Cycle 1
Health 2025-04-01 · Fire 2025-04-01
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lincoln, NE
Hillcrest Firethorn
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8601 Firethorn Lane, Lincoln, NE
(531) 739-3500
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-12-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.36
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.03
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
4.33
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,425
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9930
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.41% · Performance 24.45% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.18
Baseline 8.27% · Performance 6.74% · Measure score 4.18 · Achievement 3.68 · Improvement 4.18
Total nurse turnover
7.27
Baseline 80.85% · Performance 37.33% · Measure score 7.27 · Achievement 6.45 · Improvement 7.27
Adjusted total nurse staffing
4.57
Baseline 3.72 hours · Performance 4.38 hours · Measure score 4.57 · Achievement 4.57 · Improvement 2.70
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.13% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 388 · Observed rate 9.02% · Lower 95% interval 7.97% |
| Discharge to community | 64.78% |
50.57%
14.2 pts better
|
Better than the National Rate · Eligible stays 419 · Observed rate 63.01% · Lower 95% interval 59.36% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.58% |
95.27%
4.3 pts better
|
Numerator 235 · Denominator 236 |
| Falls with major injury | 0.85% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 236 |
| Discharge self-care score | 74.16% |
53.69%
20.5 pts better
|
Numerator 132 · Denominator 178 |
| Discharge mobility score | 81.46% |
50.94%
30.5 pts better
|
Numerator 145 · Denominator 178 |
| Pressure ulcers or injuries, new or worsened | 2.12% |
2.29%
0.2 pts better
|
Numerator 5 · Denominator 236 · Adjusted rate 2.91% |
| Healthcare-associated infections requiring hospitalization | 6.74% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 269 · Observed rate 5.95% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | 10.08% |
8.2%
1.9 pts better
|
Numerator 12 · Denominator 119 |
| Staff flu vaccination coverage | 81.03% |
42%
39 pts better
|
Numerator 94 · Denominator 116 |
| Discharge function score | 80.34% |
56.45%
23.9 pts better
|
Numerator 143 · Denominator 178 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 60 · Denominator 60 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 150 · Denominator 150 |
| Resident COVID-19 vaccinations up to date | 29.73% |
25.2%
4.5 pts better
|
Numerator 33 · Denominator 111 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.8 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.0
1.6 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
4.5%
1.9 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 2.5% · Q4 2.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 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 who lose too much weight | 3.5% |
5.3%
1.8 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 6.7% · Q4 0.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.1% |
19.5%
3.6 pts worse
|
19.6%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 20.0% · Q3 22.6% · Q4 29.6% · 4Q avg 23.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
21.6%
7.2 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.0% · Q3 12.5% · Q4 13.0% · 4Q avg 14.4% · 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 | 19.7% |
20.4%
0.7 pts better
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 20.5% · Q3 7.7% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
19.9%
6.2 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 23.3% · Q3 16.1% · Q4 7.4% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.9%
1.6 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
26.6%
2.3 pts better
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 31.1% · Q3 25.5% · Q4 16.1% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.3%
0.6 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.7% · Q3 4.8% · Q4 4.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
80.5%
19.5 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
11.6%
4.8 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.1% · Expected 10.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
75.9%
24.1 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.0% |
20.9%
13.1 pts worse
|
23.9%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.0% · Observed 28.3% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-11 · Fire 2024-04-11
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-05-16 · Fire 2023-05-16
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-01
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-04-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-14
F · Potential for more than minimal harm
2024-04-11
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 2024-05-21
F · Potential for more than minimal harm
2024-04-11
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-04-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-04-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-04-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-21
F · Potential for more than minimal harm
2024-04-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-04-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-04-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-05-21
E · Potential for more than minimal harm
2024-04-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-21
F · Potential for more than minimal harm
2023-05-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-16
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 2023-06-21
F · Potential for more than minimal harm
2023-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-12
F · Potential for more than minimal harm
2023-05-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-21
F · Potential for more than minimal harm
2023-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-21
E · Potential for more than minimal harm
2023-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-01
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 2025-05-14
D · Potential for more than minimal harm
2025-04-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-01
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 2025-05-14
D · Potential for more than minimal harm
2025-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-14
G · Actual harm
2025-02-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-10
D · Potential for more than minimal harm
2025-02-20
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 2025-03-10
F · Potential for more than minimal harm
2024-04-11
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 2024-05-21
F · Potential for more than minimal harm
2024-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-21
D · Potential for more than minimal harm
2024-04-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-21
E · Potential for more than minimal harm
2023-05-16
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 2023-06-21
D · Potential for more than minimal harm
2023-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-21
Penalties and ownership
What sits behind the stars
Ownership
Hillcrest Operating Ventures, LLC
5% Or Greater Direct Ownership Interest · Organization
Aswege-Mezenberg, Debra
Operational/Managerial Control · Individual
Hillcrest Health Systems Inc
Operational/Managerial Control · Organization
Janicki, James
Operational/Managerial Control · Individual
Janicki, James
Corporate Officer · Individual
Mulhearn, Kevin
Operational/Managerial Control · Individual
Mulhearn, Kevin
Corporate Officer · Individual
Oestmann, Matthew
Operational/Managerial Control · Individual
Oestmann, Matthew
Corporate Officer · Individual
Svendgard, Staci
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Holmes Lake Rehabilitation & Care Center
Lincoln, NE
1-star overall rating with 1-star inspections with $3,174 in total fines with 10 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Emerald Nursing & Rehab Brookside LLC
Lincoln, NE
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
#3
St. Jane de Chantal
Lincoln, NE
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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