 26 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.0 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.4 · Expected 2.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
92.8%
5.8 pts worse
|
93.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 97.7% · Q3 90.9% · Q4 67.3% · 4Q avg 87.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.1%
1.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
4.5%
0.2 pts better
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.5% · Q3 4.5% · Q4 3.8% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.4%
3.2 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 2.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.3%
1.6 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.5% · Q3 2.8% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.3% |
19.5%
3.8 pts worse
|
19.6%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 21.4% · Q3 27.5% · Q4 25.0% · 4Q avg 23.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.9% |
21.6%
10.3 pts worse
|
16.7%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 24.1% · Q3 39.3% · Q4 37.0% · 4Q avg 31.9% · 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 | 32.4% |
20.4%
12 pts worse
|
16.3%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 28.9% · 4Q avg 32.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
19.9%
3.3 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 36.6% · Q3 37.5% · Q4 10.6% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.6% |
1.6%
3 pts worse
|
1.0%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 4.8% · Q3 3.7% · Q4 0.0% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.9%
About the same
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 0.0% · Q3 5.0% · Q4 2.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
26.6%
0.5 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 30.1% · Q3 23.2% · Q4 31.4% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
4.3%
2.6 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 11.7% · Q3 7.1% · Q4 2.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
80.5%
4.4 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.3% · Q3 66.0% · Q4 43.2% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.5% |
11.6%
6.9 pts worse
|
12.0%
6.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 18.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.5% |
2.4%
2.1 pts worse
|
1.6%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.3% · Q3 4.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
75.9%
21.4 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
20.9%
5.8 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 15.8% · Expected 24.9% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-06-20
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-06-30
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-06-30
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 2025-06-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-06-14
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 2024-06-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-14
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-06-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-14
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-14
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-06-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-10
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-10
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-10
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-10
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-10
Inspection history
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-20
Health
Post nurse staffing information every day.
Corrected 2025-06-20
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 2025-06-20
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-06-20
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-06-20
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 2025-06-20
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-20
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 2025-06-20
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-20
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-20
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-06-20
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-20
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-06-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-22
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-06-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-28
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-28
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-16
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-05
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-05
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-05
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-05
Penalties and ownership
Fine · fine $16,801
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
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Grand Island, NE
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