Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
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 Mid-nebraska Lutheran Home during CMS and state inspections, most recent first.
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.
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 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 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 | — | 0 | 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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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.