Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Holdrege Memorial Homes, Inc during CMS and state inspections, most recent first.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found gaps in staff training, inconsistent reporting, and unclear protocols, leaving residents unprotected from these risks.
The facility did not include the actual hours worked by RNs, LPNs, or nurse aides on its daily posted nurse staffing reports, as required by policy. The posted reports only listed the number of staff per shift and the resident census, and this omission was confirmed by the DON.
The facility failed to complete required pre-employment health screenings for a re-hired nurse aide, did not enforce hand hygiene or personal grooming standards among dietary staff during meal service, and did not maintain sanitary storage or proper documentation for oxygen and nebulizer equipment for two residents. Additionally, enhanced barrier precautions and PPE availability were not consistently implemented for residents at risk for MDROs, with staff lacking awareness of protocols.
The facility did not submit MDS assessments for several residents within the required 14-day period after completion. Due to the MDSC's frequent absences and lack of backup, assessments were either finalized but not transmitted or submitted but not reviewed and accepted on time, affecting all sampled residents.
The facility did not ensure that care plans were individualized, person-centered, or included measurable goals and interventions for residents with complex needs such as respiratory infections, diabetes, nutrition, UTIs, and fluid restrictions. For example, a resident with ongoing respiratory issues had a care plan that only addressed antibiotics and oxygen, while another with diabetes and significant weight gain had no care plan interventions for nutrition or education. Staff interviews confirmed that care plans were not consistently updated to reflect residents' current needs or preferences.
The facility did not provide or document risk versus benefit information for psychotropic medications to two residents and their representatives. Despite multiple medication changes and the use of high-risk drugs, there was no evidence that risks, benefits, options, or alternatives were discussed or acknowledged. Staff confirmed that the facility did not have a process for reviewing or documenting this information.
A resident was discharged without the required notification to the state LTC Ombudsman. Review of records and interviews with the Social Services Director revealed that the facility's process only included ombudsman notification for hospital transfers, not discharges, resulting in the omission of the discharge notice for this resident.
A resident with multiple sclerosis and a denuded area on the left buttock did not receive comprehensive wound assessments or have treatment orders in place. Documentation was incomplete and did not follow best practice guidelines or facility policy, and staff confirmed that the wound was not fully assessed or managed according to protocol.
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.
The facility failed to report incidents of serious bodily injury within the required timeframe for two residents. One resident with a fractured fibula and another with a fractured femur experienced delays in reporting to APS, exceeding the two-hour requirement. The Director of Nursing confirmed these delays during an interview.
The facility failed to properly store oxygen tubing and CPAP mask/tubing for several residents, leading to potential cross-contamination. Observations showed that oxygen and CPAP supplies were not stored in bags as required by facility policy. The Director of Nursing confirmed the expectation for proper storage, but it was not followed, indicating a lapse in infection prevention and control practices.
The facility failed to ensure that three nursing assistants completed the required 12 hours of continuing education annually, as mandated by licensure regulations. Interviews revealed a lack of awareness among staff regarding the required hours, and the Director of Nursing confirmed the oversight in monitoring education hours. The absence of a Staff Development Coordinator contributed to the deficiency, with the Payroll Coordinator responsible for auditing and notifying supervisors about incomplete education hours.
A resident with asthma did not have their nebulizer cleaned after each use, contrary to facility policy, leading to potential cross-contamination. Observations showed liquid residue in the nebulizer chamber, and interviews with the resident, an LPN, and the DON confirmed the failure to rinse the nebulizer as required.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the required systems to safeguard residents from these incidents were either not in place or not adequately enforced. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training, inconsistent reporting mechanisms, and a lack of clear protocols for identifying and responding to potential abuse, neglect, or theft events. As a result, residents were left vulnerable due to the absence of comprehensive preventive measures and oversight, as directly evidenced by the survey findings.
Failure to Post Actual Nurse Staffing Hours on Daily Reports
Penalty
Summary
The facility failed to ensure that the required daily posting of nurse staffing information included the actual hours worked for each staff category. Observations on multiple dates revealed that the Report of Nursing Staff Directly Responsible for Resident Care was posted in a common area, and while the reports listed the number of RNs, LPNs, and nurse aides assigned to each shift, they did not include the actual hours worked by each staff category as required by facility policy. The posted reports only indicated the number of staff per shift and the resident census, omitting the specific work hours for each staff type. Record review of the facility's policy confirmed that the daily posting should include the actual time worked during each shift for every category and type of nursing staff. During an interview, the Director of Nursing acknowledged that the posted reports did not contain the required information regarding actual hours worked. No information was provided about any residents' medical history or condition in relation to this deficiency.
Multiple Infection Control Failures in Staff Screening, Hand Hygiene, and Equipment Storage
Penalty
Summary
The facility failed to ensure that pre-employment health screenings were completed for a newly re-hired nurse aide. Although the facility's policy required all new hires to complete a health screening and tuberculosis test during general orientation, the personnel and medical files for the nurse aide did not contain documentation of a health screening for the current hire date. The business office and infection preventionist confirmed that the health screen was not repeated upon re-hire, despite a gap in employment. Dietary staff were observed not adhering to hand hygiene and personal grooming standards during meal service. A dietary aide with long artificial nails, which is prohibited by facility policy, was seen serving food and drinks to residents without performing hand hygiene between tasks or wearing gloves. The dietary manager was aware of the artificial nails but did not consider them a concern, and the infection preventionist confirmed that artificial nails should not be worn in the dietary department. The aide's competency review indicated requirements for short, unpolished, and clean nails, as well as proper handwashing, which were not followed during the observed meal service. The facility also failed to maintain sanitary storage and documentation for oxygen delivery devices and nebulizer equipment for two residents. Observations revealed that oxygen tubing was stored on the floor or in bags with outdated or missing labels, and there were no clear directions in the administration records for changing the equipment as required by policy. Additionally, enhanced barrier precautions (EBP) were not properly implemented for residents with wounds or at risk for multidrug-resistant organisms. PPE was not available near or outside resident rooms as required, and staff were not consistently aware of EBP protocols. These failures affected multiple residents, including those with chronic wounds, respiratory conditions, and those requiring supplemental oxygen.
Failure to Submit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to ensure that all Minimum Data Set (MDS) assessments for residents were submitted to the State within the required 14-day period after completion. This deficiency affected all seven residents sampled, as their MDS data was either finalized but not transmitted or submitted but not reviewed and accepted within the mandated timeframe. The facility's policy requires timely and accurate completion and submission of MDS assessments in compliance with federal and state regulations, with oversight by the MDS Coordinator and the interdisciplinary team. However, due to the MDS Coordinator's frequent absences and being the sole individual responsible for MDS data, the submission process was delayed, and no other staff monitored or managed the workload in the Coordinator's absence. Record reviews confirmed that for each of the seven residents sampled, the MDS data was either finalized but not sent or was in a production batch that had not been reviewed and accepted within the required period. Interviews with the MDS Coordinator corroborated that the assessments were not submitted on time, and there was no backup process in place to ensure timely submission during the Coordinator's absence. The facility census at the time was 73 residents, and the deficiency was identified through both record review and staff interviews.
Failure to Develop and Implement Individualized, Measurable Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, individualized care plans were developed and implemented for several residents, as required by both federal and state regulations. Specifically, care plans lacked person-centered goals, measurable objectives, and appropriate interventions for conditions such as respiratory infections, diabetes, nutrition, urinary tract infections, fluid restrictions, and resident choices. For example, one resident with a complex medical history including pneumonia, heart failure, and chronic kidney disease experienced multiple medication changes and ongoing respiratory symptoms, yet the care plan only addressed antibiotic use and oxygen therapy, omitting other relevant interventions for respiratory status and chronic cough. Another resident with diabetes, bilateral lower extremity amputations, and significant weight gain had a care plan that did not address nutritional choices, diabetic education, or set measurable weight goals, despite the resident keeping high-sugar snacks at the bedside and expressing knowledge of the risks. Similarly, a resident with a history of recurrent urinary tract and yeast infections had a care plan that only addressed a single episode of UTI and did not reflect the resident's infection history or all relevant interventions. Observations and interviews confirmed that care plans were not updated to reflect ongoing or recurrent issues, and that interventions were not tailored to the residents' individual needs and preferences. Additionally, a resident with chronic kidney disease and a physician-ordered fluid restriction was known by staff and family to be noncompliant with the restriction, but this was not reflected in the care plan. Interviews with staff, including the MDS Coordinator and DON, confirmed that care plans were often not personalized, and that acute issues were removed from care plans once resolved, without maintaining a history of significant conditions. The facility's own policy required individualized, comprehensive care plans, but in practice, care plans were not consistently updated or detailed to guide staff in providing individualized care.
Failure to Inform Residents and Representatives of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents and their representatives were fully informed about the risks, benefits, options, and alternatives of psychotropic medications prior to starting or changing such medications. For two of five sampled residents, documentation and interviews revealed that no risk versus benefit information was provided or discussed in plain language, and there was no evidence that residents or their representatives signed or received any such information. Instead, the facility only documented that family members were notified of medication changes in the progress notes, without specifying the content of those discussions. One resident, who was cognitively intact and had multiple complex diagnoses including breast cancer, diabetes, hypertension, and coronary artery disease, received several psychotropic medications for anxiety and depression. The medical record showed multiple medication changes, including new orders for Buspar, Ativan, and Hydroxyzine, but there was no documentation of any risk and benefit discussion or signed acknowledgment by the resident or representative. The MDS Coordinator and DON both confirmed that the facility did not have a process for reviewing or documenting the risks and benefits of psychotropic medications with residents or their representatives. Another resident, with diagnoses including Alzheimer's disease, insomnia, nightmare disorder, depression, unspecified dementia with agitation, and convulsions, was prescribed multiple high-risk medications such as antipsychotics, antidepressants, anticonvulsants, and diuretics. The care plan included non-pharmacological interventions and monitoring for side effects, but there was no available documentation of risk versus benefit information being provided to the resident or representative. The DON confirmed that the facility had never reviewed or documented such information with residents or their representatives.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the state Long Term Care Ombudsman of a resident's discharge, as required by both facility policy and regulatory requirements. Record review showed that a resident was admitted and subsequently discharged, but there was no documentation in the medical record indicating that a discharge notice was provided to the ombudsman. The facility's policy specifies that a copy of all discharge notices must be sent to the ombudsman and relevant state agencies, with documentation of the date this was completed in the resident's record. Interviews with the Social Services Director (SSD) revealed that the SSD was unaware of the requirement to notify the ombudsman of resident discharges, and only notified the ombudsman of hospital transfers. Review of the facility's monthly notification email and the Emergency Transfers From Facility form confirmed that the resident's discharge was not included in the ombudsman notification. The SSD confirmed that the omission was due to a lack of awareness of the requirement.
Failure to Routinely Assess and Obtain Treatment Orders for Resident Wound
Penalty
Summary
The facility failed to ensure that wounds were comprehensively assessed on a routine basis and did not obtain treatment orders for a wound for one resident. The resident, who had multiple sclerosis and was admitted with a denuded area on the left buttock, was identified as having a potential for skin breakdown. The care plan included weekly skin assessments but did not list any treatment interventions for the wound. Documentation in the resident's records showed inconsistent and incomplete wound assessments, with missing details such as anatomical location, wound characteristics, and pain or symptom reporting. Progress notes and skin condition records indicated the presence of an open area on the left buttock, but assessments lacked comprehensive information as outlined in best practice guidelines and facility policy. Despite ongoing documentation of the wound, there were no physician orders for wound care in the resident's medical record during the review period. Interviews with nursing staff and the DON confirmed that the wound was not fully assessed or documented on a routine or weekly basis, and that no treatment orders were obtained for the area. This failure to follow established protocols and obtain necessary physician orders resulted in a deficiency related to the comprehensive assessment and management of wounds.
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.
Delayed Reporting of Serious Bodily Injuries
Penalty
Summary
The facility failed to report incidents resulting in serious bodily injury within the required timeframe for two residents. Resident 2, who had a history of a fractured right fibula, dizziness, type 2 diabetes mellitus, and dementia, experienced a fall on 10/19/2024. Initially, the resident denied injury, but later notes indicated bruising and pain to the right ankle, which was eventually diagnosed as a fracture on 10/21/2024. The incident was reported to Adult Protective Services (APS) on 10/22/2024, more than two hours after the suspicion of serious bodily injury was formed, and the investigative report was submitted to the state agency after more than five calendar days. Resident 6, with diagnoses including a fractured right femur, irregular heartbeat, heart failure, dementia, high blood pressure, and a history of a heart attack, was found on the floor on 08/16/2024 with pain and inability to move the right leg. The resident was transported to the emergency room and diagnosed with a right femur fracture. The incident was reported to APS on 08/19/2024, again exceeding the two-hour reporting requirement. The Director of Nursing confirmed these reporting delays during an interview on 12/16/2024.
Improper Storage of Oxygen and CPAP Supplies
Penalty
Summary
The facility failed to properly store oxygen tubing and CPAP mask/tubing to prevent potential cross-contamination for several residents. Observations revealed that Resident 7's oxygen tubing was not stored in the attached bag on the concentrator when not in use, despite the facility policy requiring such storage. Similarly, Resident 23's CPAP mask and tubing were found draped over the CPAP machine without a storage bag, and the oxygen tubing was also improperly stored. The Director of Nursing confirmed that the facility's expectation was to store these supplies in a bag to prevent cross-contamination, but this was not adhered to. Resident 59's oxygen tubing was observed to be under the handle of the concentrator and not stored in a bag, as required by the facility's policy. The Director of Nursing acknowledged that the staff had been educated on the proper storage practices, yet the tubing was still not stored according to policy. Additionally, Resident 53's oxygen tubing was found coiled and tucked under the concentrator handle without being stored in a bag, and the nasal prongs were not properly positioned in the resident's nostrils during use. Resident 42's oxygen tubing was observed to be improperly stored, with the nasal cannula touching the wheelchair tire and the tubing wrapped around the flow meter of a portable oxygen tank. The facility's policy did not address the storage of oxygen tubing with portable tanks, and the Director of Nursing confirmed that the expectation was for the tubing to be stored in a bag when not in use. These observations indicate a failure to adhere to infection prevention and control practices, as outlined in the facility's policy.
Deficiency in Nursing Assistant Continuing Education Compliance
Penalty
Summary
The facility failed to ensure that three nursing assistants completed the required 12 hours of continuing education annually, as mandated by the licensure reference number 175 NAC 12.006.4(B)(ii)(1). Specifically, NA-A, NA-C, and NA-D did not meet the continuing education requirements, with NA-A completing zero hours, NA-C completing 11.75 hours, and NA-D completing 9.25 hours within their respective annual periods. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adequately monitor or enforce the completion of these education hours. Interviews with nursing assistants NA-F and NA-G indicated a lack of awareness regarding the exact number of required continuing education hours, with incorrect estimates of 72 and 40 hours, respectively. The Director of Nursing confirmed the oversight in monitoring the education hours and acknowledged that staff continued to work without completing the required training. Additionally, the Business Office Manager confirmed the absence of a Staff Development Coordinator, with the Payroll Coordinator responsible for auditing education hours and notifying supervisors. However, the facility's policy of withholding annual pay increases until education hours are completed was not sufficient to ensure compliance with the training requirements.
Failure to Clean Nebulizer After Use
Penalty
Summary
The facility failed to ensure proper cleaning of a Metered Dose Inhaler (Nebulizer) after each use, which is necessary to prevent potential cross-contamination. This deficiency was identified for one resident, who was diagnosed with asthma and had a prescribed order for Ipratropium-Albuterol solution to be administered via nebulization three times a day. The facility's policy on administering medications through a nebulizer requires that the equipment be rinsed in warm water after each use to ensure safe administration of inhaled medications. Observations and interviews revealed that the nebulizer used by the resident was not being rinsed after treatments. On two separate occasions, a clear liquid was observed in the nebulizer chamber, indicating it had not been cleaned. Interviews with the resident and a Licensed Practical Nurse (LPN) confirmed that the nebulizer was not rinsed after each use. The Director of Nursing also confirmed that the facility's expectation, as per policy, was for staff to rinse the nebulizer after medication administration, which was not being followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 88 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Holdrege
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Homes Health Care Center | 2.5 mi | ★★★★★ | 13 | 0 |
| Bertrand Nursing Home | 15.2 mi | ★★★★★ | 0 | 0 |
| Brookestone Gardens | 20.9 mi | ★★★★★ | 8 | 0 |
| Bethany Home, Inc | 21.6 mi | ★★★★★ | 0 | 0 |
| Mt Carmel Home - Keens Memorial | 22.3 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Holdrege Memorial Homes, Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.