Below average — CMS composite of the measures below.
The next survey window likely opens 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 Mid-nebraska Lutheran Home during CMS and state inspections, most recent first.
The facility failed to report, investigate, and submit the results of an allegation of neglect involving a resident with dementia, impaired cognition, and assistance needs for toileting and dressing. A police officer responded to a complaint that the resident was locked in their room, but the facility had no evidence that the allegation was reported to the State agency or that an investigation was completed, and the DON/Administrator confirmed the lapse.
Late or Missing Informed Consent for Psychotropic Medications: The facility failed to obtain informed consent in advance for psychotropic meds for four residents. Records showed residents with dementia, depression, anxiety, bipolar disorder, and behavior issues received antidepressant, antianxiety, and antipsychotic meds before consent was signed, and one resident had no consent on file for a psychotropic med. The MDS Coordinator confirmed the consents were obtained after the meds had already been started or were missing.
Failure to offer and document flu and pneumococcal vaccinations. The facility did not provide required resident education on vaccine risks and benefits, and records showed that one resident had consented to Prevnar 20 but did not receive it, while two other residents had no evidence of screening, education, offering, or receipt of the indicated vaccines.
A resident with severe cognitive impairment and total dependence on staff was found with significant bruising and swelling on the right foot. The facility did not conduct a thorough investigation into the cause of the injury, failed to interview staff or evaluate transfer procedures, and did not report the results to the State Agency as required by policy.
Failure to Report Injury of Unknown Origin: A resident with severe cognitive impairment, non-Alzheimer dementia, and a psychotic disorder developed significant bruising and swelling to the R foot, with staff documenting physician notification but no witnessed cause for the injury. The DON confirmed the incident was not reported to the State Agency as an injury of unknown origin.
Failure to identify and document resident change in condition: A resident with a history of pneumonia and coughing with liquids coughed forcefully and reported increased SOB after oral meds were given with water. The resident continued coughing, later refused water because of fear of coughing or choking, and the chart lacked documentation of the episode along with VS, lung sounds, and O2 levels. Later notes showed productive cough, wheezes, weakness, low BP, and O2 sat of 92%, and the resident was admitted to the hospital with pneumonia; the DON confirmed the physician was not notified of the cough.
A resident with severe cognitive impairment, dementia, anxiety, depression, and behavioral symptoms was receiving psychotropic medications for behavior management. The record showed GDRs for Venlafaxine and Divalproex ER were marked contraindicated, but there was no resident-specific rationale documented to support either contraindication.
An LPN failed to wash hands or use hand sanitizer before preparing medications for a resident and handled oral meds with gloved hands instead of pouring them directly into a medication cup. The LPN touched the computer mouse and medication cart drawer with gloved hands while preparing a multivitamin and L-methylfolate, and the DON confirmed the expected hand hygiene and medication handling process.
Two residents were not properly screened, educated, or offered the COVID-19 vaccine as required by facility policy. One resident's representative signed consent, but the vaccine was not administered, and another resident's record had no evidence of vaccine status screening, education on risks and benefits, or vaccine offer/administration. The IP confirmed the missing education and vaccine process during interview.
A resident with multiple diagnoses experienced a fall resulting in a head injury and severe back pain, with symptoms worsening over several days. Despite persistent complaints and escalating pain, staff did not notify the PCP of the change in condition until the resident became unresponsive and required hospital transfer for a brain bleed, contrary to facility policy requiring prompt physician notification.
A resident with multiple medical conditions experienced a fall resulting in a head laceration and ongoing severe back pain. Despite continued complaints of pain, increased confusion, and behavioral changes, staff did not complete or document assessments as required by facility policy. The resident's condition deteriorated over several days, culminating in lethargy and unresponsive pupils, which led to hospital transfer and diagnosis of a brain bleed.
Two residents in the facility experienced multiple falls, some resulting in injury, due to the facility's failure to identify causal factors and develop effective interventions. Despite the residents' medical conditions and history of falls, the facility did not consistently revise or implement new strategies to prevent further incidents, highlighting a significant deficiency in care planning and risk management.
A resident with a feeding tube was prescribed Bacitracin ointment without a defined duration, contrary to the facility's antibiotic stewardship policy. The resident received the ointment for over five years without a stop date, as confirmed by the DON, leading to a deficiency.
A facility failed to securely store medications, leaving a medication cart unlocked and unattended, and medications unsecured in a resident's room. The resident confirmed that staff left medications in the room for convenience, despite no assessment or order for self-administration. The DON verified that medications should be stored securely and the cart locked when unattended.
The facility did not submit the required PBJ data for Q3 2024, covering staffing information from April 1 to July 30, to CMS. This deficiency was confirmed during an interview with the Provisional Administrator, who stated that the facility was unaware of how to submit the information. The failure to submit the data had the potential to affect all 34 residents in the facility.
Failure to Report and Investigate Allegation of Neglect
Penalty
Summary
The facility failed to report, investigate, and submit the results of an allegation of potential neglect involving one resident to the required state agency. The facility’s Abuse and Neglect Policy required staff to immediately report suspected abuse or neglect to the Charge Nurse, DON, SSD, and Administrator, and required the Administrator or designee to notify the state licensing/certification agency, the Ombudsman, the resident’s representative, APS, the PCP, and the Medical Director within the required timeframes. The policy also required a written report of the investigation findings within 5 working days. Resident 3 had diagnoses including non-traumatic brain dysfunction, Alzheimer’s disease with late onset, high blood pressure, end stage renal disease, non-Alzheimer’s dementia, anxiety, and psychotic disorder, with impaired cognition, rejection of cares, and need for partial to moderate assistance with toileting and dressing. The resident was admitted to the Memory Care Unit due to wandering, verbal behaviors toward others, and rejection of cares. Nursing progress notes documented that a Police Officer came to the facility on a complaint of neglect after receiving a report that the resident was locked in their room. Facility investigation records showed no evidence that the allegation was reported to the State Agency or that an investigation had been completed, and the Administrator confirmed that the police did not substantiate the allegation but the facility failed to investigate, report, and submit the investigation results as required.
Late or Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain signed informed consent in advance for the use of psychotropic medications for Residents 1, 2, 11, and 21. The report states that the facility policy required residents and/or representatives to be educated on the risks related to not taking these medications and that psychotropic medications were to be used only when clinically indicated and documented. Surveyors reviewed records and found that the required consents were signed after the medications had already been started, or were missing altogether. Resident 11 had severe cognitive impairment, hallucinations, delusions, wandering, and diagnoses including non-traumatic brain dysfunction, dementia, Parkinson’s disease, anxiety, and depression. The resident received fluoxetine, lorazepam, Seroquel, and Depakote for behavior management, and the consent forms were signed after the medications had begun, ranging from 17 to 82 days later. The MDS Coordinator confirmed there was no evidence the consents were obtained before administration of the psychotropic medications. Resident 21 had severe cognitive impairment, physical and verbal behaviors, rejected care, and diagnoses of dementia, anxiety, and depression. The resident received Venlafaxine, Buspar, and Seroquel for behavior management, and the consent forms were signed after the medications had started, with one medication lacking a signed consent form. Resident 1 had severe cognitive impairment and depression and received an increased dose of Sertraline; the consent was signed 44 days after the medication started. Resident 2 had normal thinking and memory but had physical and verbal behaviors and diagnoses of anxiety, depression, and bipolar disorder; consents for Buspirone and Trazadone were signed after the medication changes, and no consent form was signed for Sertraline. The MDS Coordinator confirmed the late or missing consents during interview.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and/or provide influenza and pneumococcal vaccinations and failed to document resident education about the risks and benefits of those vaccines. The facility policy for pneumococcal vaccination required residents to be screened on admission, offered the vaccine series within 30 days, educated before the vaccine was offered, and documented if the vaccine was refused or administered. The influenza policy required residents to be offered the vaccine annually between 10/1 and 3/31 unless medically contraindicated, with education and documentation of consent or refusal in the medical record. Resident 11 was admitted and later had a Prevnar 20 consent form signed by the representative, but the record showed no evidence the pneumococcal vaccine was actually given. Resident 22 was admitted with no evidence of screening for vaccination status, no documented education about the pneumococcal vaccine, and no evidence the vaccine was offered or provided. Resident 14 was admitted with no evidence of education about the influenza vaccine and no evidence the vaccine was offered or provided. During interview, the Infection Preventionist confirmed Resident 11 was not vaccinated despite consent, and confirmed the lack of education, offering, or provision of pneumococcal vaccine for Resident 22 and influenza vaccine for Resident 14.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to complete a thorough investigation and report the results to the State Agency regarding an injury of unknown origin for one resident. According to facility policy, all suspected violations, including injuries of unknown source, were to be reported to the Administrator or designee, and notifications were to be made to the State licensing agency, ombudsman, resident's representative, APS, and the resident's physician within specified timeframes. The Administrator or designee was also responsible for completing an investigation and sending the results to the appropriate agencies within five working days. A resident with severe cognitive impairment, dependent on staff for all activities of daily living, was found to have significant bruising and minimal swelling on the right foot. The facility's investigation suggested the injury may have occurred during a transfer with a mechanical lift, but no staff interviews or evaluations of transfer procedures were conducted to confirm this. The DON and Administrator later confirmed that a thorough investigation was not completed and no report was sent to the State Agency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for one resident with severe cognitive impairment, non-Alzheimer dementia, and a psychotic disorder. The resident was dependent on staff for toileting, bathing, dressing, repositioning, transfers, and wheelchair mobility, and also had physical behaviors including hitting or scratching self. A nursing progress note documented that the physician was notified of yellow bruising to the top of the right foot measuring 15 cm by 13 cm with minimal swelling and purple and yellow bruising to the bottom of the right foot measuring 9 cm by 7 cm with minimal swelling. During observation, the resident still had yellow bruising to the top of the right foot and yellow/purple bruising to the bottom of the foot with minimal swelling, and did not respond when asked if the foot hurt. The DON confirmed that staff did not witness the incident that caused the injury, that the significant bruising and swelling should have been reported to the State Agency as an injury of unknown origin, and that the facility failed to report the injury.
Failure to identify and document resident change in condition
Penalty
Summary
The facility failed to identify and document a change in condition for one resident with a history of pneumonia and coughing with fluids. The resident’s care plan noted the history of coughing with liquids. During observation, the resident coughed forcefully and complained of increased shortness of breath after oral medications were administered, and water was given to help swallow the medications. The resident continued to cough later that morning, was able to ambulate to the bathroom without difficulty, ate the noon meal without difficulty, and later told staff they were afraid of coughing or choking on water and did not like thick liquids. The resident’s chart did not contain documentation of the coughing episode after morning medications, and there were no vital signs, respiratory assessments, or oxygen levels documented for that day or the following day. Subsequent nurse notes documented a productive cough with thick white phlegm, later yellow/green phlegm, wheezes in the lower right lung field, weakness, low blood pressure, and an oxygen level of 92%. The resident was then sent to the clinic and admitted to the hospital with pneumonia. The DON confirmed that the coughing after medications had not been documented, that vital signs, lung sounds, and oxygen levels should have been completed, and that the physician was not notified of the resident’s cough.
Missing Resident-Specific Rationale for Psychotropic GDR Contraindications
Penalty
Summary
The facility failed to ensure Resident 21 had a resident-specific rationale documented for why a gradual dose reduction (GDR) was not attempted for psychotropic medications. The resident’s record showed severe cognitive impairment, diagnoses of dementia, anxiety, and depression, and use of anti-psychotic, anti-anxiety, and anti-depressant medications. The care plan identified psychotropic medication use for behavior management, with behaviors including hitting, kicking, wandering, physical aggression, resistance to cares, delusions, agitation, and anxiety, and the resident required assistance with toileting, dressing, transfers, and hygiene. Review of the record showed active orders for Venlafaxine and Divalproex ER. Facility fax documentation to the prescriber indicated that a GDR for Divalproex ER was contraindicated and a GDR for Venlafaxine was contraindicated, but there was no resident-specific rationale documented for either medication. The MDS Coordinator confirmed that no resident-specific evidence was documented to support the contraindication of dose reduction for Venlafaxine and Divalproex ER.
Hand Hygiene and Glove Use During Medication Preparation
Penalty
Summary
The facility failed to wash hands and change gloves at appropriate intervals during medication preparation for Resident 9. The facility’s undated medication administration policy stated that staff were to wash hands prior to beginning medication administration and that oral medications in pill, gel, or capsule form in bottles were to be placed in medication cups or plastic cups before administration, not in a gloved hand. Resident 9’s Medication Review Report dated 8/8/25 listed Mega Sport Multivitamin 1 tablet by mouth daily in the morning and L-Methylfolate Oral Capsule 15 milligrams by mouth in the morning. During an observation on 9/18/25 at 8:10 AM, an LPN approached the medication cart without washing hands or using hand sanitizer and put on disposable gloves. The LPN touched the computer mouse, opened the medication cart drawer with gloved hands, picked up the multivitamin bottle, poured a pill into a gloved hand, placed it into a medication cup, documented on the computer, returned the bottle to the cart, and closed the drawer with the gloved hand. The LPN then touched the mouse again, opened the drawer, picked up the L-Methylfolate bottle, poured a pill into a gloved hand, and placed it into a medication cup. The DON later confirmed that staff were to wash hands before administering medications and that pills should not be placed in gloved hands, but should be poured directly into a medication cup.
Failure to Educate and Offer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide evidence that 2 of 5 sampled residents, Residents 11 and 22, were offered the COVID-19 vaccine and/or educated about the risks and benefits associated with the vaccine. The facility policy required residents to be screened at admission for vaccine status and eligibility, and before the vaccine was offered, the resident and/or representative were to receive education about benefits and potential side effects, with education or refusal documented in the medical record. Resident 11 was admitted on [DATE], and the record showed a COVID-19 Consent Form and Administration Record dated 4/28/25 in which the resident's representative accepted the vaccine for the resident, but there was no evidence the resident actually received the COVID-19 vaccine. Resident 22 was admitted [DATE], and the record contained no evidence the facility screened the resident for vaccination status, provided education about the risks and benefits of the COVID-19 vaccine, or offered and/or administered the vaccine. During interview on 9/23/25 at 8:49 AM, the Infection Preventionist confirmed Resident 11 was not provided education until 4/28/25 and that the facility failed to provide the vaccine after consent was signed, and confirmed there was no evidence Resident 22 received education or was offered or given the vaccine.
Failure to Notify Physician of Resident's Change in Condition After Fall
Penalty
Summary
Facility staff failed to notify a resident's Primary Care Practitioner (PCP) of significant changes in the resident's condition following a fall. The resident, who had a history of cancer, anemia, dementia, seizure disorder, anxiety, depression, and psychotic disorder, experienced a fall resulting in a superficial head cut and reported severe back pain. Over the next several days, the resident continued to complain of back and neck pain, with pain levels remaining high and little relief from prescribed medications. Documentation showed that the resident's pain persisted and worsened, with additional symptoms such as inability to turn in bed without yelling in pain. Despite these ongoing and escalating symptoms, there was no evidence in the medical record that the facility staff notified the resident's PCP of the increased back pain or changes in condition until four days after the fall, when the resident became lethargic, unresponsive, and was subsequently transferred to the hospital for a brain bleed. The facility's policy required prompt notification of the physician and documentation of such changes, but this was not followed in this case.
Failure to Assess and Monitor Resident After Fall with Injury
Penalty
Summary
The facility failed to monitor and assess a resident for a change in condition following a fall with injury. According to the facility's policy, staff are required to promptly notify the resident, physician, and representative of changes in condition, make detailed observations, and document relevant information in the medical record. However, after a resident experienced a fall resulting in a head laceration and ongoing complaints of severe back pain, staff did not complete or document assessments related to the resident's pain, increased confusion, or behavioral changes. The resident continued to report significant pain and exhibited increased confusion and behavioral issues over several days following the fall. The resident, who had a history of cancer, dementia, and other significant diagnoses, required extensive assistance with activities of daily living and had previously experienced falls. Despite ongoing symptoms such as severe pain, confusion, and behavioral changes, there was no evidence of thorough assessment or timely intervention. Four days after the fall, the resident was found lethargic with unresponsive pupils and a large bruise on the head, leading to transfer to the emergency room and subsequent diagnosis of a brain bleed. The Director of Nursing confirmed that no assessments were completed or documented regarding the resident's post-fall symptoms.
Inadequate Fall Prevention Measures for Residents
Penalty
Summary
The facility failed to adequately identify causal factors and develop effective interventions to prevent ongoing falls for two residents, Resident 29 and Resident 135. Resident 135, who had a history of fractures, arthritis, osteoporosis, previous stroke, non-Alzheimer's dementia, anxiety, and depression, experienced multiple falls, some resulting in injury. Despite these incidents, the facility did not consistently identify causal factors or revise interventions to prevent further falls. For instance, after several falls, including one that resulted in pelvic fractures, the facility failed to implement new strategies or adjust existing ones to address the resident's fall risk effectively. Resident 29, diagnosed with non-traumatic brain dysfunction, Alzheimer's disease, depression, anxiety, and dementia, also experienced multiple falls without injury. The facility's response to these falls was inadequate, as they often did not identify causal factors or develop new interventions. For example, after a fall in the corridor, no causal factors were identified, and the only intervention was to have therapy re-screen the resident, despite the resident already being on the therapy caseload. This pattern of insufficient assessment and intervention continued throughout the resident's care. The facility's failure to identify causal factors and develop effective interventions for fall prevention highlights a significant deficiency in their care planning and risk management processes. The lack of consistent and proactive measures to address the residents' fall risks contributed to repeated incidents, some of which resulted in injury. This deficiency indicates a need for improved assessment and intervention strategies to ensure resident safety and prevent future falls.
Failure to Ensure Ordered Duration for Antibiotic Ointment Use
Penalty
Summary
The facility failed to ensure that a resident's use of antibiotic ointment had an ordered duration, which is a requirement to prevent potential adverse outcomes. The facility's antibiotic stewardship policy mandates that antibiotics be prescribed for the correct indication, dose, and duration to improve resident outcomes and reduce antibiotic resistance. However, the review of the resident's care plan and medication administration record revealed that the resident had been receiving Bacitracin ointment for over five years without a defined stop date or duration of use. The resident, who had a feeding tube and received enteral nutrition, was prescribed Bacitracin ointment to be applied to the tube site twice daily every third day. Despite this, there was no clinical rationale or defined duration for the continued use of the antibiotic ointment, which was confirmed by the Director of Nursing during an interview. This ongoing use without proper orders was not in accordance with the facility's antibiotic stewardship policy, leading to the deficiency noted in the report.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage of drugs and biologicals, as evidenced by a medication cart being left unlocked and unattended, and medications being left unsecured in a resident's room. The facility's policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner, with compartments containing these items to be locked when not in use. However, observations revealed that a medication cart was left unlocked outside the dining room without staff present, and medications were left in a resident's room without proper authorization for self-administration. In the case of Resident 21, medications were found unsecured in the resident's room on two consecutive days. The resident confirmed that staff would leave the morning medications in the room for convenience, as the resident preferred to take them with breakfast. The medications included Plavix, Amlodipine, Isorbide, Loratadine, Pantoprazole, Eliquis, Guaifenesin, and Metoprolol. The Director of Nursing confirmed that the resident had not been assessed for self-administration of medications, and there was no order permitting this practice.
Failure to Submit PBJ Data for Q3 2024
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) data for the third quarter of 2024, which is a requirement for all long-term care facilities to ensure accountability and consistency in staffing information. The PBJ report, which covers staffing data from April 1 to July 30, 2024, was not submitted to the Centers for Medicare and Medicaid Services (CMS). This deficiency was identified during a record review and confirmed during an interview with the Provisional Administrator, who admitted that the facility did not know how to submit the required information. The failure to submit this data had the potential to affect all 34 residents residing within the facility.
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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 Newman Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Albion | 12.4 mi | ★★★★★ | 9 | 0 |
| Cloverlodge Care Center | 12.7 mi | ★★★★★ | 0 | 0 |
| Arbor Care Centers-countryside Llc | 18 mi | ★★★★★ | 16 | 0 |
| Community Pride Care Center | 19.3 mi | ★★★★★ | 7 | 0 |
| Genoa Community Hospital/ltc | 21.1 mi | ★★★★★ | 0 | 0 |
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