Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adept Nursing & Rehab Of Central City during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses experienced several episodes of severe behavioral disturbance, including screaming and combative actions. An LPN administered Zyprexa IM twice during one shift in response but did not notify the physician, guardian, or emergency contact about the incident or the resident's later transfer to a hospital, contrary to facility policy. Interviews and record reviews confirmed that required notifications were not made.
Staff failed to consistently use gloves or perform proper hand hygiene when handling ready-to-eat foods, and food items in storage were found unsealed, undated, or without required temperature monitoring. Additionally, hot and cold foods were served outside of safe temperature ranges, with staff demonstrating inconsistent knowledge of required standards. These actions did not comply with facility policies and created the potential for foodborne illness among all residents receiving food from the kitchen.
Surveyors found that four Medication Assistants did not have documented competencies completed as required by facility policy and regulation. Record reviews and interviews with the DON and RDO confirmed the absence of competency documentation for these staff, despite the facility's policy mandating such training and assessment.
A resident with moderate cognitive impairment was admitted without a signed advance directive on file, despite facility policy and regulatory requirements. Record reviews showed no documentation of an advance directive or code status at the time of review, and staff confirmed the document was only received and filed after the deficiency was identified.
The facility did not provide timely Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) to two residents when their Medicare coverage ended, as required by policy. In one case, the notices were signed after the last covered date, and in another, the notices were not completed at all. Staff interviews and record reviews confirmed these deficiencies.
A resident was discharged from the facility, but staff did not notify the state ombudsman as required. Review of records and staff interviews confirmed that notifications of emergency transfers and discharges were not consistently sent each month, resulting in the omission of the required discharge notification for this resident.
Staff failed to keep a urinary catheter drainage bag below the bladder during a Hoyer lift transfer for a resident with neurogenic bladder, contrary to the care plan and facility policy. Both the MA and NA involved were unsure of proper catheter bag placement, and the DON confirmed the correct procedure was not followed.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility failed to ensure that dialysis care was provided according to the resident's needs.
Surveyors found that meals were not consistently served at safe and appetizing temperatures, with hot foods below the required 135°F and some dishes appearing unappetizing or in the wrong texture. Several residents, including those with diabetes and swallowing issues, reported dissatisfaction with meal temperature and appearance, and some left food uneaten. The Food Service Manager and Administrator confirmed the deficiencies in food temperature and texture.
The facility did not provide alternative vegetables or fruits to residents who declined or did not select the items initially served, despite residents' dietary needs and preferences. Two residents reported not receiving substitutes for disliked or difficult-to-eat foods, and staff confirmed that only main dish alternatives were available, not sides. This practice was observed during meal service and confirmed by both the Food Service Manager and Administrator.
Surveyors observed strong urine odors and sticky floors in multiple hallways and rooms, with the issue persisting even after housekeeping cleaned affected areas. The DON and Administrator acknowledged the ongoing problem, attributing it to humidity, and facility policies for cleaning and inspection were not effective in resolving the unsanitary conditions.
Three cognitively intact residents who required assistance with mobility and transfers experienced repeated, prolonged delays in call light response, with documented wait times often exceeding 30 minutes and sometimes lasting over an hour. Residents reported frequent long waits for staff assistance, and leadership acknowledged that call light response times were sometimes longer than appropriate, with technical issues occasionally affecting the system.
A resident with obstructive sleep apnea did not receive appropriate follow-up for an Auto-PAP machine due to complaints about the mask being too tight. Despite frequent refusals to use the device and inquiries about a new CPAP, there were no orders addressing these concerns. Staff interviews revealed a lack of awareness and follow-up, contributing to the deficiency in care.
The facility failed to secure a catheter properly, leading to potential cross-contamination for a resident with dementia and other conditions. Additionally, staff did not adhere to hand hygiene protocols during peri care and wound care for three residents. The facility's hand hygiene policy was not followed, as confirmed by staff and the DON.
A facility failed to accurately complete a PASRR for a resident with schizoaffective disorder and PTSD. Despite these diagnoses being documented in medical records, they were omitted from PASRR screenings. Staff interviews confirmed the oversight, acknowledging that the PASRR should have included these diagnoses.
Failure to Notify Physician and Family of Significant Behavioral Changes and Transfer
Penalty
Summary
The facility failed to notify the physician, guardian, and emergency contact of a resident's significant behavioral episodes as required by policy. Record reviews showed that the resident, who had multiple psychiatric diagnoses including bipolar disorder with psychotic features, anorexia nervosa, and major depressive disorder, experienced several episodes of screaming, flailing, hitting, and combative behavior. On one occasion, an LPN was notified by a nurse aide about the resident's episode and administered Zyprexa IM twice during the shift but did not notify the physician, family, or guardian about the incident. Interviews confirmed that the guardian and emergency contact were not informed of these behavioral changes or the subsequent transfer to a hospital until after the events occurred. Facility policy requires prompt notification of the resident, physician, and representative in the event of significant changes in condition, including behavioral deterioration or transfer to another facility. Interviews with facility leadership confirmed that the nurse should have contacted the physician, guardian, and emergency contact regarding the behavioral episodes and transfer. Documentation and interviews with the resident's contacts further confirmed that required notifications were not made in accordance with policy.
Deficient Food Handling, Storage, and Temperature Control
Penalty
Summary
The facility failed to store, prepare, and serve food in a manner that prevents the potential for foodborne illness, as evidenced by multiple observations and staff interviews. Staff were seen handling ready-to-eat foods such as bread, sandwiches, and salad with bare hands, and in some cases, gloves were not used or hand hygiene was not performed before or after glove use. Additionally, staff were observed not washing their hands for the required 20 seconds, and hand hygiene was not performed after touching personal items like cell phones or after removing gloves. The facility's own policies require hand hygiene before donning gloves, after glove removal, and prohibit bare hand contact with food, but these were not consistently followed. Food storage practices were also deficient. Opened bags of macaroni noodles, raw hamburger, bread, spices, and vanilla were found unsealed, undated, or both in dry storage and refrigerators. A milk refrigerator was found without a thermometer, and staff confirmed that thermometers should be present in all refrigerators. These lapses in labeling, sealing, and temperature monitoring are contrary to the facility's food safety policies, which require all food to be stored, labeled, and maintained at safe temperatures. Temperature control of food and fluids was not maintained according to policy or professional standards. Observations showed that hot foods such as cauliflower/broccoli, tuna melt sandwiches, and hamburger patties were served below the required holding temperatures, and milk was found above the safe cold temperature threshold. Staff interviews revealed inconsistent knowledge of the correct temperature standards, with some staff citing different minimum temperatures for hot food. The facility's policy requires hot foods to be held at 135°F or greater and cold foods at or below 41°F, but these standards were not met during the survey.
Failure to Document Medication Assistant Competencies
Penalty
Summary
The facility failed to ensure that all Medication Assistants (MAs) had completed and documented competencies as required by policy and regulation. Record reviews for four sampled MAs revealed that none had documentation of completed competencies for 2024 and 2025. The MAs reviewed had hire dates ranging from 2016 to 2025, indicating that both new and existing staff were affected. Interviews with the Director of Nursing and the Regional Director of Operations confirmed that the facility was unable to provide documentation of the required competencies for these staff members. The facility's Training Requirements policy mandates that all staff, including those under contract and volunteers, must have competencies and skill sets consistent with their expected roles. The Medication Aide Procedure Checklist, which outlines the required skills for MAs, was available, but there was no evidence that the competencies had been completed or documented for the four MAs reviewed. The facility had a census of 58 at the time of the survey.
Failure to Timely Obtain and Document Advance Directive
Penalty
Summary
The facility failed to have a signed advance directive for one resident out of eight sampled, despite requirements to inform and provide written information to all adult residents regarding their right to formulate an advance directive. The resident in question had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had expressed that preferences for customary routine activities were important. Upon admission, the resident was experiencing adjustment issues, and interventions were in place to support their preferences and autonomy. However, a review of the resident's records, including the Minimum Data Set, care plan, clinical census, and electronic medical record, revealed no documentation of an advance directive or code status at the time of review. Further investigation showed that the facility's policy required communication of code status and adherence to residents' rights regarding advance directives. Despite this, the advanced directive for the resident was not present in the medical record and was only located later in the social service office, with documentation indicating it was received and dated after the initial record review. Interviews with facility staff confirmed the delay in obtaining and filing the advance directive, indicating a lapse in ensuring that the resident's rights regarding advance directives were honored in a timely manner.
Failure to Provide Timely Medicare Coverage Termination Notices
Penalty
Summary
The facility failed to provide timely notice of the end of Medicare coverage to two residents, as required by policy and federal regulations. For one resident, the Notice of Medicare Non-Coverage (NOMNC) and Advance Beneficiary Notice (ABN) were not signed until after the last covered date, rather than at least two days prior to the end of Medicare-covered services. This was confirmed by the Regional Business Office Manager, who acknowledged that the required notices were not provided within the appropriate timeframe. For another resident, there was no evidence that the NOMNC or ABN were completed at all when Medicare Part A services ended. The facility's policy states that such notices must be provided at least two days before the end of Medicare coverage to allow residents or their representatives sufficient time to make informed decisions regarding their care and financial responsibility. Record reviews and staff interviews confirmed that these procedures were not followed for the two residents in question.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state-appointed ombudsman of a resident's discharge as required by regulation. Record review showed that the facility's process for emergency transfers and discharges mandates monthly notification to the ombudsman. However, documentation revealed that notifications were not consistently sent each month, with records only available for two months within the review period. Specifically, the discharge of one resident was not reported to the ombudsman, as confirmed by both record review and staff interviews. The Regional Director of Operations acknowledged that the required notification for the resident's discharge was not completed.
Failure to Maintain Catheter Drainage Bag Below Bladder During Transfer
Penalty
Summary
A deficiency was identified when staff failed to maintain a urinary catheter drainage bag below the level of the bladder for a resident with an indwelling catheter. During a Hoyer lift transfer, the catheter drainage bag was attached to the lift arm hook at the resident's eye level, rather than being kept below the bladder as required by facility policy and the resident's care plan. Both the medication assistant and nursing assistant involved in the transfer were unsure of the correct placement for the catheter bag during the procedure. The resident involved had a history of neuromuscular dysfunction of the bladder and was dependent on staff for most activities of daily living. The care plan specifically noted the need to position the catheter bag and tubing below the bladder to prevent urinary tract infections. At the time of the incident, the resident was being treated for a urinary tract infection with antibiotics. The Director of Nursing confirmed that the catheter drainage bag should be kept below the level of the bladder, in accordance with facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Serve Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide residents with nourishing and palatable meals, as required by both facility policy and the Nebraska Food Code. Observations revealed that hot foods were not consistently served at the required temperature of 135°F or higher, with a sample meal showing a sloppy joe at 124.3°F and broccoli and cheese at 132.4°F. The broccoli and cheese dish, intended to be regular texture, appeared ground or pureed and was described as unappetizing in both appearance and texture. Several residents were observed not eating this dish, and interviews confirmed dissatisfaction with the temperature and palatability of the meals. The pears served with the meal were cold, and the appearance of the food was also questioned, with one resident stating the broccoli and cheese looked like someone had thrown up on the plate. Resident interviews further confirmed that hot foods were not always served hot, especially for those who typically ate in their rooms. Residents with various medical conditions, including diabetes, vitamin deficiencies, and swallowing issues, were affected by these inconsistencies. The Food Service Manager acknowledged that the broccoli and cheese dish was not served in the correct texture, and the Administrator confirmed that meal temperatures did not meet required standards. These findings indicate a failure to adhere to established food preparation and service guidelines, impacting the quality and palatability of meals provided to residents.
Failure to Offer Alternate Meal Items for Unselected or Refused Foods
Penalty
Summary
The facility failed to ensure that residents were offered alternative meal items when they chose not to eat the food initially served, as required by their own policy and regulatory standards. Observations during lunch revealed that several residents did not eat the broccoli and cheese dish provided, and review of a sample meal tray showed limited options, with the vegetable appearing unappetizing. Residents received menus in advance to select their meal preferences, but if they did not mark a particular item, such as a vegetable or fruit, no alternative was provided. This practice was confirmed by both residents and the Food Service Manager, who stated that only main dish alternatives were available, and that no substitute vegetables or fruits were offered if the original item was declined or unselected. Interviews with two cognitively intact residents highlighted that they did not receive alternatives for items they disliked or could not eat, such as pears or broccoli, due to personal preference or difficulty eating certain foods. The Food Service Manager and Administrator both acknowledged that the facility did not routinely offer alternative vegetables or fruits, and that residents who did not select these items simply went without them. This failure to provide appropriate alternatives had the potential to affect all residents receiving meals from the kitchen, as it did not accommodate individual dietary needs and preferences as outlined in the facility's policy.
Failure to Maintain Clean and Homelike Environment Due to Persistent Urine Odors
Penalty
Summary
Surveyors found that the facility failed to maintain a clean and homelike environment, as required by policy and regulation. Upon entering the facility, a faint odor of urine was detected at the front door, which became stronger further inside, particularly in the carpeted hallway leading from the east entrance to the main nurses' station, as well as in the south hall and some resident rooms. Specific observations included a private, unoccupied room in the east hallway that smelled strongly of urine and had a sticky floor. Later, after housekeeping mopped the floor in another room on the East Hall, the stickiness increased and the odor of urine became even more pronounced. Interviews with the DON and the Administrator confirmed awareness of the persistent urine odors throughout the hallways and some rooms, attributing the issue to humidity and seasonal changes. Both acknowledged the difficulty in addressing the odors, with the Administrator stating that staff had become accustomed to the smells. Review of facility policies indicated that regular environmental inspections and routine cleaning and disinfection were required, but these measures were not effective in preventing or eliminating the odors and unsanitary conditions observed.
Failure to Promptly Respond to Resident Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for three cognitively intact residents who required varying levels of assistance with mobility and activities of daily living. Documentation from the Minimum Data Set (MDS) and call light logs revealed that these residents experienced significant delays, with call lights remaining unanswered for periods ranging from over 20 minutes to more than two hours on multiple occasions throughout the month. These delays were corroborated by resident interviews, where each resident described frequent and prolonged waits for staff assistance, sometimes exceeding an hour. One resident, who had a history of stroke and required moderate assistance to walk, reported that call light response times had temporarily improved after filing a grievance but subsequently worsened again. Call light logs for this resident showed repeated instances of delays, including several occasions where the call light was not answered for over 30 minutes and, in one case, for more than an hour. Another resident, who used a wheelchair due to fall precautions, also reported waiting an hour or more for assistance, particularly when needing to use the restroom. The call light logs for this resident similarly documented multiple extended response times, some exceeding an hour. A third resident, who was unable to walk and required a mechanical lift with two staff members for transfers, described staff sometimes turning off the call light and promising to return, only for the resident to continue waiting. This resident's call light logs included several instances of delays over an hour, with the longest being more than two hours. Interviews with facility leadership confirmed awareness of the issue, with the Director of Nursing and Facility Administrator acknowledging that call light response times were sometimes longer than appropriate and that there had been technical issues with the call light system on certain days.
Failure to Follow Physician's Orders for Auto-PAP
Penalty
Summary
The facility failed to follow up and complete a physician's order for an Auto-PAP machine for a resident diagnosed with obstructive sleep apnea. The resident, who was admitted with a history of using CPAP since 2018, reported that the mask was too tight, which led to frequent refusals to use the device. Despite the resident's complaints and inquiries about a new CPAP, there were no orders addressing these concerns. The resident's use of the Auto-PAP decreased significantly over time, with the resident refusing to use it more often than not. Interviews with staff revealed a lack of awareness and follow-up regarding the resident's refusal to use the Auto-PAP. The RN was unaware if the doctor had been notified about the refusals, and the DON confirmed that the orders for the Auto-PAP should have been placed upon admission. Additionally, there was a lack of follow-up after contacting Midwest Respiratory for recommendations, and the facility's administrator speculated that the resident's beard might be causing the mask to feel tight. This lack of action and communication contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to secure a catheter properly, leading to potential cross-contamination during catheter care for Resident 53. During an observation, a registered nurse (RN) was seen changing the catheter bag for Resident 53, who has dementia, neurogenic bladder, intellectual disabilities, and hypothyroidism. The RN dropped the new catheter drainage bag and tubing on the floor twice but continued to use them after wiping with alcohol wipes, which was confirmed by the Infection Control Preventionist as having the potential to cause cross-contamination. Additionally, the facility failed to adhere to proper hand hygiene protocols during peri care and wound care for Residents 53, 26, and 8. A medication aide (MA) did not change gloves or perform hand hygiene after providing pericare to Resident 53, which was confirmed by the MA and the Infection Control Preventionist. Similarly, an RN did not perform hand hygiene between glove changes during wound care for Resident 26, and a licensed practical nurse (LPN) failed to perform hand hygiene before donning gloves and between tasks during wound care for Resident 8. The facility's hand hygiene policy, which requires hand hygiene when moving from a contaminated body site to a clean body site and before donning gloves, was not followed. Interviews with the staff involved and the Director of Nursing (DON) confirmed the lapses in hand hygiene practices, which are crucial to preventing the spread of infection within the facility.
PASRR Screening Deficiency for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a PASRR (Pre-admission Screening and Resident Review) for individuals with a mental disorder or intellectual disability was accurately completed for one resident. This deficiency was identified during a review of records and interviews with staff. The resident in question, who was part of a sample of 20 residents, had a history of schizoaffective disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Despite these diagnoses being documented in various medical records, they were not accurately reflected in the PASRR screenings conducted on two separate occasions. The PASRR dated 3/30/21 noted major depressive disorder and substance abuse but omitted schizoaffective disorder and PTSD. A subsequent PASRR dated 6/8/22 failed to list any diagnoses. Interviews with the Director of Nursing, Administrator, and Social Service Director confirmed the oversight, acknowledging that the PASRR should have included the resident's diagnoses of schizoaffective disorder and PTSD. The Administrator noted that the PASRR was initially completed at the hospital and was done incorrectly, and the facility's Social Worker did not identify the error.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Central City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Litzenberg Memorial County Hospital | 0.1 mi | ★★★★★ | 5 | 0 |
| Memorial Community Care | 16.1 mi | ★★★★★ | 4 | 0 |
| Westfield Quality Care Of Aurora | 16.3 mi | ★★★★★ | 1 | 0 |
| Accura Healthcare Of Fullerton | 18.2 mi | ★★★★★ | 8 | 0 |
| Midwest Covenant Home | 21.5 mi | ★★★★★ | 0 | 0 |
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