Cycle 1
Health 2024-11-21 · Fire 2024-11-21
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
York, NE
York General Hearthstone
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
2600 North Lincoln Avenue, York, NE
(402) 362-4333
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-07-12
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
0.51
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.49
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
0.30
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.34
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,729
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9839
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.84
Baseline 19.32% · Performance 20.58% · Measure score 1.84 · Achievement 1.84 · Improvement 0
Healthcare-associated infections
2.46
Baseline 5.34% · Performance 7.10% · Measure score 2.46 · Achievement 2.46 · Improvement 0
Total nurse turnover
3.17
Performance 50.72% · Measure score 3.17 · Achievement 3.17 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.87
Baseline 3.44 hours · Performance 3.89 hours · Measure score 2.87 · Achievement 2.87 · Improvement 1.42
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 7.23% · Lower 95% interval 6.9% |
| Discharge to community | 46.14% |
50.57%
4.4 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 42.67% · Lower 95% interval 35.82% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 56 · Denominator 56 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 1 · Denominator 56 |
| Discharge self-care score | 57.89% |
53.69%
4.2 pts better
|
Numerator 22 · Denominator 38 |
| Discharge mobility score | 63.16% |
50.94%
12.2 pts better
|
Numerator 24 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.1% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 56 · Observed rate 5.36% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 2.74% |
8.2%
5.5 pts worse
|
Numerator 4 · Denominator 146 |
| Staff flu vaccination coverage | 58.93% |
42%
16.9 pts better
|
Numerator 99 · Denominator 168 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 26 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 34 · Denominator 34 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 37.5% |
25.2%
12.3 pts better
|
Numerator 12 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
92.8%
2.3 pts worse
|
93.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.2% · Q2 93.1% · Q3 95.5% · Q4 90.0% · 4Q avg 90.5% |
| 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 | 7.4% |
4.5%
2.9 pts worse
|
3.3%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 4.2% · Q3 7.5% · Q4 7.1% · 4Q avg 7.4% · 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 | 1.6% |
5.3%
3.7 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
19.5%
4.1 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 17.7% · Q3 15.3% · Q4 13.6% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.1% |
21.6%
3.5 pts worse
|
16.7%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 24.5% · Q3 24.5% · Q4 24.5% · 4Q avg 25.1% · 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 | 16.5% |
20.4%
3.9 pts better
|
16.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 16.9% · Q3 7.7% · Q4 21.5% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
19.9%
9.3 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 6.9% · Q3 3.5% · Q4 16.1% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
1.6%
0.5 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.3% · Q3 1.7% · Q4 1.6% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.9%
0.3 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.8% · Q3 1.5% · Q4 2.9% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
26.6%
7.2 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 29.7% · Q3 24.3% · Q4 49.4% · 4Q avg 33.8% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.3%
2.8 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 2.7% · Q4 1.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.1% |
80.5%
9.4 pts worse
|
81.7%
10.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 90.9% · Q3 59.5% · Q4 45.5% · 4Q avg 71.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
11.6%
0.6 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 10.0% · Expected 10.1% · 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 | 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 | 19.7% |
20.9%
1.2 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 16.0% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-17 · Fire 2023-10-17
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-07 · Fire 2022-09-07
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-26
F · Potential for more than minimal harm
2024-11-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-26
F · Potential for more than minimal harm
2023-10-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-27
E · Potential for more than minimal harm
2022-09-07
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-10-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-10-17
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 2023-11-30
E · Potential for more than minimal harm
2022-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
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 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-09-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-14
Penalties and ownership
What sits behind the stars
Ownership
Bartholomew, Mitch
Corporate Director · Individual
Berg, Miles
Corporate Director · Individual
Carlson, Terri
Corporate Director · Individual
Colburn, Carrie
Corporate Director · Individual
Ermer, Steve
Corporate Director · Individual
Harris, Charles
Corporate Director · Individual
Holoch, Kristie
Corporate Director · Individual
Jensen, Jane
Corporate Director · Individual
Mcquistan, Gayle
W-2 Managing Employee · Individual
North, Tony
Corporate Director · Individual
Obermier, Jennifer
W-2 Managing Employee · Individual
Otte, Cassandra
Corporate Director · Individual
Thomas, Kelly
Corporate Director · Individual
Ulrich, James
W-2 Managing Employee · Individual
Witte, Shirley
Corporate Director · Individual
York General Hospital
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Legacy Square
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2-star overall rating with 1-star inspections with $21,645 in total fines with 7 recent health deficiencies
#2
Midwest Covenant Home
Stromsburg, NE
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Fairview Manor
Fairmont, NE
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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