9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Gretna, NE
2-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
700 Highway 6, Gretna, NE
(402) 332-3446
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
63
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avid Healthcare Group
Operator or chain grouping
Approved since
1994-06-01
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
0.50
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.49
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
82%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
13,199
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.04
Baseline 23.42% · Performance 21.16% · Measure score 3.04 · Achievement 0.58 · Improvement 3.04
Healthcare-associated infections
0
Baseline 8.02% · Performance 8.68% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 78.46% · Performance 85.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.29 hours · Performance 2.88 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 67 · Observed rate 8.96% · Lower 95% interval 7.39% |
| Discharge to community | 53.07% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 46.43% · Lower 95% interval 43.81% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 33 · Denominator 34 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 1 · Denominator 34 |
| Discharge self-care score | 45% |
53.69%
8.7 pts worse
|
Numerator 9 · Denominator 20 |
| Discharge mobility score | 35% |
50.94%
15.9 pts worse
|
Numerator 7 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.68% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 15.38% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 78 |
| Staff flu vaccination coverage | 10.67% |
42%
31.3 pts worse
|
Numerator 8 · Denominator 75 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 10 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 57.14% |
25.2%
31.9 pts better
|
Numerator 12 · Denominator 21 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.6 · Expected 2.7 · 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 1.7 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
92.8%
13.3 pts worse
|
93.4%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 75.6% · Q3 83.8% · Q4 69.8% · 4Q avg 79.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
96.1%
6.3 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 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 who have depressive symptoms | 12.4% |
4.4%
8 pts worse
|
11.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 6.2% · Q3 9.1% · Q4 15.4% · 4Q avg 12.4% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
5.3%
3.2 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 5.9% · Q3 12.9% · Q4 3.2% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
19.5%
4.4 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.7% · Q3 12.5% · Q4 8.6% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.8% |
21.6%
10.2 pts worse
|
16.7%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 36.4% · Q4 30.8% · 4Q avg 31.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 1.9% |
0.3%
1.6 pts worse
|
0.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 5.4% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.2% |
20.4%
4.2 pts better
|
16.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
19.9%
2.3 pts better
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 22.6% · Q3 11.5% · Q4 10.0% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.6%
1 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.7% · Q3 0.0% · Q4 2.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 17.6% |
26.6%
9 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 7.0% · Q3 16.4% · Q4 21.8% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
4.3%
2.7 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.1% · Q3 6.4% · Q4 9.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.8% |
80.5%
0.3 pts better
|
81.7%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 71.9% · Q3 71.9% · Q4 83.3% · 4Q avg 80.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.4% |
11.6%
9.8 pts worse
|
12.0%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 25.6% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.4%
0.8 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
75.9%
0.9 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.4% |
20.9%
8.5 pts worse
|
23.9%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.4% · Observed 38.5% · Expected 31.1% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Pharmacy Service (2 deficiencies)
17 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-08
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-09-28
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 2023-09-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-28
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-28
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-09-28
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-28
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-28
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-09-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-28
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 2023-09-28
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-28
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-28
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-09-28
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-06-29
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-12
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-06-29
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-12
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-06-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-29
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-08-12
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-29
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 2022-06-29
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-29
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-12
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-08-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-29
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-06-29
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-06-29
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-13
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-06-13
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-13
Health
Post nurse staffing information every day.
Corrected 2024-11-30
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 2024-11-30
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 2024-05-14
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-05-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-16
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-28
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 2023-09-28
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-28
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-28
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-26
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-06-26
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-06-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-26
Penalties and ownership
Payment Denial · denial start 2025-05-23 · 21 days
21 day denial
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
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
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