Grand Island, NE

Tiffany Square

4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

3119 West Faidley Avenue, Grand Island, NE

(308) 384-2333

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

103

Certified beds

Average residents

73

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

Vetter Senior Living

Operator or chain grouping

Approved since

1989-03-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.66

Registered nurse staffing

LPN hours / resident day

0.53

Licensed practical nurse staffing

Aide hours / resident day

3.40

Nurse aide staffing

Weekend hours

3.78

Weekend nurse staffing

RN turnover

18%

Annual RN turnover

Total nurse turnover

33%

Annual nurse turnover

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
Number of outpatient emergency department visits per 1000 long-stay resident days 1.1
2.0
0.9 pts better
1.8
0.7 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 78.9%
92.8%
13.9 pts worse
93.4%
14.5 pts worse
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 2.2%
4.5%
2.3 pts better
3.3%
1.1 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 0.8%
4.4%
3.6 pts better
11.4%
10.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 3.0%
5.3%
2.3 pts better
5.4%
2.4 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.0%
19.5%
5.5 pts better
19.6%
5.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 11.1%
21.6%
10.5 pts better
16.7%
5.6 pts better
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 32.0%
20.4%
11.6 pts worse
16.3%
15.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 25.8%
19.9%
5.9 pts worse
14.9%
10.9 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 3.0%
1.6%
1.4 pts worse
1.0%
2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 3.8%
2.9%
0.9 pts worse
1.7%
2.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 32.9%
26.6%
6.3 pts worse
19.8%
13.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 5.2%
4.3%
0.9 pts worse
5.1%
0.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 82.5%
80.5%
2 pts better
81.7%
0.8 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 15.4%
11.6%
3.8 pts worse
12.0%
3.4 pts worse
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 1.7%
2.4%
0.7 pts better
1.6%
0.1 pts worse
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 78.4%
75.9%
2.5 pts better
79.7%
1.3 pts worse
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 20.9%
20.9%
About the same
23.9%
3 pts better
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-04 · Fire 2025-12-04

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-10-16 · Fire 2024-10-16

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Cycle 3 Health 2023-10-05 · Fire 2023-10-05

6 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-12-04

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-12-31

E · Potential for more than minimal harm 2025-12-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-12-31

E · Potential for more than minimal harm 2025-12-04

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2025-12-31

F · Potential for more than minimal harm 2024-10-16

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2024-11-20

F · Potential for more than minimal harm 2024-10-16

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2024-11-20

F · Potential for more than minimal harm 2024-10-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-20

F · Potential for more than minimal harm 2023-10-05

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-05

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-05

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-11-17

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-12-31

E · Potential for more than minimal harm 2025-12-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-12-31

D · Potential for more than minimal harm 2025-12-04

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-12-31

D · Potential for more than minimal harm 2025-01-13

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-02-17

E · Potential for more than minimal harm 2024-10-16

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-11-20

E · Potential for more than minimal harm 2024-10-16

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 2024-11-20

E · Potential for more than minimal harm 2024-10-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-11-20

D · Potential for more than minimal harm 2024-10-16

F661 · Resident Assessment and Care Planning Deficiencies

Health

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Corrected 2024-11-20

D · Potential for more than minimal harm 2024-10-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-11-20

D · Potential for more than minimal harm 2024-10-16

F761 · Pharmacy Service Deficiencies

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 2024-11-20

D · Potential for more than minimal harm 2024-02-14

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-03-20

F · Potential for more than minimal harm 2023-10-05

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 2023-11-17

D · Potential for more than minimal harm 2023-10-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-05

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-17

C · Minimal harm 2023-10-05

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-11-17

Penalties and ownership

What sits behind the stars

Ownership

Vetter Senior Living

5% Or Greater Direct Ownership Interest · Organization

100% 22 facilities 2016-12-23
Fruehling, Richard

Operational/Managerial Control · Individual

0% 1 facilities 2017-07-01
Fruehling, Richard

Contracted Managing Employee · Individual

0% 1 facilities 2017-07-01
Olson, Stephanie

Operational/Managerial Control · Individual

0% 1 facilities 2021-09-22
Olson, Stephanie

Contracted Managing Employee · Individual

0% 1 facilities 2021-09-22
Stuhr, Brian

Operational/Managerial Control · Individual

0% 23 facilities 2017-07-01
Stuhr, Brian

Corporate Officer · Individual

0% 23 facilities 2017-06-15
Stuhr, Brian

Contracted Managing Employee · Individual

0% 23 facilities 2017-07-01
Vanekeren, Glenn

Operational/Managerial Control · Individual

0% 22 facilities 2017-07-01
Vanekeren, Glenn

Corporate Officer · Individual

0% 22 facilities 2017-06-15
Vanekeren, Glenn

Contracted Managing Employee · Individual

0% 22 facilities 2017-07-01
Vetter Senior Living

Operational/Managerial Control · Organization

0% 22 facilities 2016-12-23
Vetter, Eldora

Operational/Managerial Control · Individual

0% 23 facilities 2017-07-01
Vetter, Eldora

Corporate Officer · Individual

0% 23 facilities 2017-06-15
Vetter, Eldora

Contracted Managing Employee · Individual

0% 23 facilities 2017-07-01
Vetter, Jack

Operational/Managerial Control · Individual

0% 23 facilities 2017-07-01
Vetter, Jack

Corporate Officer · Individual

0% 23 facilities 2017-06-15
Vetter, Jack

Contracted Managing Employee · Individual

0% 23 facilities 2017-07-01
Vsl Vetter Health Services LLC

Operational/Managerial Control · Organization

0% 22 facilities 2017-07-01

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