Mid-Nebraska Lutheran Home
109 North 2nd Street, Newman Grove, NE 68758 · Madison County · 45 certified beds · avg 33 residents/day · certified since May 5, 1997
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 12, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 9, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 24, 2023 · F-0580
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 6, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (23)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 13, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 17, 2025 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Nov 17, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 17, 2025 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Apr 24, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 12, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Sep 12, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 12, 2024 | C · Minimal risk, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Aug 24, 2023 | ▲ G · Actual harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Aug 24, 2023 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Aug 24, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 24, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 24, 2023 | C · Minimal risk, facility-wide | The facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 1 | G ▲ |
| 2024 | 4 | 1 | G ▲ |
| 2025 | 10 | 0 | E |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $45,162, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Sep 12, 2024 | Fine | $45,162 |
| Sep 12, 2024 | Payment Denial | 62 days from Oct 8, 2024 |
| Aug 24, 2023 | Payment Denial | 14 days from Sep 22, 2023 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.31 | 4.33 | 3.95 | top 12% in Nebraska; top 9% in the U.S. |
| Registered Nurse hours | 0.30 | 0.72 | 0.69 | bottom 4% in Nebraska; bottom 9% in the U.S. |
| Weekend total nurse staffing | 4.86 | 3.79 | 3.50 | top 8% in Nebraska; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.24 | 0.47 | 0.48 | bottom 14% in Nebraska; bottom 20% in the U.S. |
| Total nursing staff turnover (%) | 42.2 | 48.7 | 45.8 | top 39% in Nebraska; top 42% in the U.S. |
| RN turnover (%) | 60.0 | 44.1 | 42.9 | bottom 32% in Nebraska; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.60, RN 0.26, weekend 4.22. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Mid Nebraska Lutheran Home Assn | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/01/1966 |
| Caubarrus, Angela | Individual | Corporate Director | NOT APPLICABLE | 01/01/2019 |
| Lapka, David | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2007 |
| Lueken, Lindsi | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/01/2013 |
| Mid Nebraska Lutheran Home Assn | Organization | Operational/Managerial Control | NOT APPLICABLE | 08/01/1966 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you explain health changes and treatment options to residents and their families?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Good Samaritan Society - Albion | 12.4 mi | Albion, NE | ★★★★★ | 5/5 | |
| Cloverlodge Care Center | 12.7 mi | St Edward, NE | ★★★★☆ | 4/5 | |
| Arbor Care Centers-Countryside LLC | 18.0 mi | Madison, NE | ★★☆☆☆ | 2/5 | |
| Community Pride Care Center | 19.3 mi | Battle Creek, NE | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 285213.