Cycle 1
Health 2025-05-22 · Fire 2025-05-22
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lincoln, NE
Old Cheney Rehabilitation
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5431 South 16th Street, Lincoln, NE
(531) 739-3200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Promontory Healthcare
Operator or chain grouping
Approved since
2017-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 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
1.26
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.57
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
2.21
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.27
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,342
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.36% · Performance 27.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.57% · Performance 7.78% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
5.15
Baseline 6.05 hours · Performance 4.54 hours · Measure score 5.15 · Achievement 5.15 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 290 · Observed rate 9.31% · Lower 95% interval 7.66% |
| Discharge to community | 55.21% |
50.57%
4.6 pts better
|
No Different than the National Rate · Eligible stays 325 · Observed rate 50.15% · Lower 95% interval 49.95% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 226 · Denominator 226 |
| Falls with major injury | 1.33% |
0.77%
0.6 pts worse
|
Numerator 3 · Denominator 226 |
| Discharge self-care score | 53.74% |
53.69%
0.1 pts better
|
Numerator 79 · Denominator 147 |
| Discharge mobility score | 57.82% |
50.94%
6.9 pts better
|
Numerator 85 · Denominator 147 |
| Pressure ulcers or injuries, new or worsened | 2.65% |
2.29%
0.4 pts worse
|
Numerator 6 · Denominator 226 · Adjusted rate 4.14% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 227 · Observed rate 7.93% · Lower 95% interval 5.54% |
| Staff COVID-19 vaccination coverage | 27.59% |
8.2%
19.4 pts better
|
Numerator 16 · Denominator 58 |
| Staff flu vaccination coverage | 50.88% |
42%
8.9 pts better
|
Numerator 58 · Denominator 114 |
| Discharge function score | 57.82% |
56.45%
1.4 pts better
|
Numerator 85 · Denominator 147 |
| Transfer of health information to provider | 97.56% |
95.95%
1.6 pts better
|
Numerator 80 · Denominator 82 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 132 · Denominator 132 |
| Resident COVID-19 vaccinations up to date | 26.21% |
25.2%
1 pts better
|
Numerator 27 · Denominator 103 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
4.5%
4.5 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.5% |
4.4%
2.1 pts worse
|
11.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
5.3%
1.6 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
19.5%
3.9 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.0% |
21.6%
14.4 pts worse
|
16.7%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
19.9%
5.1 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
26.6%
5.3 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
4.3%
0.2 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
80.5%
18.4 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 99.3% · Q3 98.3% · Q4 98.3% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.1% |
11.6%
0.5 pts worse
|
12.0%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 12.8% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
2.4%
2.1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.7% |
75.9%
18.8 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
20.9%
6.8 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 28.7% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-13 · Fire 2024-06-13
10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-21 · Fire 2023-06-21
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-06
E · Potential for more than minimal harm
2025-05-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-06
F · Potential for more than minimal harm
2024-06-13
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 2024-07-19
F · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-19
F · Potential for more than minimal harm
2023-06-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-25
F · Potential for more than minimal harm
2023-06-21
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 2023-07-28
F · Potential for more than minimal harm
2023-06-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-25
E · Potential for more than minimal harm
2023-06-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-21
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-22
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 2025-07-06
E · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-06
E · Potential for more than minimal harm
2025-05-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-06
D · Potential for more than minimal harm
2025-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-06
F · Potential for more than minimal harm
2024-06-13
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-13
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-07-26
F · Potential for more than minimal harm
2024-06-13
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 2024-07-26
F · Potential for more than minimal harm
2024-06-13
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 2024-07-26
D · Potential for more than minimal harm
2024-06-13
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 2024-07-26
D · Potential for more than minimal harm
2024-06-13
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 2024-07-26
D · Potential for more than minimal harm
2024-06-13
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-04-17
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 2024-05-10
D · Potential for more than minimal harm
2024-04-17
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 2024-05-10
D · Potential for more than minimal harm
2024-04-17
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-05-10
F · Potential for more than minimal harm
2023-06-21
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 2023-07-28
E · Potential for more than minimal harm
2023-06-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-28
Penalties and ownership
What sits behind the stars
Ownership
Adamson, James
5% Or Greater Indirect Ownership Interest · Individual
Azimov, Zafar
5% Or Greater Indirect Ownership Interest · Individual
Adamson, James
Corporate Director · Individual
Ammon Walkers Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Bright, Renae
Corporate Officer · Individual
Dein, Michele
Operational/Managerial Control · Individual
Dein, Michele
Corporate Officer · Individual
Glazer, Paul
5% Or Greater Direct Ownership Interest · Individual
Haynes, Anna
Corporate Officer · Individual
Huntsman, Casey
5% Or Greater Direct Ownership Interest · Individual
Ira - Lcharvet
5% Or Greater Direct Ownership Interest · Organization
Promontory Healthcare Companies LLC
5% Or Greater Direct Ownership Interest · Organization
Promontory Healthcare Companies LLC
Operational/Managerial Control · Organization
Promontory Healthcare Management LLC
Operational/Managerial Control · Organization
Quest Ira Inc
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Tabitha At The Landing
Lincoln, NE
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Emerald Nursing & Rehab Lancaster LLC
Lincoln, NE
1-star overall rating with 1-star inspections with Special Focus status with $79,725 in total fines with 15 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#3
Sumner Place
Lincoln, NE
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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