Cycle 1
Health 2024-12-05 · Fire 2024-12-05
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Grand Island, NE
Emerald Nursing & Rehab Lakeview
2-star overall rating with 3-star inspections with $13,000 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1405 West Hwy 34, Grand Island, NE
(308) 382-6397
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Emerald Healthcare
Operator or chain grouping
Approved since
1991-06-01
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
0.45
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.38
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,045
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.19
Baseline 60.87% · Performance 50.65% · Measure score 3.19 · Achievement 3.19 · Improvement 2.34
Adjusted total nurse staffing
1.14
Baseline 4.21 hours · Performance 3.40 hours · Measure score 1.14 · Achievement 1.14 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.53% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 7.55% · Lower 95% interval 6.24% |
| Discharge to community | 46.25% |
50.57%
4.3 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 32.56% · Lower 95% interval 32.49% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 22.73% |
53.69%
31 pts worse
|
Numerator 5 · Denominator 22 |
| Discharge mobility score | 31.82% |
50.94%
19.1 pts worse
|
Numerator 7 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 18.52% |
2.29%
16.2 pts worse
|
Numerator 5 · Denominator 27 · Adjusted rate 20.67% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.06% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 94 |
| Staff flu vaccination coverage | 2.8% |
42%
39.2 pts worse
|
Numerator 3 · Denominator 107 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 11 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.8
1.1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
92.8%
5.5 pts worse
|
93.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.0% · Q2 82.0% · Q3 86.0% · Q4 86.6% · 4Q avg 87.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
96.1%
6.4 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
4.5%
1.2 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.6% · Q3 5.3% · Q4 4.5% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
4.4%
0.5 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.2% · Q3 6.2% · Q4 3.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
5.3%
2.4 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 8.9% · Q3 5.9% · Q4 3.3% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
19.5%
3.6 pts better
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 13.8% · Q3 17.0% · Q4 20.6% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 41.3% |
21.6%
19.7 pts worse
|
16.7%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 38.9% · Q3 50.0% · Q4 33.3% · 4Q avg 41.3% · 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 | 7.0% |
20.4%
13.4 pts better
|
16.3%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 8.9% · Q4 3.6% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
19.9%
10.7 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 8.9% · Q3 11.8% · Q4 5.1% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.6%
0.3 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.0% |
2.9%
2.1 pts worse
|
1.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.4% · Q3 9.1% · Q4 3.1% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
26.6%
2.6 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 32.6% · Q3 22.1% · Q4 31.5% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
4.3%
3.1 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 6.8% · Q3 6.3% · Q4 5.9% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
80.5%
5.2 pts better
|
81.7%
4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.0% · Q2 92.1% · Q3 91.0% · Q4 78.5% · 4Q avg 85.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
11.6%
2.2 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 16.2% · Expected 13.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
2.4%
1 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 2.9% · Q4 4.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
75.9%
14.6 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
20.9%
6 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 29.7% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
4 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
14 health deficiencies
Top issue: Infection Control (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-05
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 2025-01-16
E · Potential for more than minimal harm
2024-12-05
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 2025-01-16
E · Potential for more than minimal harm
2024-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-16
F · Potential for more than minimal harm
2023-11-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-15
F · Potential for more than minimal harm
2022-08-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-04
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 2022-09-16
E · Potential for more than minimal harm
2022-08-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-05
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 2025-01-16
E · Potential for more than minimal harm
2024-12-05
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 2025-01-16
E · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-05
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-01-16
F · Potential for more than minimal harm
2023-11-02
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 2023-12-15
E · Potential for more than minimal harm
2023-11-02
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 2023-12-15
D · Potential for more than minimal harm
2023-11-02
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 2023-12-15
D · Potential for more than minimal harm
2023-11-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-07-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-03-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-05
F · Potential for more than minimal harm
2022-08-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-04
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 2022-09-16
F · Potential for more than minimal harm
2022-08-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-04
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-04
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 2022-09-16
E · Potential for more than minimal harm
2022-08-04
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 2022-09-16
E · Potential for more than minimal harm
2022-08-04
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 2022-09-16
E · Potential for more than minimal harm
2022-08-04
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
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 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-04
F918 · Environmental Deficiencies
Health
Provide a bathroom in or located near each resident’s room.
Corrected 2022-09-16
Penalties and ownership
What sits behind the stars
$13,000
2023-03-27
Fine
Fine · fine $13,000
Fine
Ownership
Jw Nebraska Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Walden, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Bank Of Oklahoma
Operational/Managerial Control · Organization
Chafetz, Yisroel
Operational/Managerial Control · Individual
Emerald Healthcare LLC
Operational/Managerial Control · Organization
Evolve Therapy Services LLC
Operational/Managerial Control · Organization
Fleischmann, David
Operational/Managerial Control · Individual
Franklin, Brenda
Operational/Managerial Control · Individual
Goff, Kiley
Operational/Managerial Control · Individual
Gopin, Brian
Operational/Managerial Control · Individual
Guerrero, Jessica
Operational/Managerial Control · Individual
Hinrikus, Adam
Operational/Managerial Control · Individual
Limestone Fiscal Services LLC
Operational/Managerial Control · Organization
Merch Pay Inc
Operational/Managerial Control · Organization
Sattar, Arif
Operational/Managerial Control · Individual
Saul N Friedman & Company
Operational/Managerial Control · Organization
Wellsky Corporation
Operational/Managerial Control · Organization
Wichman, Jeri Jo
Operational/Managerial Control · Individual
Zimmet Healthcare Services Group LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Tabitha At Prairie Commons
Grand Island, NE
2-star overall rating with 1-star inspections with $10,296 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
CHI Health St. Francis
Grand Island, NE
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Cedars at Broadwell
Grand Island, NE
1-star overall rating with 1-star inspections with $16,801 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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