Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holmes Lake Rehabilitation & Care Center during CMS and state inspections, most recent first.
Unsafe and untimely meal service: Cook-A prepared lunch chicken without counting portions, then served the meal using the same gloved hands to move food on plates and handle hot plates and dish covers. The entrée was 11 pieces short, and the Dietary Mgr later grilled additional chicken for the remaining residents after lunch service had already started.
Failure to Use EBP During G-Tube Care: An LPN administered G-tube medications to a resident with a feeding tube without wearing the required gown, despite an EBP sign on the door and a facility policy requiring gown and glove use for residents with feeding tubes. Later, two LPNs attempted to unclog the resident’s G-tube without gowns, and the DON confirmed that gown and gloves should have been worn during G-tube medication administration.
The facility did not notify DHHS within the required 5 working days after a change in the DON position, with notification sent significantly late. The DON confirmed the delay and acknowledged errors in the recorded service dates. This issue had the potential to impact all residents in the facility.
Multiple residents with significant medical and mobility needs experienced frequent and prolonged delays in staff response to call lights, with some waiting up to two hours for assistance. Device Activity Reports and direct observations confirmed that staff often failed to respond within the facility's expected timeframe, and staff members were seen walking past rooms with active call lights without checking on residents.
A resident with multiple medical conditions and no cognitive impairment was the subject of an abuse allegation. The facility did not submit the required 5-day written investigation report to DHHS within the mandated timeframe, instead sending it two days late. The DON confirmed the delay in submission.
The facility failed to have a nursing services representative present during care plan conferences for several residents, contrary to its policy. The policy requires the presence of the DON or an RN designee at these conferences. Documentation showed that nursing services were absent for multiple residents on several occasions, and the facility Administrator confirmed the DON's expected attendance.
A resident with Type 2 Diabetes Mellitus received an incorrect insulin dose due to a nurse's failure to prime the insulin pen and dial the prescribed dose before injection. The facility's policy requires these steps to ensure accurate dosing, but the nurse did not follow them, as confirmed by interviews with the nurse and facility staff.
A facility failed to follow infection control procedures during peri care for a resident with a cerebral infarct. A Nurse Aide removed the resident's clothing and soiled brief without gloves, then applied gloves but did not change them or perform hand hygiene before wiping the peri/rectal area. This breach was confirmed by the facility's Regional Nurse Consultant and the Nurse Aide.
The facility failed to ensure proper infection control practices, with staff observed not wearing N-95 masks correctly and not following hand hygiene protocols. A resident in a COVID-positive room was attended by an RN wearing a surgical mask instead of an N-95 mask, who also mishandled a COVID sample and neglected handwashing between glove changes. These actions were contrary to the facility's infection prevention policies.
The facility failed to maintain kitchen cleanliness and proper temperature control of fluids, posing a risk for food-borne illness to all 47 residents. Observations revealed environmental concerns such as a ceiling exhaust fan and light panels coated with a dark substance, food debris in storage areas, and improper fluid temperatures during lunch service. The Dietary Manager confirmed the fluids were not within safe temperature limits, violating the facility's food safety policy.
The facility failed to handle laundry properly, leading to potential cross-contamination, and did not implement Enhanced Barrier Precautions for residents with catheters. Additionally, a resident's PAP device was missing a filter, and another resident's CPAP mask was improperly stored, increasing infection risks.
The facility did not ensure that its nurse aides completed the required 12 hours of continuing education annually. A review of the facility's policy indicated that it must provide at least 12 hours of in-service training each year. However, an interview confirmed that four staff members had not completed the required education hours, with only abuse and neglect training completed in the past year. This deficiency could potentially affect all 47 residents.
The facility failed to provide adequate bathing services for several residents, with documented gaps in bathing over extended periods. A resident with dementia did not receive a bath for 25 days, while another with severe cognitive impairment went without for 40 days. Additionally, a resident's indwelling catheter was not changed monthly as ordered, due to unavailability of latex-free catheters. The DON confirmed these deficiencies in care.
The facility failed to notify the representatives of two residents after falls, as required by their policy. One resident, severely cognitively impaired, had multiple falls, including one from a recliner, without family notification. Another resident with moderate cognitive impairment also experienced falls without representative notification. Staff interviews confirmed the oversight.
A resident with severe cognitive impairment and a history of falls experienced multiple falls from a power recliner due to the facility's failure to update the care plan with new interventions. Despite the facility's policy requiring assessment and intervention adjustments after falls, these were not completed. Observations showed the recliner remote was often out of reach, contributing to the falls. The facility also failed to conduct new Recliner Chair Assessments and did not adequately inform the resident's family about the risks or notify them of all fall incidents.
A facility failed to provide a valid rationale for a resident's PRN Lorazepam prescription, which was not re-evaluated or discontinued as required. Despite the resident's cognitive awareness and absence of anxiety in their MDS, Lorazepam was prescribed for anxiety without a stop date. The facility's pharmacy recommended discontinuation or a clinical rationale, but this was not addressed, leading to a deficiency.
A resident with multiple diagnoses and a high risk for falls experienced numerous falls without new interventions being implemented. Despite being cognitively intact, the resident's falls resulted in injuries, and the facility's safety monitoring sheets showed inconsistent completion. Staff interviews confirmed the lack of new interventions and consistent monitoring.
Unsafe and untimely meal service
Penalty
Summary
The facility failed to ensure food was served in a safe and timely manner. The kitchen menu listed mealtimes as 8:00 AM for breakfast, noon for lunch, and 6:00 PM for supper, and the Dietary Manager confirmed those mealtimes during interview. On 4/9/26 at 7:00 AM, Cook-A was observed preparing the lunch meal by opening two bags of chicken breast and placing them in two greased pans, but did not count how many chicken breasts had been placed in the pans. The Dietary Manager told Cook-A there did not appear to be enough chicken breast for the residents, while Cook-A stated there was enough chicken. At noon, Cook-A was observed serving lunch after taking temperatures of the chicken, rice, and vegetables. While serving, Cook-A used gloved hands to move the food around on the plates and handled hot plates and dish covers with the same gloves without changing them during the serving process. During the meal service, the main entrée was 11 pieces short. At 12:45 PM, the Dietary Manager began grilling 11 chicken breasts, and the chicken was grilled in 15 minutes, coated with Swiss sauce, and placed on plates for the remaining residents. The Administrator later confirmed that Cook-A should not have been touching or moving the food around on the plates with contaminated gloves and that the Dietary Manager should have counted the chicken breasts when there was concern there was not enough for the meal.
Failure to Use Enhanced Barrier Precautions During G-Tube Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were used during G-tube feeding and medication administration for one resident who was admitted with nutritional problems related to dysphagia following a cerebral infarction. During an observation, an LPN administered gastric tube medications to the resident without wearing the required gown for EBP. The resident’s room door had an EBP sign posted, and the facility’s MDRO PPE-Enhanced Barrier Precaution policy stated that EBP is to be worn for residents with indwelling medical devices such as feeding tubes. The observation also showed the LPN placing a barrier on the tray table and using hand sanitizer before administering the medications, but not wearing a gown. Later, when the resident’s G-tube became clogged and two LPNs attempted to unclog it, neither wore gowns during the procedure, although gloves were used during part of the care. Interviews with the LPN and the DON confirmed that a gown and gloves should have been worn when administering medications via the G-tube.
Failure to Timely Notify State Agency of DON Change
Penalty
Summary
The facility failed to notify the Department of Health and Human Services (DHHS) within 5 working days regarding a change in the Director of Nursing (DON) position, as required by licensure regulations. Record review showed that the previous DON's service ended on 2/2/2024 and the new DON began on 2/3/2024, but DHHS did not receive notification of this change until 3/31/2025. Interviews with the DON confirmed that the notification was not sent within the required timeframe and that the service dates should have been recorded as 2025. This lapse had the potential to affect all residents in the facility, which had a census of 50 at the time.
Failure to Respond Promptly to Resident Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for four residents, resulting in significant delays in meeting resident needs. Observations, interviews, and record reviews revealed that residents frequently experienced extended wait times for staff to respond to their call lights, with some instances exceeding one hour and, in one case, up to two hours. Device Activity Reports confirmed numerous occurrences where call lights were not answered within the expected timeframe, with many responses taking between 22 and 168 minutes. The DON confirmed that call lights should be answered in less than 20 minutes, but this standard was not met. One resident with a history of cerebral infarction, hemiplegia, diabetes, and other complex medical needs reported waiting up to two hours for assistance, particularly during evening shifts. Another resident with moderate cognitive impairment and multiple health conditions described waiting up to 1.5 hours for call light responses. A third resident, dependent on staff for most activities of daily living and with a history of falls and skin issues, was observed by the surveyor to have their call light ignored by multiple staff members over a period of more than 30 minutes, despite visible indicators that the call light was active. A fourth resident with hemiplegia, cerebrovascular disease, and other chronic conditions also reported frequent delays, sometimes waiting up to two hours for staff response. The documented delays in call light response were corroborated by both resident interviews and electronic call system records, which showed repeated and prolonged response times well beyond the facility's stated expectation. Staff members, including nurse aides and other personnel, were observed walking past rooms with active call lights without checking on the residents' needs, further contributing to the deficiency.
Failure to Timely Submit 5-Day Abuse Investigation Report
Penalty
Summary
The facility failed to complete and submit a 5-day written investigation report to the Department of Health and Human Services (DHHS) following an allegation of abuse involving a resident. According to the facility's own investigation form, such reports must be faxed to Health Facility Investigations within 5 working days from the date of the allegation or incident. However, for an incident involving a resident with multiple medical conditions, including hemiplegia, hemiparesis, cerebrovascular disease, atrial fibrillation, diabetes, anxiety, and a history of falls, the required report was not sent within the mandated timeframe. Record review showed that the resident, who had no cognitive impairment as indicated by a BIMS score of 15, was the subject of an abuse allegation on 3/18/25. The investigation report related to this allegation was submitted to DHHS on day 7, exceeding the 5-day requirement. The Director of Nursing confirmed in an interview that the report was sent late, acknowledging the failure to meet the regulatory deadline.
Absence of Nursing Services in Care Plan Conferences
Penalty
Summary
The facility failed to have a nursing services representative present during care plan conferences for four sampled residents, despite the facility's policy requiring such attendance. The policy, dated September 2019, mandates that care plan conferences should include the resident, their family or legal representative, the Clinical Reimbursement Manager/MDS Coordinator, and the Director of Nursing Services (DON) or a Registered Nurse (RN) designee. The absence of nursing services was documented in the care plan conference notes for three residents on multiple occasions. An interview with the facility Administrator confirmed that the DON was expected to attend these conferences but did not for the residents in question.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. During an observation, a registered nurse (RN) administered insulin to a resident without priming the insulin pen or dialing the prescribed dose before injection. This action was confirmed by the RN during an interview, acknowledging that the pen should have been primed and the correct dose dialed to ensure accurate administration. The resident involved had an active diagnosis of Type 2 Diabetes Mellitus and was on a prescribed regimen of Insulin Glargine, with specific dosages ordered by the physician. The facility's policy on using the Flexpen Insulin Competency requires priming the pen to remove air bubbles and ensure the full dose of insulin is administered. The failure to follow this procedure was observed and confirmed by both the RN and the facility's administrator. Additionally, the Regional Nurse Consultant confirmed that there were 13 residents in the facility requiring injectable insulin, indicating a broader potential for similar errors if procedures are not consistently followed.
Infection Control Breach During Peri Care
Penalty
Summary
The facility failed to ensure proper infection control procedures during peri care for Resident 11, who was admitted with a primary diagnosis of cerebral infarct. During an observation, Nurse Aide (NA)-F was seen assisting Resident 11 to the bathroom and removing the resident's pants and soiled brief without wearing gloves. After performing hand hygiene and applying gloves, NA-F removed the resident's shoes, pants, and soiled brief, then applied a clean brief. However, NA-F did not change gloves or perform hand hygiene before wiping the resident's peri/rectal area. This was confirmed by both the facility's Regional Nurse Consultant and NA-F during interviews, acknowledging that gloves should have been changed before providing perineal care.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, as evidenced by multiple observations of staff not wearing N-95 masks correctly and not adhering to hand hygiene protocols. Nurse Aide-A, the Social Service Director, and a Maintenance worker were observed wearing N-95 masks without securing both straps over their heads, which was confirmed through interviews. Additionally, a Registered Nurse (RN) entered a COVID-positive resident's room wearing a surgical mask instead of an N-95 mask, and failed to follow proper procedures for handling a COVID sample, including placing it on a clean barrier and washing hands between glove changes. The facility's infection prevention and control program policy, as well as the hand hygiene protocol, were not followed, leading to potential cross-contamination risks. The RN was observed placing a COVID sample directly on a treatment cart without a barrier, and not washing hands after removing gloves, which was acknowledged during an interview. The Director of Nursing confirmed that staff should wear N-95 masks correctly and adhere to hand hygiene practices. The facility's policies emphasize the importance of hand hygiene as a primary means to prevent infection spread, yet these were not adhered to during the observed incidents.
Kitchen Cleanliness and Temperature Control Deficiencies
Penalty
Summary
The facility failed to maintain the cleanliness of the kitchen, which posed a potential risk for food-borne illness affecting all 47 residents who consumed food prepared in the facility's kitchen. During an observation, several environmental concerns were noted, including a ceiling exhaust fan coated with a fuzzy dark gray/black substance located above the food preparation area, ceiling light panels with multiple specks of a dark gray/black substance, and exhaust fans in the dry storage room similarly coated. Additionally, food debris was found on the bottom shelf of the freezer, and two white bins in the dry storage room contained food debris and were coated with a dark gray, thick, and shiny substance. A storage rack near the dry storage room door had staff personal items and visible food debris, and a wheeled cart with an attached can opener was coated with food debris and a brown, thick, shiny substance. The floor in the dishwashing area was also coated with a dark gray substance. The facility also failed to ensure that fluids were maintained within the required temperature range, as observed during a lunch service. A test tray prepared for residents eating in their rooms revealed that the temperatures of the fluids were not within safe limits. The white milk was at 60 degrees, tomato juice at 62 degrees, and iced tea at 61 degrees, all of which were concerning to the Dietary Manager (DM), who refused to taste test them. The DM confirmed that the temperatures were not cold enough and should not have been served to the residents, indicating a failure to adhere to the facility's food safety policy, which defines the danger zone for temperatures as above 41 degrees Fahrenheit and below 135 degrees Fahrenheit.
Deficiencies in Infection Control and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper handling of contaminated and clean laundry, leading to potential cross-contamination. Observations revealed that staff members, including nursing assistants and housekeeping aides, were carrying linens and laundry in a manner that allowed them to come into contact with their clothing. This was contrary to the facility's policies, which required that soiled linens be handled in a way that prevents contamination and that clean linens be transported on covered carts. The Director of Nursing confirmed that the staff should not allow laundry to touch their clothing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling catheters. Observations showed that there was no EBP signage or personal protective equipment (PPE) available outside the rooms of residents with catheters, despite the facility's policy requiring such measures. Interviews with staff confirmed that these precautions were not in place, which could increase the risk of infection transmission. Additionally, the facility did not ensure that a resident's Positive Airway Pressure (PAP) device was properly maintained. The device was missing a filter, which should have been replaced according to the manufacturer's recommendations. Another resident's CPAP mask was not stored correctly, as it was found lying uncovered on the floor and draped over furniture, contrary to the facility's policy that required masks to be stored in labeled plastic bags. These oversights in equipment maintenance and storage could contribute to the spread of infections.
Failure to Ensure Required Continuing Education for Nurse Aides
Penalty
Summary
The facility failed to ensure that its nurse aides completed the required 12 hours of continuing education annually, as mandated by state and federal regulations. A review of the facility's policy on training and continuing education for nurse aides revealed that the facility is responsible for providing at least 12 hours of in-service training each year, based on the employment date. However, an interview with the facility's Corporate Nurse Consultant confirmed that four staff members, hired on various dates, had not completed the required continuing education hours. The only training these staff members had completed in the past year was related to abuse and neglect. This deficiency had the potential to affect all 47 residents in the facility.
Deficiencies in Bathing Services and Catheter Management
Penalty
Summary
The facility failed to provide adequate bathing services for several residents, as evidenced by the lack of documented baths or refusals over extended periods. Resident 2, with a diagnosis of dementia and moderately impaired cognition, did not receive a bath or have a refusal documented for two separate periods totaling 25 days. Similarly, Resident 35, who had severe cognitive impairment, went without a documented bath or refusal for a total of 40 days. Resident 38, with moderately impaired cognition, also experienced gaps in bathing services, with no baths or refusals documented for 20 days. Interviews with staff confirmed the absence of a specific bath aide and reliance on a posted list for daily bathing assignments. Resident 31 reported receiving only one shower in the previous four weeks, despite being scheduled for showers twice weekly. This resident, who preferred to be clean-shaven, had visible facial hair growth, indicating a lack of personal hygiene care. The facility's documentation confirmed that Resident 31 had not received a shower in 39 days, and the care plan lacked any mention of bathing preferences. The Director of Nursing acknowledged the expectation for weekly baths and confirmed the deficiency in providing personal hygiene services. Additionally, the facility failed to change Resident 31's indwelling catheter monthly as per the physician's order. The resident, with a diagnosis of neurogenic bladder and moderately impaired cognition, had not had their catheter changed since July, despite orders for monthly changes. Progress notes indicated that the catheter was not changed due to the unavailability of latex-free catheters, and the Director of Nursing confirmed the oversight. This failure to adhere to physician orders further highlights the facility's deficiencies in providing necessary care.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify the representatives of two residents following their falls, as required by their Fall Management policy. Resident 23, who was severely cognitively impaired, experienced multiple falls, including one on 10/02/2024, from a power lift recliner. Despite the policy stating that the family and physician should be notified and the incident documented, the family was not informed of this fall. The family member/POA only learned of the incident by accident during a visit to the facility, and the Clinical Nurse Consultant confirmed the oversight. Similarly, Resident 38, who had a moderate cognitive impairment, experienced falls on 9/18/2024 and 9/24/2024. The facility's records showed that the resident's representative was not notified of these incidents, contrary to the facility's expectations. Interviews with the facility's staff, including the Administrator and Corporate Nurse, confirmed that the representative should have been informed. The facility's process was to notify the physician and family as soon as possible, but this was not adhered to in these cases.
Failure to Implement Fall Prevention Interventions for a Resident
Penalty
Summary
The facility failed to implement necessary interventions to prevent falls for Resident 23, who was identified as being at high risk for falls due to multiple medical conditions, including muscle weakness, a history of falling, Alzheimer's disease, and difficulty walking. The resident was severely cognitively impaired, requiring substantial assistance for daily activities and transfers. Despite the resident's history of falls, the facility did not update the care plan with new interventions following falls on 09/24/2024 and 10/02/2024, which involved the resident sliding out of a power recliner. The facility's Fall Management policy required assessment and intervention adjustments after a fall, but these were not completed for Resident 23. The resident had multiple falls from the power recliner, yet the care plan lacked new interventions to address these incidents. Observations revealed that the power recliner remote was often out of reach or improperly secured, contributing to the resident's falls. Interviews with nursing assistants confirmed a lack of awareness of specific care plan interventions to prevent further falls from the recliner. Additionally, the facility did not conduct new Recliner Chair Assessments following each fall, as confirmed by the Clinical Nurse Consultant. The resident's family was not adequately informed about the risks associated with the power recliner or notified of all fall incidents, leading to concerns about the resident's safety. The facility's failure to update the care plan and conduct necessary assessments contributed to the ongoing risk of falls for Resident 23.
Failure to Provide Rationale for PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that a valid rationale was provided and the provider's order was followed for a resident's PRN Lorazepam prescription. The resident, who was admitted with diagnoses of restlessness, agitation, depression, and psychotic disorder, was cognitively aware with a BIMS score of 15 out of 15. Despite the absence of anxiety in the resident's MDS for mood disorders, the resident was prescribed Lorazepam for anxiety. The facility's Medication Regimen Review policy requires that any irregularities be reported and acted upon, and PRN orders for psychotropic drugs are limited to 14 days unless extended with documented rationale. The facility's pharmacy recommended discontinuing the Lorazepam or providing a clinical rationale and reassessment date, but there was no evidence of the physician addressing this recommendation. The resident's order for Lorazepam, which started without a stop date, was not re-evaluated in 30 days as ordered. Interviews with the Clinical Nurse Consultant confirmed that the rationale for continuing the PRN Lorazepam was not provided, and the medication was not stopped or re-evaluated as required.
Failure to Implement and Re-evaluate Fall Prevention Interventions
Penalty
Summary
The facility staff failed to implement and re-evaluate interventions to prevent ongoing falls for a resident identified as high risk for falls. The resident had multiple diagnoses, including Wernick's Encephalopathy, amputation, depression, alcohol abuse, generalized anxiety disorder, hypertension, repeated falls, encephalopathy, hypotension, muscle weakness, and a history of falling. Despite being cognitively intact, the resident experienced numerous falls, some resulting in injuries such as a fractured nose, multiple bruises, and a laceration to the face. The facility's Comprehensive Care Plan (CCP) did not indicate any new interventions following these falls, and the Morse Fall Scale assessments consistently identified the resident as high risk for falling. The facility's Fall Investigation Reports revealed that the root cause of the falls was the resident self-transferring. However, the initial interventions to prevent falls were to continue current safety measures without implementing new strategies. This pattern continued despite the resident experiencing multiple falls over several months. Additionally, the facility's Safety Monitoring sheets, which required staff to complete hourly safety checks, showed numerous instances where staff did not initial the checks, indicating a lack of consistent monitoring. Interviews with facility staff, including a Certified Medication Assistant (CMA), a Nursing Assistant (NA), and the Director of Nursing (DON), confirmed that the resident was a high fall risk and that the safety monitoring sheets were not consistently completed. The DON acknowledged that the safety monitoring was the primary intervention in place for months and admitted that no new interventions were implemented with each fall to prevent future incidents. This failure to update and communicate fall prevention interventions contributed to the ongoing risk of falls for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Jane De Chantal | 0.6 mi | ★★★★★ | 27 | 0 |
| Ambassador Health Of Lincoln | 1.1 mi | ★★★★★ | 3 | 0 |
| Eventide Lincoln Care Center | 1.6 mi | ★★★★★ | 4 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 1.6 mi | ★★★★★ | 27 | 0 |
| Eastmont | 1.8 mi | ★★★★★ | 6 | 0 |
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