Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Dunklau Gardens
Fremont, NE · 106 certified beds · Last Life Safety survey May 1, 2025
CMS Certification Number 285119 · first certified May 1992
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
- Ownership changed October 1, 2018 (change of ownership)from FREMONT HEALTH
Position within NE
29 citations — more than 89% of the 180 certified nursing homes in NE. Compared within NE rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 13. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to July 2026), and past the point by which nine in ten NE facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in NE are typically surveyed 12–14 months after the last one (median 13), measured over 271 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 29 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NE, and nationally. Surveyors differ markedly between states, so the NE figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 29 |
| Median facility in NE | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 8, 2023 | 19 |
| April 23, 2024 | 7 |
| May 1, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0511 | Have properly installed electrical wiring and gas equipment. | 3 | 2025-05-01 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2024-04-23 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2025-05-01 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-06-08 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2023-06-08 |
| K-0161 | Use approved construction type or materials. | 1 | 2023-06-08 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2023-06-08 |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 1 | 2023-06-08 |
What the citations cover
- Smoke Deficiencies 8
- Egress Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 3
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Egress Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Services Deficiencies | 3 |
| Construction Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 1, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 24, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 24, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (May 24, 2025) |
April 23, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (May 30, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (May 30, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (May 30, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 30, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (May 30, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 30, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 30, 2024) |
June 8, 2023 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 11, 2023) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (August 8, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (July 6, 2023) |
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (June 9, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0251 | Conform to length requirements for dead end corridors. | Deficient, Provider has date of correction (June 28, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 28, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 28, 2023) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (July 6, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 14, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 27, 2023) |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | Waiver has been granted (August 18, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 9, 2023) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (June 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 11, 2023) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (June 9, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.