Cycle 1
Health 2024-10-08 · Fire 2024-10-08
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Lincoln, NE
Holmes Lake Rehabilitation & Care Center
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
6101 Normal Blvd, Lincoln, NE
(402) 489-7175
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-08-01
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
0.29
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.61
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
0.90
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.29
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
78%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,392
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.34
Performance 18.50% · Measure score 6.34 · Achievement 6.34 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
4.78
Performance 6.40% · Measure score 4.78 · Achievement 4.78 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0
Baseline 54.10% · Performance 88.16% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.42
Baseline 4.89 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.07% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 1.82% · Lower 95% interval 6.08% |
| Discharge to community | 35.48% |
50.57%
15.1 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 25% · Lower 95% interval 26.23% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.04% |
95.27%
2.8 pts better
|
Numerator 50 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 14 · Denominator 42 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 14 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 51 · Adjusted rate 4.01% |
| Healthcare-associated infections requiring hospitalization | 6.4% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 2.7% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 126 |
| Staff flu vaccination coverage | 35.48% |
42%
6.5 pts worse
|
Numerator 55 · Denominator 155 |
| Discharge function score | 59.52% |
56.45%
3.1 pts better
|
Numerator 25 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 3.57% |
25.2%
21.6 pts worse
|
Numerator 1 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.0
0.7 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.6% |
92.8%
19.2 pts worse
|
93.4%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.7% · Q2 72.9% · Q3 72.1% · Q4 72.7% · 4Q avg 73.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 69.4% |
96.1%
26.7 pts worse
|
95.5%
26.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 69.4% |
| 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 2.3% · Q2 4.2% · Q3 7.0% · Q4 4.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
4.4%
3 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 7.7% · Q4 10.5% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
5.3%
3.1 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
19.5%
9 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.3% · Q3 12.1% · Q4 13.3% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.1% |
21.6%
3.5 pts better
|
16.7%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.6% · Q3 18.5% · 4Q avg 18.1% · 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 | 24.6% |
20.4%
4.2 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
19.9%
3.3 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 14.6% · Q3 21.2% · Q4 33.3% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.2% |
1.6%
3.6 pts worse
|
1.0%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 3.4% · Q3 5.0% · Q4 6.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
2.9%
0.6 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.2% · Q3 7.1% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
26.6%
3.6 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 38.9% · Q3 25.9% · Q4 27.9% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.3%
0.7 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 1.5% · Q3 4.0% · Q4 9.7% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.5% |
80.5%
27 pts worse
|
81.7%
28.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.8% · Q2 55.3% · Q3 55.2% · Q4 57.8% · 4Q avg 53.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
11.6%
7.4 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
2.4%
0.2 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 3.4% · Q4 2.9% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 32.0% |
75.9%
43.9 pts worse
|
79.7%
47.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 32.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.5% |
20.9%
6.4 pts better
|
23.9%
9.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 12.5% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2022-11-08 · Fire 2022-11-08
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-08
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 2024-11-20
E · Potential for more than minimal harm
2024-10-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-20
F · Potential for more than minimal harm
2023-11-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-01-10
F · 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 2024-03-10
F · Potential for more than minimal harm
2023-11-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-11-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-11-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-11-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-10
F · Potential for more than minimal harm
2022-11-08
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
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 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-31
F · Potential for more than minimal harm
2022-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-11-08
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 2022-12-31
E · Potential for more than minimal harm
2022-11-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-11-08
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-12-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-10
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2025-07-18
E · Potential for more than minimal harm
2025-06-10
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-06-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-01-13
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 2025-02-24
D · Potential for more than minimal harm
2025-01-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-24
D · Potential for more than minimal harm
2025-01-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
D · Potential for more than minimal harm
2024-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
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 2024-11-20
F · Potential for more than minimal harm
2024-10-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-20
F · Potential for more than minimal harm
2024-10-08
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-11-20
E · Potential for more than minimal harm
2024-10-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-20
D · Potential for more than minimal harm
2024-10-08
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 2024-11-20
D · Potential for more than minimal harm
2024-10-08
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 2024-11-20
D · Potential for more than minimal harm
2024-10-08
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 2024-11-20
D · Potential for more than minimal harm
2024-03-13
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 2024-04-20
F · Potential for more than minimal harm
2023-11-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-11-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-11-30
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-11-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-09-06
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 2023-10-10
F · Potential for more than minimal harm
2022-11-08
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 2022-12-31
F · Potential for more than minimal harm
2022-11-08
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 2022-12-31
F · Potential for more than minimal harm
2022-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-31
E · Potential for more than minimal harm
2022-11-08
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-08
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 2022-12-31
D · Potential for more than minimal harm
2022-11-08
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 2022-12-31
D · Potential for more than minimal harm
2022-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-31
D · Potential for more than minimal harm
2022-11-08
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 2022-12-31
D · Potential for more than minimal harm
2022-11-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-31
Penalties and ownership
What sits behind the stars
$3,174
2023-05-15
Fine
Fine · fine $3,174
Fine
Ownership
Holmes Lake Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Chafetz, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Chafetz, Yisroel
Operational/Managerial Control · Individual
Moss, Jacque
Operational/Managerial Control · Individual
Sattar, Arif
Operational/Managerial Control · Individual
Vnb New York LLC
5% Or Greater Security Interest · Organization
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