Cycle 1
Health 2025-07-22 · Fire 2025-07-22
15 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Omaha, NE
Emerald Nursing & Rehab Legacy Pointe llc
2-star overall rating with 2-star inspections with $56,445 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3110 Scott Circle, Omaha, NE
(402) 455-6636
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Emerald Healthcare
Operator or chain grouping
Approved since
2000-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing
LPN hours / resident day
0.57
Licensed practical nurse staffing
Aide hours / resident day
2.39
Nurse aide staffing
Weekend hours
3.01
Weekend nurse staffing
RN turnover
38%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.1% |
92.8%
7.7 pts worse
|
93.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
96.1%
7.2 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
4.5%
0.8 pts better
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.4%
2.1 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.3%
0.3 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
19.5%
3.2 pts worse
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 30.8% |
21.6%
9.2 pts worse
|
16.7%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.7% |
20.4%
4.3 pts worse
|
16.3%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
19.9%
9.4 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.6%
1.2 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
2.9%
0.8 pts better
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 34.7% |
26.6%
8.1 pts worse
|
19.8%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.3%
0.5 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.7% |
80.5%
46.8 pts worse
|
81.7%
48 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.2% |
75.9%
10.7 pts worse
|
79.7%
14.5 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-11-30 · Fire 2023-11-30
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-07-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-15
E · Potential for more than minimal harm
2025-07-22
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-09-15
F · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-19
F · Potential for more than minimal harm
2023-11-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-11-30
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 2024-01-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-28
F · Potential for more than minimal harm
2025-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-07-22
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 2025-08-22
E · Potential for more than minimal harm
2025-07-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
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 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
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 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
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 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-07-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-08-22
D · Potential for more than minimal harm
2024-11-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-05-23
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 2024-06-19
E · Potential for more than minimal harm
2024-05-23
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 2024-06-19
D · Potential for more than minimal harm
2024-05-23
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 2024-06-19
D · Potential for more than minimal harm
2024-05-23
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-06-19
D · Potential for more than minimal harm
2024-01-03
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 2024-01-17
D · Potential for more than minimal harm
2023-11-30
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-30
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 2024-01-17
D · Potential for more than minimal harm
2023-11-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-30
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 2024-01-03
D · Potential for more than minimal harm
2023-11-30
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-03
Penalties and ownership
What sits behind the stars
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$11,645
2023-12-11
Fine
Fine · fine $11,645
Fine
$3,176
2023-11-06
Fine
Fine · fine $3,176
Fine
$7,409
2023-10-17
Fine
Fine · fine $7,409
Fine
Ownership
Emerald Nursing & Rehab Legacy Pointe LLC
5% Or Greater Direct Ownership Interest · Organization
Chafetz, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Chafetz, Yisroel
Operational/Managerial Control · Individual
Chafetz, Yisroel
Corporate Director · Individual
Lahasky, Ephram
5% Or Greater Indirect Ownership Interest · Individual
Legacy Pointe Opco Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Runyan, Cheryl
W-2 Managing Employee · Individual
Walden, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Walden, Jacob
Operational/Managerial Control · Individual
Walden, Jacob
Corporate Director · Individual
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#2
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#3
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