Cycle 1
Health 2025-03-12 · Fire 2025-03-12
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Omaha, NE
The Lighthouse at Lakeside Village
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
17600 Arbor Street, Omaha, NE
(402) 717-0200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
36
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Immanuel
Operator or chain grouping
Approved since
2009-05-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 5 overall / 4 health / 5 staffing / 4 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
1.60
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.14
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.51
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
6.25
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
2.74
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
5.49
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.68
CMS adjusted RN staffing hours
Adjusted total hours
6.57
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,031
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0160
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.53
Baseline 15.92% · Performance 19.33% · Measure score 4.53 · Achievement 4.53 · Improvement 0
Healthcare-associated infections
4
Baseline 5.51% · Performance 6.64% · Measure score 4 · Achievement 4 · Improvement 0
Total nurse turnover
7.09
Baseline 48.98% · Performance 34.69% · Measure score 7.09 · Achievement 7.09 · Improvement 5.42
Adjusted total nurse staffing
8.72
Baseline 4.76 hours · Performance 5.56 hours · Measure score 8.72 · Achievement 8.72 · Improvement 7.32
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.23% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 4.51% · Lower 95% interval 6.24% |
| Discharge to community | 42.19% |
50.57%
8.4 pts worse
|
Worse than the National Rate · Eligible stays 141 · Observed rate 41.13% · Lower 95% interval 36.36% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 75 · Denominator 78 |
| Falls with major injury | 1.28% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 78 |
| Discharge self-care score | 65.15% |
53.69%
11.5 pts better
|
Numerator 43 · Denominator 66 |
| Discharge mobility score | 53.03% |
50.94%
2.1 pts better
|
Numerator 35 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 77 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 4% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 7.41% |
8.2%
0.8 pts worse
|
Numerator 6 · Denominator 81 |
| Staff flu vaccination coverage | 37.7% |
42%
4.3 pts worse
|
Numerator 23 · Denominator 61 |
| Discharge function score | 63.64% |
56.45%
7.2 pts better
|
Numerator 42 · Denominator 66 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 58 · Denominator 58 |
| Resident COVID-19 vaccinations up to date | 39.02% |
25.2%
13.8 pts better
|
Numerator 16 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
92.8%
5 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q4 100.0% · 4Q avg 97.8% |
| 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 | 4.5% |
4.5%
About the same
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 0.0% · Q4 0.0% · 4Q avg 4.5% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.3%
0.6 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% |
| 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 | 10.9% |
21.6%
10.7 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.9% · 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% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.9% |
20.4%
11.5 pts worse
|
16.3%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.0% |
19.9%
15.1 pts worse
|
14.9%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.0% · 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 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
2.9%
1.8 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 40.0% |
26.6%
13.4 pts worse
|
19.8%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.8% · Q2 34.0% · Q4 40.2% · 4Q avg 40.0% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
4.3%
3.3 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 4.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
80.5%
10.8 pts better
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 96.8% · Q3 93.1% · Q4 82.2% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.4% |
11.6%
1.2 pts better
|
12.0%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.4% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
2.4%
0.4 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 4.0% · Q4 2.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.0% |
75.9%
5.1 pts better
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
20.9%
1.1 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 15.3% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-03-21 · Fire 2023-03-21
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-26
F · Potential for more than minimal harm
2024-04-04
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-04-25
F · Potential for more than minimal harm
2024-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-25
E · Potential for more than minimal harm
2024-04-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-25
E · Potential for more than minimal harm
2024-04-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-25
F · Potential for more than minimal harm
2023-03-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-11
F · Potential for more than minimal harm
2023-03-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-04-12
E · Potential for more than minimal harm
2023-03-21
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 2023-05-11
E · Potential for more than minimal harm
2023-03-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-21
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-05-11
E · Potential for more than minimal harm
2023-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-12
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 2025-03-24
D · Potential for more than minimal harm
2025-03-12
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-03-12
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 2025-03-24
D · Potential for more than minimal harm
2025-03-12
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 2025-03-24
D · Potential for more than minimal harm
2025-03-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-24
D · Potential for more than minimal harm
2024-04-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-04-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-25
D · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-25
D · Potential for more than minimal harm
2023-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-24
D · Potential for more than minimal harm
2023-03-21
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 2023-04-24
Penalties and ownership
What sits behind the stars
Ownership
Alloway, Cindy
Corporate Director · Individual
Balluff, Mary
Corporate Director · Individual
Bear, Scott
Operational/Managerial Control · Individual
Bear, Scott
Corporate Officer · Individual
Bear, Scott
Contracted Managing Employee · Individual
Benson, Ellsworth
Corporate Director · Individual
Bergman-Evans, Brenda
Corporate Director · Individual
Bothof, John
Corporate Director · Individual
Bothof, John
Corporate Officer · Individual
Bullock, Steve
Corporate Director · Individual
Burns, Randal
Corporate Director · Individual
Carmel-Cooper, Bianca
W-2 Managing Employee · Individual
Cress, Allen
W-2 Managing Employee · Individual
Friedlund, Danny
Corporate Director · Individual
Gurley, Eric
Operational/Managerial Control · Individual
Gurley, Eric
Corporate Director · Individual
Gurley, Eric
Corporate Officer · Individual
Gurley, Eric
Contracted Managing Employee · Individual
Hawlik, Teresa
Corporate Director · Individual
Howerter, Scott
Corporate Director · Individual
Johnson, Scott
Corporate Director · Individual
Nichols, Clarence
Corporate Director · Individual
Paladino-Kaminski, Julie
Operational/Managerial Control · Individual
Paladino-Kaminski, Julie
Corporate Officer · Individual
Paladino-Kaminski, Julie
Contracted Managing Employee · Individual
Parker, Mary
Corporate Director · Individual
Powers, Jill
Corporate Director · Individual
Powers, Jill
Corporate Officer · Individual
Scanlan, Steven
Corporate Director · Individual
Scholer, Susan
Contracted Managing Employee · Individual
Sealer, Tamara
Operational/Managerial Control · Individual
Sealer, Tamara
Corporate Officer · Individual
Sealer, Tamara
Contracted Managing Employee · Individual
Skolkin, Andrea
Corporate Director · Individual
Thompson, Roger
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Newport House
Omaha, NE
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Brookestone Meadows Rehabilitation and Care Center
Elkhorn, NE
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Brookestone Village
Omaha, NE
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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