Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Linden Court during CMS and state inspections, most recent first.
Food storage and prep practices were deficient when surveyors found expired buttermilk, improperly stored and opened food items, and undated opened pasta in kitchen storage areas. During meal prep, a CL handled raw meat, casseroles, and parmesan cheese with inadequate hand hygiene and reused soiled gloves and utensils, while a CA also reached over a food cart with uncovered arms and washed hands for only 10 seconds before handling dessert.
Staff failed to consistently follow infection control practices when caring for residents in Red Zone and Light Red Zone rooms. Observations showed NAs and an Hskp moving between infectious and non-infectious rooms while wearing the same PPE, not changing masks or disinfecting eyewear, not performing HH, and handling dishes, supplies, and handrails in the hallway. The DON and IP were also observed in the area while these practices occurred, and the Hskp confirmed rooms on transmission-based precautions were cleaned interspersed with rooms that were not on precautions.
Failure to notify the ombudsman of two resident discharges. Record review showed two residents were discharged, but a fax from the SSS did not show that either discharge had been reported. The Administrator confirmed the ombudsman was not notified, and the DON stated the facility had no discharge policy and that the nursing discharge checklist did not include duties for departments outside nursing.
MDS coding was inaccurate for two residents. One resident with NSTEMI was receiving clopidogrel, an antiplatelet, but the MDS marked Antiplatelet as No instead of Yes. Another resident with Bipolar Disorder had a PASRR Level II determination, but the significant change MDS marked PASRR as No and skipped the related Level II section even though staff confirmed the resident should have been coded as Yes.
Chemical wipes were left in plain view on toilet tanks in bathrooms used by three residents, including residents with ESBL, dementia, and macular degeneration. Staff and the administrator acknowledged the wipes were accessible in areas used by residents who may have memory or vision issues, and the SDS identified the product as a disinfectant with eye irritation hazards and cautions to keep it out of reach.
A resident with dementia, urinary incontinence, and long-term antibiotic use remained on daily Bactrim for UTI prophylaxis without a stop date. The DON confirmed there had been no stop trial since admission, and the IP and DON stated the facility tracked antibiotics only while infection signs and symptoms were present, with no continuous monitoring or additional follow-up for long-term antibiotic therapy.
A resident's wedding ring was reported missing by a family member, prompting an incomplete investigation by facility staff. The search included the resident's room and interviews with some staff and a roommate's family member, but did not include all staff with access or a documented timeline of the ring's disappearance. Required documentation of interviews and a thorough investigation, as outlined in facility policy, were not completed.
The facility did not consistently implement its elopement prevention protocols, resulting in incomplete Elopement Risk Manuals, unsecured entrance doors without adequate supervision, and insufficient staff education on elopement procedures. Several high-risk residents were not properly documented in the required manuals, and some staff were unaware of which residents were at risk or how to access relevant information.
Surveyors identified that several residents' MDS assessments were inaccurately coded, including incorrect documentation of medication use and incomplete care area assessment (CAA) summaries. For example, medications were listed as administered when they were not, and required rationales for care planning decisions regarding cognitive impairment and urinary incontinence were left blank or not addressed. MDS coordinators confirmed these errors and omissions during interviews.
A resident's care plan was not updated to remove anticoagulant and antidepressant medications that were no longer being administered, as confirmed by the MAR and MDS review. Facility policy requires care plans to be revised after each MDS assessment and as needed, but this was not done in this case.
The facility failed to ensure proper hand hygiene and hair restraint use in the kitchen, potentially affecting all residents. Culinary Lead-B did not perform hand hygiene after handling raw meat, and Culinary Assistant-C was observed without a hair restraint. The facility relied on the 2017 Nebraska Food Code for guidance but lacked a specific policy for hair restraints.
The facility failed to follow infection control practices during environmental cleaning and PPE application. A housekeeping staff member was observed not changing gloves between rooms, and a Nurses Assistant improperly applied a gown before entering an Enhanced Barrier Precautions room. These actions were confirmed to be against facility policy by the Infection Preventionist nurse.
The facility failed to include specific medical needs in the care plans of two residents. One resident on anticoagulant therapy did not have this treatment reflected in their care plan, while another resident undergoing hemodialysis lacked a focus area for dialysis in their care plan. These omissions were confirmed by facility staff.
A resident experienced significant weight loss, but the facility failed to update the care plan to reflect this change. Despite the resident's dietary needs changing to a mechanical soft diet, the care plan still indicated a regular diet. Interviews with staff revealed a lack of communication and follow-through in updating the care plan, with the MDS Nurse and RD not ensuring the care plan reflected the resident's current needs.
A resident was discharged without a complete discharge summary, missing key information such as a recapitulation of stay, assistance needs, continence status, skin condition, and medication reconciliation. The LPN responsible was unaware of the requirements, and the facility lacked a specific discharge policy, relying instead on an incomplete checklist.
The facility failed to administer medications correctly, resulting in a 9.38% error rate. A resident received rivaroxaban without food, another was given potassium chloride without food, and a third received an incorrect dosage of MiraLAX. These errors highlight non-compliance with medication protocols.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
Food storage and preparation practices were found to be out of compliance during survey observations and interviews. In the walk-in refrigerator, surveyors observed a half-gallon bottle of buttermilk dated best by 4/11/2026, a tray of hamburger stored above a pan of cheesecake with loose saran wrap, and in the walk-in freezer an opened box of hamburger patties that was not sealed. In dry storage, a bottle of Coffee Mate hazelnut liquid creamer had a caved-in lid and was available for use, and opened packages of penne and rotini pasta were resealed without any date showing when they were opened. The Culinary and Dining Coordinator confirmed these items during interview. During meal preparation observations, the Culinary Lead handled raw hamburger meat and food items with inadequate hand hygiene and glove changes. The Culinary Lead completed hand hygiene for 10 seconds, put on gloves, handled raw meat, and continued using the same soiled gloves while breaking up meat and transferring meat from an opened package into a pan. Later, the Culinary Lead stirred casseroles, placed a soiled spoon on top of another pan, reused the spoon after wiping the handle with a paper towel, and used the same gloves while handling parmesan cheese and stirring additional food items. In another observation, a Culinary Assistant reached over clothing protectors on a food transport cart with uncovered arms, and in the satellite kitchen the Culinary Assistant used different scoops for food items, washed hands for 10 seconds, and then grabbed dessert from the refrigerator. Chef-O confirmed that hands needed to be washed for 20 seconds and gloves should have been changed before touching meat and cheese.
Infection Control Lapses With PPE, Hand Hygiene, and Room Cleaning
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not consistently change PPE, perform hand hygiene, or separate work in infectious rooms from non-infectious rooms. Survey observations identified multiple residents with Red Zone or Light Red Zone signage on their doors, including residents in rooms designated for COVID-19 isolation. Guidance reviewed by surveyors stated that staff caring for residents with SARS-CoV-2 infection should wear full PPE and remove and discard the respirator after the patient care encounter, and that hand hygiene should be performed before and after resident contact and between resident rooms. During observation, a nurse aide exited an infectious room wearing full PPE, moved dishes to a cart, applied ABHR to gloved hands, and then entered multiple other resident rooms while wearing the same PPE. The nurse aide also touched a light switch, stood in the hallway talking to another staff member while still in PPE, removed gown and gloves only after leaving the rooms, and touched eyewear with a bare hand before performing hand hygiene. Another nurse aide was observed entering and exiting a red zone room, then entering the nurse's station and later another resident room without first disinfecting eyewear or changing the mask. Additional observations showed staff handling food and supplies in the hallway while wearing PPE from red zone rooms, touching handrails, and interacting with other staff without changing or disinfecting PPE between rooms. Housekeeping practices were also inconsistent with the infection control guidance reviewed by surveyors. A housekeeper was observed exiting a room with housekeeping supplies, placing the supplies into the cart without disinfecting them, then putting on a new gown and gloves and entering another room without changing the mask or disinfecting eyewear. The same housekeeper was later observed cleaning a red zone room and then moving to another room that was not on transmission-based precautions, with the housekeeper confirming in interview that rooms in the Red Zone or Light Red Zone were cleaned interspersed with rooms that were not on transmission-based precautions when there were many infected residents. The Infection Preventionist confirmed hand hygiene expectations during resident care and between rooms, and survey observations also documented staff leaving rooms without performing hand hygiene and leaving red zone rooms without cleaning eye protection or changing masks.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the ombudsman of the discharge of 2 sampled residents, Residents 116 and 118. Record review showed Resident 116 was discharged from the facility on 3/17/2026, and Resident 118 was discharged on 3/13/2026. A fax sent to the ombudsman by the Social Services Supervisor on 4/1/2026 showed no evidence that either resident’s discharge had been reported. During interview on 04/14/2026 at 2:22 PM, the Administrator confirmed the ombudsman had not been notified of either discharge. During interview on 4/15/2026 at 2:00 PM, the DON stated the facility did not have a policy related to resident discharge and said the nursing department used a discharge checklist that did not include duties for departments outside nursing.
MDS Coding Errors for Antiplatelet Medication and PASRR Status
Penalty
Summary
The facility failed to ensure Resident 3’s MDS was coded accurately for antiplatelet medication use. Record review showed the resident was admitted with a diagnosis of NSTEMI myocardial infarction and had an order for clopidogrel bisulfate 75 mg daily, which was documented as administered from March 4 through March 29, 2026. The RAI Manual states antiplatelet should be coded Yes if the resident received antiplatelet medications during the 7-day lookback period, but Resident 3’s MDS marked Antiplatelet as No. An MDS-L confirmed that clopidogrel should have been marked Yes and was not. The facility also failed to code Resident 5’s PASRR status accurately on the MDS. Resident 5 had a diagnosis of Bipolar Disorder and a PASRR Level II Determination Notification showing approval for 180 days at a nursing home without additional services. The annual MDS marked A1500 as Yes and identified serious mental illness, but the significant change MDS later marked A1500 as No and skipped A1510, indicating the resident was not currently considered by the state Level II PASRR process. Interviews with MDS nursing and social services staff confirmed the PASRR sections on the MDS should have been marked Yes for Resident 5, and the Director of Social Services-Consultant confirmed Resident 5 was a Level II and that it was missed on the significant change MDS.
Chemical Wipes Left Accessible in Resident Bathrooms
Penalty
Summary
The facility failed to provide an environment free of accident hazards related to chemicals in resident bathrooms for three residents. During observation, a cylindrical container of Micro-Kill D1 Germicidal Wipes was found sitting on the toilet tank in the bathroom used by Resident 92, with a wipe hanging out of the lid. Resident 92 stated they did not know anything about it. Staff later confirmed the wipes are used for residents who occupy bathrooms with transmissible bacteria, and Resident 92’s record showed ESBL and a care plan intervention to maintain an environment free of clutter and safety hazards. A similar observation in the bathroom shared by Residents 18 and 113 showed another container of Micro-Kill D1 Germicidal Wipes sitting on the toilet tank. Resident 18 stated they did not know anything about it, and Resident 113 was sleeping and unable to be aroused. Resident 18’s record showed ESBL and dementia, while Resident 113’s record showed macular degeneration and a care plan intervention to maintain an uncluttered environment free of obstacles and safety hazards. Maintenance staff confirmed the wipes were present in the bathroom and stated they did not know if the wipes were acceptable to keep there for residents with memory or vision issues. The SDS for the wipes identified them as a disinfectant with eye irritation hazards and cautioned to keep them out of reach of children and avoid contact with eyes or clothing. The administrator agreed that a confused or visually impaired resident could mistake the container for personal cleansing wipes when it was accessible and in plain view.
Failure to Track Stop Date for Long-Term Antibiotic Use
Penalty
Summary
The facility failed to ensure a stop date for an antibiotic medication for one resident. Resident 15 had diagnoses including unspecified dementia with behavioral disturbance, cognitive communication deficit, urinary incontinence, auditory hallucinations, and long-term current use of antibiotics. The resident’s orders included Bactrim 400-80 mg, 1 tablet by mouth daily, related to long-term use of antibiotics, with instructions to continue the order, but no stop date was identified for the antibiotic. Record review also showed the resident had been admitted with an antibiotic for UTI prophylaxis that was changed to Bactrim after admission. The DON confirmed there had not been a stop trial on the antibiotic since admission and that there had been no attempt at alternatives recommended by the pharmacist for other medications listed on the MRR. The IP and DON confirmed the facility tracked antibiotic cases in PCC while signs and symptoms of infection were present, but there was no continuous observation or tracking of antibiotics for residents on long-term antibiotic therapy, and no additional follow-up for medication reviews or trials off the antibiotic for this resident.
Failure to Thoroughly Investigate Missing Resident Property
Penalty
Summary
The facility failed to conduct and document a thorough investigation into the misappropriation of a resident's property, specifically a wedding ring belonging to a resident who had been admitted in July 2022. The resident's personal inventory included several rings of value, and the missing wedding ring was reported by a family member after noticing its absence during a visit. The family member had last seen the ring during a previous visit and, upon discovering it missing, reported it to the nurse on duty. The facility's investigation, as documented, included searching the resident's room and the unit, and interviewing the roommate's daughter, but did not include interviews with all staff who had access to the resident or the resident's belongings. Further, the investigation did not document interviews with all potentially involved staff, nor did it establish a clear timeline for when the ring was last seen. Interviews were conducted with the nurse and aide on duty at the time of the report and the ADON, but the findings from these interviews were not documented. The facility also did not rule out the possibility that misappropriation had occurred, and interviews with other residents were not completed due to their impaired cognition. These actions and omissions are contrary to the facility's own policy, which requires all allegations of abuse or neglect to be thoroughly investigated and documented.
Failure to Maintain Elopement Prevention Protocols and Supervision
Penalty
Summary
The facility failed to provide a safe environment for residents identified as being at risk for elopement, as evidenced by multiple lapses in the implementation of its elopement prevention policy. Observations revealed that the front entrance doors were accessible by sensor and were not consistently monitored or secured, with front desk staffing not covering all hours when the doors were unlocked. Staff members assigned to the front desk were not always aware of their responsibilities regarding monitoring the entrance or the procedures for elopement prevention. Additionally, there was no wander guard system in place to prevent residents from exiting through the front door. Record reviews showed that the Elopement Risk Manuals, which were supposed to contain up-to-date Missing Resident Identification Forms for all residents at risk, were incomplete or missing forms for several high-risk residents across multiple units. Staff interviews indicated a lack of awareness among some nursing assistants regarding which residents were at risk for elopement and where to locate the Elopement Risk Manuals. Furthermore, the process for updating these manuals was not consistently followed, and some staff members responsible for updates were unclear about the procedures. Education and preparedness for elopement prevention were also insufficient. Not all staff had received required training on elopement prevention, and attendance at in-service education events was incomplete. After an actual elopement incident involving a resident, no additional education was provided to staff. Elopement drills were conducted with limited staff participation, and there was a lack of follow-up education after incidents. These deficiencies affected a significant number of residents identified as high risk for elopement.
Inaccurate Coding and Incomplete Documentation in Resident Assessments
Penalty
Summary
The facility failed to accurately code and complete comprehensive assessments for several residents, as evidenced by discrepancies between the Minimum Data Set (MDS) documentation and supporting medical records. For one resident, the MDS indicated the use of anticoagulant and antidepressant medications during the observation period, but the medication administration record showed that these medications were not in use during that time. Interviews with MDS coordinators confirmed that these medications should not have been coded on the MDS. Another resident was coded on the MDS as having received anticonvulsant medication during the look-back period, but a review of physician orders and the electronic medication administration record revealed no such medication was prescribed or administered. The MDS coordinator confirmed the error in coding. Additionally, the care area assessment (CAA) summaries for two residents were incomplete or incorrectly documented. For one resident, cognitive impairment and urinary incontinence were identified as issues, but the rationale for not addressing these in the care plan was left blank, and the decision not to address them was not explained. The MDS coordinator acknowledged these areas should have been marked to be addressed and properly documented. For another resident, the CAA for urinary incontinence was marked to be addressed in the care plan, but the section requiring a description of the impact and rationale for the care plan decision was left blank. The MDS coordinator confirmed this documentation was incomplete. These findings demonstrate failures in the accurate coding of assessments and completion of care area assessment summaries for multiple residents.
Care Plan Not Updated to Reflect Discontinued Medications
Penalty
Summary
The facility failed to update the care plan for one resident to accurately reflect current care needs. Record review showed that the resident's care plan, last updated on 04/30/2025, listed anticoagulant and antidepressant medications as active, even though the medication administration record indicated that neither medication was in use during the Minimum Data Set (MDS) observation period. The most recent quarterly MDS assessment was completed on 04/23/2025. Facility policy requires that the comprehensive care plan be reviewed and revised by the interdisciplinary team after each comprehensive or quarterly MDS assessment, and as needed. Interviews with the MDS Coordinator RN and LPN confirmed that the care plan should not have included the anticoagulant and antidepressant medications, as the resident was no longer taking them during the relevant period.
Failure in Hand Hygiene and Hair Restraint Compliance in Kitchen
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols and hair restraint requirements in the kitchen, potentially affecting all 104 residents. During an observation, Culinary Lead-B (CL-B) was seen preparing meatloaf and did not perform hand hygiene after handling uncooked ground beef. CL-B removed gloves after handling the meat, discarded them, and continued to handle other food items and containers with bare hands before completing hand hygiene only at the end of the preparation process. Interviews with CL-B and the Culinary Director confirmed the failure to perform hand hygiene as required after handling raw meat. Additionally, the facility did not enforce the use of hair restraints in the kitchen as per the 2017 Nebraska Food Code, which the facility used for guidance. An observation revealed Culinary Assistant-C (CA-C) walking through the food preparation area without a hair restraint. The Culinary Director, who was present during the observation, confirmed that CA-C should have been wearing a hair restraint. The facility lacked a specific policy for hair restraints, relying instead on the state food code.
Infection Control Lapses in PPE and Environmental Cleaning
Penalty
Summary
The facility failed to adhere to infection control practices during environmental cleaning and the application of Personal Protection Equipment (PPE). Observations on the 100 Hall revealed a housekeeping staff member exiting a resident's room with gloves on, then replenishing supplies at the housekeeping cart and entering another room without changing gloves. This practice was repeated in three resident rooms. Additionally, a Nurses Assistant was observed improperly applying a gown by not tying it at the neck before entering an Enhanced Barrier Precautions room. Interviews confirmed that these actions were not in line with the facility's policies, as the housekeeping staff should have removed gloves and performed hand hygiene between rooms, and the Nurses Assistant should have properly secured the gown before entering the room. The Infection Preventionist nurse confirmed that the observed practices were against the facility's infection control policies, emphasizing the need for hand hygiene and proper PPE application. The facility's census at the time was 104 residents, indicating the potential for widespread impact due to these lapses in infection control.
Deficiencies in Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, which resulted in deficiencies in addressing their specific medical needs. Resident 99, who was admitted with a diagnosis of cardiac arrhythmia and a history of blood clots, was on long-term anticoagulant therapy. However, the care plan for Resident 99 did not include a focus area for anticoagulant use, which was confirmed by the MDS nurse during an interview. This oversight meant that the care plan did not reflect the necessary monitoring and interventions required for the resident's anticoagulant therapy. Similarly, Resident 97, who was on hemodialysis due to end-stage renal disease, did not have dialysis included as a focus area in their care plan. Despite being scheduled for dialysis three times a week since admission, the care plan lacked any mention of dialysis-related interventions or monitoring. This was confirmed by both the MDS nurse and the Director of Nursing, who acknowledged the omission and the importance of including dialysis in the care plan due to its potential side effects and complications.
Failure to Update Care Plan for Resident's Weight Loss
Penalty
Summary
The facility failed to ensure that the care plan for a resident, identified as Resident 94, was reviewed and revised to reflect significant weight loss. The resident, who was admitted with diagnoses including pneumonia, altered mental status, and functional diarrhea, experienced a 7% weight loss over 30 days. Despite this, the care plan was not updated to include new interventions or strategies to address the weight loss. The resident's care plan, dated several months after admission, still reflected a regular diet, even though the resident had been changed to a mechanical soft diet due to difficulty chewing. Interviews with facility staff revealed a lack of communication and follow-through in updating the care plan. The MDS Nurse, responsible for overseeing the care plan, indicated that each department was responsible for entering their own data and interventions, but the care plan was not revised to reflect the resident's current needs. The Registered Dietician believed the existing care plan was sufficient, despite acknowledging the resident's dietary changes. The Director of Nursing confirmed that the care plan should have been updated to include the resident's weight loss under the core focus area, indicating a lapse in the facility's care planning process.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, identified as Resident 102, who was discharged on 10/31/2024. The discharge summary lacked critical information such as a recapitulation of the resident's stay, details on physical functioning and assistance level needs, continence status, skin condition, and a reconciliation of medications. The resident had a history of a right femur fracture with surgical correction and high blood pressure, and was on a high-risk anticoagulant medication. The Minimum Data Set (MDS) indicated that the resident required supervision with bathing, setup assistance with eating, and was independent with other activities of daily living, was occasionally incontinent of urine, and had no skin conditions. Interviews with the LPN responsible for completing the discharge summary and the Director of Nursing revealed that the necessary sections of the discharge summary were left incomplete due to a lack of awareness of the requirements. The facility did not have a specific policy regarding discharges but used a checklist to ensure all steps were completed. However, the checklist failed to ensure the inclusion of all necessary information in the discharge summary, leading to the deficiency identified by the surveyors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications correctly to three residents, resulting in a medication error rate of 9.38%, which exceeds the acceptable threshold of less than 5%. Resident 99, who has a history of blood clots and is on anticoagulants, was given rivaroxaban without food, contrary to the physician's order that it should be administered with food to ensure efficacy. Similarly, Resident 3, diagnosed with dementia and GERD, received potassium chloride without food, which was against the prescribed order to administer it with or after meals to prevent gastrointestinal irritation. Additionally, Resident 96, who suffers from constipation, was given an incorrect dosage of MiraLAX. The RN measured the MiraLAX powder using a medication cup instead of the bottle's lid, leading to an incorrect dosage. The RN was unaware of the proper conversion from cubic centimeters to grams, resulting in a failure to administer the correct 17 grams as prescribed. These errors highlight a lack of adherence to medication administration protocols, contributing to the facility's high medication error rate.
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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 North Platte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of North Platte | 0.6 mi | ★★★★★ | 0 | 0 |
| Adept Nursing & Rehab Of North Platte | 2.1 mi | ★★★★★ | 4 | 0 |
| Adept Nursing & Rehab Of Sutherland | 16.8 mi | ★★★★★ | 13 | 2 |
| Hilltop Estates | 36.6 mi | ★★★★★ | 0 | 0 |
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