Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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 17 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Linden Court.
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 August 2026) and official state health department websites.