Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Lighthouse At Lakeside Village during CMS and state inspections, most recent first.
Missing Criminal Background Check for Minor Nurse Aide: The facility failed to complete a criminal background check for one sampled nurse aide. Record review showed the aide was hired as a minor, and HR confirmed the check had not been done because of the employee’s age. Facility policy listed a criminal background check as part of required pre-hire screening.
Failure to timely report abuse, injury, and theft allegations: the facility did not report a suspected abuse incident involving a resident, a fall with injury requiring ED care and sutures, and an unauthorized check cashing within required timeframes, and it did not submit written investigative reports to the state agency. The DON and Social Worker confirmed the missing state reports, and the abuse policy required reporting within 2 hours for abuse or serious bodily injury and written investigation submission within 5 working days.
The facility failed to ensure proper food storage and handling, with expired and undated food items found in storage and freezers. During food preparation, recipe measurements were not followed, and proper hand hygiene and glove use were neglected. The facility's policies on food storage and hygiene were not adhered to, as confirmed by the Executive Chef.
The facility did not transmit an MDS record to CMS within the required time frame for a resident. The assessment, completed on a specified date, was not sent due to it being incorrectly marked as not to be transmitted. Both the MDS Specialist and Corporate Nurse Specialist confirmed the error and the facility's adherence to RAI manual guidelines.
The facility failed to update the Comprehensive Care Plans (CCPs) for two residents to reflect their current Do Not Resuscitate (DNR) status. Despite changes in resuscitation status being documented in the Resuscitation Authorization and Order Summary Reports, the CCPs continued to list the residents as CPR/Full Code. This discrepancy was confirmed by the Social Services Designee.
A resident with severe cognitive impairment and a history of various medical conditions was at risk for hot liquid burns. Despite the care plan requiring hot liquids to be served in cups with lids and consumed at a table, the resident was observed receiving coffee without a lid on two occasions. Facility staff were not notified of this deviation from the care plan, leading to a confirmed deficiency in safety measures.
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12% error rate. Two residents were affected: one received Alendronate with other medications instead of on an empty stomach, and another received Omeprazole after breakfast instead of 60 minutes before meals. The errors were confirmed by the nursing staff.
The facility failed to ensure accurate MDS coding for two residents. One resident's MDS did not reflect their Hospice status, and another resident's MDS incorrectly indicated IV fluid use while in the facility. These inaccuracies were confirmed by the facility's nursing leadership.
The facility staff failed to maintain a medication error rate below 5%, resulting in an 8% error rate. Two residents were affected: one received a crushed medication that should not have been crushed, and another did not receive their prescribed Tylenol due to an oversight, despite the medication being in stock.
The facility failed to ensure proper infection control practices during personal care for two residents. One staff member did not change gloves or perform hand hygiene after washing a resident's peri area, and another used hand sanitizer on gloved hands instead of changing gloves. These actions were confirmed by the staff involved and a registered nurse.
Missing Criminal Background Check for Minor Nurse Aide
Penalty
Summary
The facility failed to ensure a criminal background check was completed for 1 of 5 sampled staff members, Nurse Aide A. A review of background screening checks completed on 3/19/24 for Nurse Aide A did not show a completed criminal background check, and an employee report dated 5/27/26 showed Nurse Aide A had a hire date of 3/18/24. During interviews on 5/27/26, the Human Resource Business Partner confirmed the criminal background check had not been completed because Nurse Aide A was a minor and stated that an additional request would need to be made to the vendor to complete the check for a minor employee. The facility policy titled Abuse-Prevention and Reporting, dated 4/7/26, listed criminal background check as part of the required pre-hire screening for applicants.
Failure to Timely Report Abuse, Injury, and Theft Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse and significant injury were reported to the appropriate authorities within the required timeframes and failed to ensure written investigation reports were submitted to the state agency within 5 working days for three residents. One incident involved Resident 2, where a nurse aide was observed being rough with the resident by grabbing the resident’s wrists and pulling on them. The nurse aide was sent home and later terminated, and the facility completed an internal investigation with interviews of other staff who had entered the room. However, the initial report was not made within 2 hours, and the online report was submitted to Adult Protective Services several days later; the Director of Nursing confirmed it was not submitted to the state survey agency. Another incident involved Resident 1, who fell and was sent to the emergency department with a 1 cm laceration above the right eye requiring 3 sutures. The facility called the Adult Protective Service abuse/neglect hotline and submitted a self-report, but the report did not identify submission to the state survey agency, and the Director of Nursing confirmed it was not reported there. A third incident involved Resident 3, who reported a missing blank check that had been cashed for $450 without authorization. The facility reported the matter to Adult Protective Services and police, but the Resident Concern Report did not identify that an investigative report had been submitted to the state survey agency, and the Social Worker confirmed no such report was submitted.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a kitchen tour. Expired food items were found in the dry storage area, including opened bags of corn flakes, white chips, and cheese sticks, among others, without proper dating. Additionally, several items in the freezers, such as breaded meat, french fries, and chicken nuggets, were opened and undated. Interviews with the Sous Chef and Executive Chef confirmed these items were improperly stored and should have been removed from use. During food preparation, the facility did not adhere to recipe measurements, as observed with the preparation of scrambled eggs with ham and cheese. The Lead Cook did not measure the ham, eggs, or milk according to the recipe, and used an undetermined amount of each ingredient. Furthermore, the Lead Cook failed to maintain proper hand hygiene and glove use, handling food with soiled gloves and not washing hands with soap after discarding egg shells. The facility's policies on food storage, sanitary conditions, hand washing, and glove use were not followed. The policies require all foods to be labeled and dated, and for hand hygiene to be performed after handling soiled equipment or utensils. The Executive Chef acknowledged the discrepancies in recipe adherence and hygiene practices, indicating a lack of compliance with professional standards for food service safety.
Failure to Transmit MDS Record Timely
Penalty
Summary
The facility failed to transmit a Minimum Data Set (MDS) record to the Centers for Medicare and Medicaid Services (CMS) within the required time frame for one resident. According to the Resident Assessment Instrument (RAI) manual, the facility is obligated to transmit the MDS within 14 days of its completion. In this case, the assessment for the resident, with an assessment reference date of November 19, 2024, was completed on December 2, 2024, but was not transmitted to CMS. An interview with the MDS Specialist revealed that the MDS was incorrectly marked as not to be transmitted, and the specialist confirmed that the record should have been submitted. Additionally, the Corporate Nurse Specialist confirmed that the facility adheres to the guidelines in the RAI manual for MDS transmission.
Failure to Update Code Status in Care Plans
Penalty
Summary
The facility failed to update the Comprehensive Care Plan (CCP) to accurately reflect the code status for two residents. Resident 5, who was admitted with severe cognitive impairment and multiple diagnoses including myocardial infarction and dementia, had a change in resuscitation status from CPR to Do Not Resuscitate (DNR). Despite this change being documented in the Resuscitation Authorization and Order Summary Report, the CCP still indicated the resident's code status as CPR/Full Code. This discrepancy was confirmed during an interview with the Social Services Designee (SSD). Similarly, Resident 12, who had moderate cognitive impairment and several serious health conditions such as chronic respiratory failure and congestive heart failure, also experienced a change in code status from CPR to DNR. Although the updated Resuscitation Authorization and Order Summary Report reflected this change, the CCP continued to list the resident's code status as CPR. This oversight was also confirmed by the SSD during an interview. The facility's failure to update the CCPs for these residents represents a deficiency in maintaining accurate and current care plans.
Failure to Implement Hot Liquid Safety Measures for Resident
Penalty
Summary
The facility failed to implement interventions to prevent the potential for hot liquid burns for a resident with severe cognitive impairment. The resident, who had a history of non-ST elevation myocardial infarction, metabolic encephalopathy, and unspecified dementia with behavioral disturbance, was identified as being at risk for injury related to hot liquid burns. The resident's care plan specified that hot liquids should be served in cups with lids and consumed only while sitting at a table. However, during dining observations, the resident was served coffee in a paper cup without a lid on two separate occasions. Interviews with facility staff, including a lead server, registered nurse, nursing assistant, and care partners, revealed that none were notified that the resident was served coffee without a lid, contrary to the care plan's interventions. The Director of Nursing confirmed that the resident was at risk for hot liquid burns and acknowledged that the care plan required lids on cups containing hot liquids. The failure to adhere to the care plan's interventions for hot liquid safety was confirmed, indicating a deficiency in the facility's implementation of safety measures for residents at risk of burns.
Medication Administration Errors Result in 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a 12% error rate. This was evidenced by three medication errors out of 25 opportunities, affecting two residents. Resident 36 was admitted with a diagnosis of periprosthetic fracture and osteoporosis. During an observation, RN-A administered Alendronate along with other medications, contrary to the physician's order and manufacturer's recommendation that it should be given on an empty stomach and 30 minutes before any other medication or food. The Director of Nursing confirmed this error. Resident 1, admitted with aspiration pneumonitis and GERD, was observed to have received Omeprazole after breakfast, despite the physician's order to administer it 60 minutes before meals. RN-A acknowledged the error, explaining that some residents prefer to receive all medications together to avoid being woken up. The Assistant Director of Nursing confirmed the expectation to administer Omeprazole as per the physician's order. The facility's medication administration policy requires medications to be labeled with specific instructions, which were not followed in these instances.
Inaccurate MDS Coding for Hospice and IV Fluids
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) was accurately coded for two residents. Resident 1, who was admitted to Hospice services in January 2022, had an MDS that did not reflect their Hospice status. The Director of Nursing confirmed that Resident 1 had been on Hospice for a long time and that the MDS was incorrectly coded. Resident 1 was severely cognitively impaired and dependent on staff for all activities of daily living, with a terminal prognosis related to advanced Alzheimer's disease. Resident 10's MDS was also inaccurately coded. The MDS indicated that Resident 10 had received intravenous (IV) fluids as a resident, which was incorrect. The Assistant Director of Nursing confirmed that Resident 10 did not receive IV fluids while in the facility but had received them in the hospital prior to admission. Resident 10 was diagnosed with Alzheimer's Disease and vascular dementia and was dependent on staff for all activities of daily living. The inaccuracies in the MDS for both residents were confirmed through interviews with the facility's nursing leadership.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility staff failed to ensure it was free of a medication error rate of 5% or greater, resulting in an error rate of 8%. Observations were made of 25 medications administered, revealing 2 errors affecting 2 of 3 sampled residents. For Resident 8, the medication error involved the improper crushing of mucous relief 600 mg, which was not supposed to be crushed. Care Partner (CP)-B crushed the medication and mixed it with applesauce before administering it to Resident 8. Both CP-B and Registered Nurse (RN)-E confirmed that the medication should not have been crushed, indicating a clear deviation from the facility's policy on medication administration, which specifies that only medications approved by the manufacturer and pharmacy, and which have a provider order, are to be crushed. For Resident 25, the medication error involved the unavailability of Tylenol 500 mg, which was supposed to be administered twice a day. CP-B noted the unavailability of the medication and informed RN-E. However, it was later confirmed by RN-A that the facility had Tylenol 500 mg in stock, and the medication was not given to Resident 25 as required. The Director of Nursing (DON) confirmed that the failure to administer the medication constituted an omission medication error. The facility's policy on medication administration emphasizes the importance of following professional standards, including the 6 rights of medication administration and ensuring that documentation is completed before setting up medication for the next resident.
Infection Control Deficiencies in Personal Care Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during personal care for two residents. In one instance, a Nursing Assistant (NA-D) was observed providing a shower to a resident (Resident 20) and placed washcloths in the sink, which could lead to cross-contamination. NA-D did not change gloves or perform hand hygiene after washing the resident's peri area and buttocks before washing other parts of the resident's body. This was confirmed by NA-D and RN-E, who acknowledged the risk of cross-contamination from placing washcloths in the sink and not changing gloves appropriately. In another instance, a Care Partner (CP-C) was observed providing care to a resident (Resident 2) and used Alcohol Based Hand Rub (ABHR) on gloved hands instead of removing the gloves and performing hand hygiene. CP-C handled the resident's dentures, adjusted the resident's bed, and changed the resident's brief without changing gloves. This improper use of ABHR on gloved hands was confirmed by CP-C and RN-E, who stated that gloves should have been removed and hand hygiene performed on bare hands.
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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 Omaha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newport House | 2.5 mi | ★★★★★ | 8 | 0 |
| Brookestone Meadows Rehabilitation And Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Brookestone Village | 2.9 mi | ★★★★★ | 10 | 0 |
| The Banyan At Montclair | 3.3 mi | — | 19 | 0 |
| Hillcrest Millard Llc | 3.5 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.