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CEDARS AT BROADWELL LLC

Grand Island, NE · Hall County · For profit - Limited Liability company · 76 certified beds

📍 800 Stoeger Drive, Grand Island, NE 68803  ·  📞 (308) 382-5440

Medicare ID: 285221  ·  Last Medicare inspection: May 21, 2025

Special Focus Facility (SFF)
CMS has identified this as a facility with a history of serious quality issues that requires enhanced oversight and more frequent inspections.
Overall Safety Score
44
out of 100
Concerning
Component Scores
17
Inspection
38
Staffing
52
Enforcement
80
Complaints
42
Quality
📋 Last inspected: May 21, 2025 📦 CMS data as of: May 2026

Score Breakdown

Inspection
17
Staffing
38
Enforcement
52
Complaints
80
Quality Outcomes
42

What the numbers mean

CEDARS AT BROADWELL LLC scored 44 out of 100 — 24 points below the state average of 68.

📋 Inspections: 32 citations over the last 36 months — 17 more than the state average (15). 1 was rated serious (G+) — an inspector determined it caused or risked harm to a resident.

🚨 Staffing: Staffing levels are well below average — this is a serious concern. Understaffing leads to worse resident outcomes. We strongly recommend asking for staffing schedules and speaking with current residents or family members before making any decision.

⚠️ Penalties & enforcement: CMS has recorded 1 enforcement action totaling $16,801 against this facility. Penalties are only issued after a facility fails two levels of regulatory review — meaning this is a serious escalation beyond a standard citation. Ask for a written explanation of every fine and what corrective actions were taken.

💬 Complaints: Some complaint-driven inspections have occurred. These are unannounced visits triggered by formal concerns from residents, families, or staff. Ask the facility how they handle resident grievances.

⚠️ Resident quality outcomes: Some quality measures are below national benchmarks. Areas like fall prevention, pain management, or medication use may warrant closer attention.

What inspectors found (last 3 surveys)

32
Total citations
State avg: 15.2
1
Serious (G+)
State avg: 0.6
0
Repeat findings

Top concern areas

32

⚖ Penalties & Enforcement

Federal civil monetary penalties (CMPs) are only issued after a facility has failed two levels of regulatory review — meaning problems were found on inspection and the facility could not rebut the findings. This is a serious escalation beyond a standard citation.

$16,801
Total federal fines
1
Enforcement action

⚠ Each enforcement action required CMS to make a separate non-compliance determination — meaning this facility failed two levels of regulatory review before any fine was issued. Ask management specifically what violations triggered these fines and what corrective steps were taken.

📋 Enforcement Context Analysis
📊
Enforcement score: 52/100 — 34 points below the state average of 86/100 — worse than most comparable facilities. A score below 70 indicates a meaningful enforcement history that warrants direct conversation with facility management.
Serious Citations That May Have Triggered Enforcement
Abuse & neglect prevention policies — No harm, could worsen · May 21, 2025
Pharmacy policies & procedures — No harm, could worsen · May 21, 2025
F0940 — No harm, could worsen · May 21, 2025

📅 Per-action enforcement records (date, fine amount, and penalty type for each individual action) are sourced from a separate CMS enforcement dataset and will be added in a future data update.

🩹

Resident Wellbeing — Key Indicators

These are the measures families ask about most. They come from CMS clinical assessments of every resident — not just inspection reports. Stars (★) count toward the official CMS quality star rating.

Antipsychotic medication use
1.6% lower is better
Share of long-stay residents given antipsychotic drugs. High use can signal residents being over-medicated rather than receiving attentive care.
Flu vaccination rate
32.8% higher is better
Share of long-stay residents vaccinated against the flu this season. Higher is better.
Re-hospitalized after discharge
19.8% lower is better
How often short-stay residents who went home ended up back in the hospital within 30 days. Risk-adjusted for resident health.
Hospitalization rate
20.7% lower is better
How often long-stay residents were hospitalized over the past year. Adjusted for how sick residents were.

Source: CMS MDS Quality Measures & Medicare claims data. Scores shown are the most recent 4-quarter averages for long-stay residents.

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⚠️
Overall Assessment — Serious Concerns  ·  44/100
This facility has notable issues in the federal inspection record that require careful evaluation.
What to do next: Do not choose without thoroughly reviewing all citations below and getting answers in writing from management.
🛑
CMS Special Focus Facility
CMS has placed this facility on its Special Focus Facility list — a designation reserved for nursing homes with a persistent pattern of serious problems and substandard care. These facilities receive more frequent inspections and are under enhanced federal oversight. This is one of the most serious designations a nursing home can receive.
Federal Penalty: $16,801
CMS has imposed civil monetary penalties totaling $16,801 against this facility. Penalties are only levied after a separate non-compliance determination — meaning a facility must fail two levels of regulatory review before a fine is issued. Ask management specifically what violations triggered these fines and what corrective actions were taken.
👥
Staffing Below Federal Minimum Standards
This facility provides 0.53 RN hours per resident per day — below the CMS minimum of 0.75 hours. Total nurse staffing is 2.84 hours per resident per day — below the CMS minimum of 2.87 hours. Understaffing is the strongest predictor of poor inspection outcomes. Ask specifically about RN coverage on evenings, nights, and weekends.

What this facility's data shows

📋 Inspections
Inspection record is well below average. Multiple or serious deficiencies found.
👥 Staffing
Staffing is below recommended levels. Ask about RN coverage on nights and weekends.
⚖ Penalties
Facility has received federal fines or enforcement sanctions. Requires direct explanation from management.
💬 Complaints
Complaint activity is low — few formal complaints filed by residents or families.
Multiple quality measures are below national benchmarks. Ask management directly about resident care practices.
⚠ Serious Findings on Record: 1 citation(s) where inspectors found actual harm or immediate jeopardy to residents. See Section D for the full details and ask management how each was resolved.
Score breakdown — the numbers behind this assessment
👥 Staffing 38
What it measures RN hours per resident per day, total nurse hours, and RN turnover rate.
💡 Understaffing is the strongest single predictor of poor inspection outcomes.
📋 Inspection 17
What it measures Number, severity (A–L), and scope of deficiencies found. Repeat findings carry extra weight.
💡 Every citation in Section D feeds directly into this score.
⚖ Penalties 52
What it measures Whether CMS escalated from a deficiency citation to actual financial or operational sanctions.
💡 A penalty means the facility already failed a second level of regulatory review.
💬 Complaints 80
What it measures Volume of complaint-triggered inspections and the share that were substantiated.
💡 Complaint surveys are unannounced — they often surface issues annual surveys miss.
🎯 Quality outcomes 42
What it measures Resident outcome measures: falls, pressure ulcers, antipsychotic use, weight loss, hospitalizations.
💡 Reflects the lived experience of residents beyond what inspectors observe.

Each pillar scores 0–100 and is combined into the overall score. A strong overall can mask a weak pillar — compare all four and see how they stack against the state average in Section B.

🏗 How This Facility Compares to NE State Averages

Comparing a facility to others in the same state puts its score in context. A facility might have 8 citations and that could be above average in one state and below in another. Green means this facility is doing better than its peers; red means it's falling short.

Metric This facility NE avg vs. State
Overall score
The combined Senior Care Report Card score out of 100.
44 68 ▼ Worse than state avg
Inspection score
How well the facility performs on standard health surveys.
17 55 ▼ Worse than state avg
Staffing score
RN hours, total nurse hours, and staff turnover from CMS payroll data.
38 60 ▼ Worse than state avg
Penalty score
Fines, payment denials, and enforcement actions on file.
52 86 ▼ Worse than state avg
Complaint score
Volume of complaint surveys and substantiated complaints.
80 90 ▼ Worse than state avg
Quality score
Resident clinical outcomes vs national benchmarks: falls, antipsychotics, pain, vaccination, hospitalizations.
42 52 ▼ Worse than state avg
Citations (3 yrs)
Total number of deficiencies cited in the last 36 months.
32 15.2 ▼ Worse than state avg
Serious citations
Citations rated severity G or higher (actual harm or immediate jeopardy).
1 0.6 ✓ At avg

📅 Inspection Timeline

State health inspectors visit nursing homes on a regular cycle — typically every 12 to 15 months — and document every deficiency they find. The timeline below shows the date and scale of each inspection visit over the past several years. A pattern of worsening surveys is a red flag even if the most recent visit looks clean.

2025-05-21
18 citations
2024-10-08
1 citations
2024-05-14
7 citations
2024-02-01
1 citations  (1 serious)
2023-05-16
5 citations

Bar length proportional to citation count. Red = serious findings (severity G+). Orange = elevated. Green = low.

📄 Full Citation Record

Every time state inspectors visit a nursing home, they write up anything that doesn’t meet federal standards. Each write-up is called a citation.

Each citation shows what the problem was and how serious it was, using a color-coded badge:

Green — No residents harmed Yellow — Risk of harm, no injury Orange — A resident was harmed Red — Life or safety in danger

A Repeat tag means the same problem appeared in a previous inspection — it was not fully corrected the first time. Citations shown cover the last two years.

Survey: 2025-05-21 18 citation(s)
F0607 No harm, could worsen
Abuse & neglect prevention policies
F0732 No harm, could worsen
Pharmacy policies & procedures
F0940 No harm, could worsen
F0940
F0880 No harm, could worsen
Infection prevention & control
F0947 No harm, could worsen
Nurse aide training program
F0838 No harm, could worsen
Facility assessment update
F0761 No harm, could worsen
Medication storage & labeling
F0552 No harm, could worsen
Right to be informed of care choices
F0641 No harm, could worsen
Accuracy of resident assessment
F0688 No harm, could worsen
Range of motion & mobility
F0800 No harm, could worsen
Dietary services provided
F0712 No harm, could worsen
F0712
F0645 No harm, could worsen
BHP referral requirements
F0605 No harm, could worsen
F0605
F0791 No harm, could worsen
Physician services arrangement
F0684 No harm, could worsen
Quality of care
F0578 No harm, could worsen
F0578
F0609 No harm, could worsen
Timely reporting of alleged violations
Survey: 2024-10-08 1 citation(s)
F0686 No harm, could worsen
Pressure ulcer prevention & treatment
Survey: 2024-05-14 7 citation(s)
F0880 No harm, could worsen
Infection prevention & control
F0656 No harm, could worsen
Comprehensive care plan
F0657 No harm, could worsen
Care plan timing & review
F0584 No harm, could worsen
F0584
F0760 No harm, could worsen
Medication error — no significant harm
F0684 No harm, could worsen
Quality of care
F0697 No harm, could worsen
Pain management
🩹

How Are Residents Doing?

Inspections tell you whether a facility followed the rules. These measures tell you how residents actually fared — whether they fell, experienced pain, lost weight, or were over-medicated. CMS collects this data through regular clinical assessments that nurses complete for every resident. Unlike inspections, which happen once a year, these assessments happen continuously.

⚠ Attention: 3 of 8 star-rated measures show rates above what\'s typically considered acceptable. This means the facility may be struggling in areas that directly affect residents\' day-to-day wellbeing — not just its inspection record.

How to read these cards: Each card shows one measure. Lower percentages are better for most (e.g. fewer falls), but higher is better for vaccination rates and community return. ★ Star rating marks measures CMS uses in its official quality star rating.

Long Stay Residents — 2025Q1-2025Q4
★ Star rating
Daily activity decline
29.7% lower is better
Share of long-stay residents who lost the ability to dress, eat, or move around independently over the past year. Rising rates can signal that residents aren't receiving enough physical therapy or that staffing is too thin to support mobility.
★ Star rating
Urinary tract infections
2.3% lower is better
Share of long-stay residents who had a urinary tract infection. While some UTIs are unavoidable, high rates can point to poor hydration practices, catheter hygiene, or rushed care routines.
★ Star rating
Antipsychotic medication use
1.6% lower is better
Share of long-stay residents given antipsychotic drugs. These medications carry serious risks for older adults. High use often signals that a facility is medicating residents to manage behavior instead of addressing needs through attentive, person-centered care.
★ Star rating
Percentage of long-stay residents experiencing on…
4.6% lower is better
Percentage of long-stay residents experiencing one or more falls with major injury
★ Star rating
Flu vaccination rate
32.8% higher is better
Share of long-stay residents vaccinated against the flu. Nursing homes are high-risk environments for flu outbreaks. Anything below 90% warrants a question about the facility's vaccination policy.
★ Star rating
Percentage of long-stay residents with pressure u…
5.7% lower is better
Percentage of long-stay residents with pressure ulcers
★ Star rating
Percentage of long-stay residents who received an…
33.3% lower is better
Percentage of long-stay residents who received an antipsychotic medication
Physical restraints used
5.7% lower is better
Share of long-stay residents physically restrained (lap belts, side rails). Federal regulations require restraints to be a last resort. High use is a red flag for understaffed facilities cutting corners on behavioral care.
Signs of depression
1.1% lower is better
Share of long-stay residents showing symptoms of depression. Social isolation, lack of meaningful activities, and poor staffing all contribute. This measure reflects the emotional quality of life inside the facility.
Unexplained weight loss
0.0% lower is better
Share of long-stay residents who lost 5% or more of body weight unexpectedly. This can indicate inadequate nutrition, difficulty eating without assistance, or unaddressed medical issues.
Percentage of long-stay residents assessed and ap…
78.7% lower is better
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
Pneumonia vaccination rate
26.6% higher is better
Share of long-stay residents vaccinated against pneumococcal pneumonia — one of the leading causes of death in older adults. Higher is better.
Percentage of long-stay residents assessed and ap…
98.0% lower is better
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
Percentage of long-stay residents with new or wor…
29.3% lower is better
Percentage of long-stay residents with new or worsened bowel or bladder incontinence
Short Stay Residents — 2025Q1-2025Q4
★ Star rating
Worsening depression symptoms
5.0% lower is better
Share of long-stay residents whose depression got measurably worse over the past year — despite being in a care facility.
Percentage of short-stay residents assessed and a…
62.2% lower is better
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
Emergency room visits (short-stay)
97.3% lower is better
Share of short-stay residents sent to the ER during their recovery stay. ER visits are disruptive for recovering patients and sometimes avoidable with better on-site clinical management.

Source: CMS MDS Quality Measures (2025Q1-2025Q4). Collected via standardized clinical assessments — not inspector visits.

🏥

Hospitalization & ER Visits

These numbers come directly from Medicare claims — real billing records of every time a resident was hospitalized or sent to the emergency room. They\'re among the most objective measures of care quality because they can\'t be influenced by how a facility writes up an assessment. The adjusted score is the most meaningful number — it\'s been corrected to account for how sick residents were, so a facility treating frailer patients isn\'t unfairly penalized.

What to look for: An adjusted score significantly above the expected score means this facility hospitalizes residents more often than peer facilities with similar patient populations — that gap is worth asking about directly.

Short Stay Residents — 20241001-20250930
★ Star rating
Re-hospitalized after going home
19.8% risk-adjusted rate
Actual: 22.2% Expected: 26.8%
✓ Better than expected for similar residents
How often short-stay residents who went home ended up back in the hospital within 30 days. A high rate suggests residents were discharged before they were ready, or that the facility didn't coordinate follow-up care well. Risk-adjusted so facilities treating sicker residents aren't unfairly penalized.
★ Star rating
Hospitalization rate (long-stay)
20.7% risk-adjusted rate
Actual: 22.2% Expected: 12.0%
▲ Higher than expected — worth asking about
How often long-stay residents were hospitalized over the past year, adjusted for how ill they were. A high rate relative to expectations suggests the facility may be sending residents to the hospital for issues that skilled nursing staff should be able to manage on-site.
Long Stay Residents — 20241001-20250930
★ Star rating
Number of hospitalizations per 1000 long-stay res…
1.9% risk-adjusted rate
Actual: 3.2% Expected: 3.2%
About the same as similar facilities
Number of hospitalizations per 1000 long-stay resident days
★ Star rating
Number of outpatient emergency department visits …
1.9% risk-adjusted rate
Actual: 2.6% Expected: 2.3%
About the same as similar facilities
Number of outpatient emergency department visits per 1000 long-stay resident days

Source: CMS Medicare claims data. Scores are risk-adjusted — they account for how ill residents were when admitted so facilities treating sicker populations aren\'t penalized for it.

💬 Questions to Ask Before Touring

These questions are generated specifically from this facility's score profile and citation history — not a generic checklist. A facility's willingness to answer them openly, and the quality of their answers, is itself an important signal. Bring this list when you tour or call.

  1. Federal inspectors found 1 citation rated as causing actual harm or immediate jeopardy in the public record. Walk us through each incident: what happened, who was affected, and what specific policy or staffing changes have been put in place since?
  2. CMS data shows this facility is significantly below the state average for total nurse hours and RN-specific hours per resident day. What is the actual RN coverage on evenings, nights, and weekends — not the regulatory minimum, but what residents consistently receive?
  3. What is your 90-day CNA and nurse turnover rate? How do you ensure a resident sees the same familiar caregivers across a given week?
  4. This facility has a significant CMS enforcement history. Can you identify each action in the past three years, what it was for, and what systemic — not just procedural — changes were made to prevent recurrence?
  5. Some resident outcome measures are below average here. What is your current approach to fall prevention, pain management, and quarterly medication review?
  6. 1 citation in the public record were rated as causing actual harm to a resident. Can you describe what occurred in each case and what specific safeguards are now in place?
  7. Can we speak privately with two or three current residents or their families?

👪 Family Decision Guide

This guide translates this facility's data into practical next steps for families. It is not a recommendation for or against placement — it is a structured framework for the conversations you need to have before making a decision.

✓ Positives to confirm

  • Low complaint activity — ask if there is a family council you can speak with
  • No pattern of repeat violations detected

⚠ Areas to probe

  • Inspection score is low — ask for the most recent state survey results
  • Staffing concerns — request staffing schedules and ask about agency nurse use
  • Penalty history present — ask what enforcement actions occurred and outcomes
  • Serious-harm citations on record — require a written explanation of corrective action
  • Always speak with at least two current residents or family members independently

📈 Score History

The score is recalculated every time CMS releases updated data (typically monthly). A consistent downward trend is more concerning than a single low score. An improving trend after a period of poor performance may indicate management changes are taking effect. Your subscription will alert you whenever the score changes materially.

2026-05-07
44 — Concerning

🏢 Ownership & Operators

Ownership matters because large corporate chains sometimes prioritize cost controls over care quality. CMS requires every nursing home to disclose its owners, operators, and managing employees. Frequent ownership changes can disrupt staffing and operations — which is why we flag facilities that changed ownership in the past 12 months.

🔗 WEISZ, DAVID operates 13 facilities across NE, CT. This is a large operator — consider researching their overall network quality.
Owner / Operator Role Ownership % Effective
WEISZ, DAVID Individual 1970-01-01
TULIP INVESTMENTS NE LLC Organization 1970-01-01
MUIR, DANIELLE Individual 1970-01-01
BRASS NE TRUST Organization 1970-01-01
COPPER NE TRUST Organization 1970-01-01
NE 11 HOLDINGS OPCO LLC Organization 1970-01-01
NE SNF HOLDINGS LLC Organization 1970-01-01
SF 4140 OLDE WASHINGTON BOULEVARD REAL PROPERTY LLC Organization 1970-01-01
SILVER NE TRUST Organization 1970-01-01
DOURO VALLEY INVESTMENT, LLC Organization 1970-01-01
SILBERSTEIN, ARI Individual 1970-01-01
BSD BEIS HEALTH TRUST Organization 1970-01-01
GOLD NE TRUST Organization 1970-01-01

🔔 Monthly tracking is now free

We check CMS data monthly. Use the tracking form above and we will email you when new citations appear, scores change, or enforcement actions are added.

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Monthly report update
New citation alerts
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Score trend tracking
🏠 Verify this data on Medicare.gov
All data in this report comes from the CMS Care Compare database. You can review the official public record directly on Medicare.gov — including the full inspection narrative, star ratings, and any recent enforcement actions.
View on Medicare.gov ↗

This report reflects publicly available CMS data only and is updated monthly. Severity codes and narratives are reproduced directly from the CMS health inspection database. Senior Care Report Card scores are independently computed and are not affiliated with or endorsed by CMS or Medicare.gov.

Data source: CMS Care Compare · Methodology · State Ombudsman

This report uses public CMS nursing home data and simplified scoring to help families ask better questions. It is not a recommendation, ranking, medical opinion, legal opinion, or substitute for an in-person visit. Source data last published by CMS: May 5, 2026.