Cycle 1
Health 2024-08-22 · Fire 2024-08-22
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
27 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
Lincoln, NE
Emerald Nursing & Rehab Brookside LLC
1-star overall rating with 1-star inspections with $53,267 in total fines with 15 recent health deficiencies with 27 fire-safety deficiencies in the latest cycle
4735 South 54th Street, Lincoln, NE
(402) 488-0977
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
173
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Emerald Healthcare
Operator or chain grouping
Approved since
1975-01-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.42
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
0.92
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,232
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.82
Baseline 19.20% · Performance 20.59% · Measure score 1.82 · Achievement 1.82 · Improvement 0
Healthcare-associated infections
0
Baseline 6.90% · Performance 8.34% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 66.40% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.11
Baseline 3.97 hours · Performance 3.39 hours · Measure score 1.11 · Achievement 1.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 8.79% · Lower 95% interval 6.55% |
| Discharge to community | 47.06% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 36.99% · Lower 95% interval 35.6% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.49% |
95.27%
1.2 pts better
|
Numerator 55 · Denominator 57 |
| Falls with major injury | 3.51% |
0.77%
2.7 pts worse
|
Numerator 2 · Denominator 57 |
| Discharge self-care score | 60.98% |
53.69%
7.3 pts better
|
Numerator 25 · Denominator 41 |
| Discharge mobility score | 31.71% |
50.94%
19.2 pts worse
|
Numerator 13 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 7.41% |
2.29%
5.1 pts worse
|
Numerator 4 · Denominator 54 · Adjusted rate 6.4% |
| Healthcare-associated infections requiring hospitalization | 8.34% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 34.21% |
8.2%
26 pts better
|
Numerator 65 · Denominator 190 |
| Staff flu vaccination coverage | 71% |
42%
29 pts better
|
Numerator 71 · Denominator 100 |
| Discharge function score | 53.66% |
56.45%
2.8 pts worse
|
Numerator 22 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.85% |
25.2%
21.3 pts worse
|
Numerator 1 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.0
0.1 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
92.8%
7.3 pts worse
|
93.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 92.1% · Q3 89.5% · Q4 88.4% · 4Q avg 85.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.5% |
96.1%
13.6 pts worse
|
95.5%
13 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
4.5%
About the same
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 5.6% · Q3 4.7% · Q4 2.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
4.4%
5.2 pts worse
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 6.2% · Q3 15.5% · Q4 4.8% · 4Q avg 9.6% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
5.3%
0.5 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.6% · Q3 10.1% · Q4 1.4% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
19.5%
5 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 14.5% · Q3 15.5% · Q4 15.3% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
21.6%
0.5 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 20.0% · Q3 25.0% · Q4 21.2% · 4Q avg 22.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.7% |
20.4%
9.3 pts worse
|
16.3%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 34.1% · Q3 27.2% · Q4 26.6% · 4Q avg 29.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.5% |
19.9%
6.6 pts worse
|
14.9%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 35.1% · Q3 27.1% · Q4 21.1% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.6%
1.6 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.3% · Q3 2.4% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.9%
0.5 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.6% · Q3 3.6% · Q4 3.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
26.6%
6.1 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.1% · Q2 31.6% · Q3 27.5% · Q4 29.2% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.3%
2.2 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.5% · Q4 3.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.5% |
80.5%
30 pts worse
|
81.7%
31.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 45.5% · Q3 52.2% · Q4 59.8% · 4Q avg 50.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
11.6%
0.7 pts worse
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 14.5% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.3% |
2.4%
1.9 pts worse
|
1.6%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 6.7% · Q4 7.1% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.8% |
75.9%
43.1 pts worse
|
79.7%
46.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
20.9%
1.1 pts worse
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 23.6% · Expected 25.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-26 · Fire 2023-09-26
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
20 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
19 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
25 fire-safety deficiencies
Top issue: Smoke (11 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-22
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-01
F · Potential for more than minimal harm
2023-09-26
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-09-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-12-14
F · Potential for more than minimal harm
2023-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-09-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-09-26
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-09-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-09-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-26
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-26
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-09-26
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-11-10
F · Potential for more than minimal harm
2022-09-29
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-10-23
F · Potential for more than minimal harm
2022-09-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-09-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-09-29
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-09-29
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-09-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-23
E · Potential for more than minimal harm
2022-09-29
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-11-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-09-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-06-02
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-03-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-01-23
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-02-20
J · Immediate jeopardy
2024-10-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-08-22
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-10-01
F · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-01
E · Potential for more than minimal harm
2024-08-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-07-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-04-09
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-02-06
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-06
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2024-03-22
F · Potential for more than minimal harm
2023-09-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-09-26
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
J · Immediate jeopardy
2023-06-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-06-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-16
F · Potential for more than minimal harm
2022-09-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-23
F · Potential for more than minimal harm
2022-09-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-10-23
F · Potential for more than minimal harm
2022-09-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-23
D · Potential for more than minimal harm
2022-09-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-23
C · Minimal harm
2022-09-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-23
Penalties and ownership
What sits behind the stars
$26,000
2024-10-21
Fine
Fine · fine $26,000
Fine
$0
2024-10-21
Payment Denial
Payment Denial · denial start 2024-11-13 · 5 days
5 day denial
$3,529
2024-01-02
Fine
Fine · fine $3,529
Fine
$8,469
2023-12-11
Fine
Fine · fine $8,469
Fine
$0
2023-09-26
Payment Denial
Payment Denial · denial start 2023-12-19 · 44 days
44 day denial
$15,269
2023-06-01
Fine
Fine · fine $15,269
Fine
Ownership
Walden, Jacob
5% Or Greater Direct Ownership Interest · Individual
Chafetz, Yisroel
5% Or Greater Direct Ownership Interest · Individual
Chafetz, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Chafetz, Yisroel
Operational/Managerial Control · Individual
Chafetz, Yisroel
Corporate Director · Individual
Dunn, Madelyne
W-2 Managing Employee · Individual
Fleischmann, David
Contracted Managing Employee · Individual
Gopin, Brian
Corporate Director · Individual
Walden, Jacob
Operational/Managerial Control · Individual
Walden, Jacob
Corporate Director · Individual
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#3
St. Jane de Chantal
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