Holmes Lake Rehabilitation & Care Center
Lincoln, Nebraska · CCN 285164
23 surveys since 2011. The first finding at harm level was recorded in 2016.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 87
- Surveys
- 23
- Harm or worse
- 3
- Immediate jeopardy
- 1
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 97
- Ownership
- For profit - Corporation
- Chain
- Independent
- County
- Lancaster
- Medicare-certified since
- 1995
CMS ratings
- Overall
- 2
- Health inspection
- 3
- Staffing
- 1
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 26 for-profit facilities of 66–99 beds in Nebraska.
Last survey on record
Apr 9, 2026
214 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.24 | 3.50 |
| Registered-nurse hours per resident day | 0.28 | — |
| Annual nurse turnover | 84.0% | 62.5% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1250.0% | E520.8% | F729.2% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F8805×
Provide and implement an infection prevention and control program.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F8122×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F9472×
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
In the surveyor’s words
From the most serious findings on record at Holmes Lake Rehabilitation & Care Center, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF844Jun 10, 2025
Licensure Reference Number 175 NAC 12-006.04(E) Based on interviews and record reviews, the facility failed to provide notification to Department of Health and Human Servcies (DHHS) within 5 working days of a change in Director of Nursing (DON) position. This had the potential to affect all the residents that reside in the facility. The facility census was 50. Findings are: Record review of the facilities notification of the change in DON that was sent to State Agency revealed the previous DON service end date was 2/2/2024 and the new DON service start date was 2/3/2024. […]
- No harm, potential for more than minimal, widespreadF812Oct 8, 2024
Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview and record review; the facility failed to maintain the cleanliness of the kitchen to prevent the potential for food-borne illness and failed to ensure fluids were provided that were maintained within the required temperature range. This had the potential to affect all 47 residents that ate food prepared in the facility kitchen. The facility census was 47. Findings are: A. Record review of the Nebraska Food Code dated 2017. Section 4-602.13 revealed that nonfood- contact surfaces of equipment shall be cleaned at a frequency necessary to prevent the accumulation of soil residues. […]
- No harm, potential for more than minimal, widespreadF880Oct 8, 2024
Licensure Reference Number 175 NAC 12-006.19(C)(i) Licensure Reference Number 175 NAC 12-006.18(B) Based on observation, interview, and record review, the facility failed to ensure staff handled contaminated and clean laundry and linens to prevent cross contamination, failed to ensure Enhanced Barrier Precautions (EBP) signage was posted and Personal Protective Equipment (PPE) was available for staff use in 3 (Residents 23, 31, and 40) of 4 sampled resident's rooms, failed to ensure 1 (Resident 5) of 2 sampled resident's Positive Airway Pressure (PAP, a machine use to treat sleep apnea) device contained a filter, and failed to clean and store PAP supplies for 1 (Resident 2) of 2 sampled residents. […]
- No harm, potential for more than minimal, widespreadF947Oct 8, 2024
Licensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on record review and interview; the facility failed to ensure current staff were completing the required 12 hours of continuing education annually. This had the potential to affect all residents in the facility. The facility identified a census of 47. Findings are: A record review of the facility policy titled Required Training, Certification and Continuing Education of Nurse Aides, dated 11-17; 1-2024 revealed the following guidelines; It is the policy of this facility too comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing educate of its nurse aides. 5. […]
- No harm, potential for more than minimal, widespreadF732Nov 30, 2023
Based on observation and interview, the facility failed to ensure daily nurse staffing was posted. This had the potential to affect all 50 residents in the facility. Findings are: An observation on 11/30/2023 at 10:40 AM revealed, the daily posted nurse staffing reports for the facility were placed in a clear plastic folder taped to the window of the Administrator's office with dates of 03/04/2023, 03/06/2023, 03/07/2023, 03/08/2023, and 03/09/2023. In an interview on 11/30/2023 at 11:32 AM with the Accounting Director (AD) revealed, the daily posted nurse staffing reports were going to be the AD's responsibility and they have not been completed since 03/09/2023. […]
Read 23 findings in full →The most serious and the most recent: 23 of 87 on record.
Every survey on record
FindingsAt actual harm or above
- Apr 9, 2026Standard2 findings
- Jun 10, 2025Complaint3 findings
- Jan 13, 2025Complaint3 findings
- Oct 21, 2024Complaint1 finding
- Oct 8, 2024Standard and complaint7 findings
- Mar 13, 2024Complaint1 finding
- Nov 30, 2023Standard6 findings
- Sep 6, 2023Complaint1 finding
Show the 15 earlier surveys
- Nov 8, 2022Standard10 findings
- May 27, 2021Standard9 findings
- Oct 1, 2020Infection control2 findings · 1 harm
- Sep 8, 2020Infection control1 finding
- Aug 22, 2019Standard11 findings
- Feb 26, 2019Complaint1 finding · 1 harm
- Apr 30, 2018Standard2 findings
- Apr 18, 2017Standard and complaint1 finding
- Feb 1, 2016Standard7 findings · 1 harm
- May 13, 2015Complaint1 finding
- Jan 8, 2015Standard5 findings
- Feb 19, 2014Standard3 findings
- Nov 8, 2012—2 findings
- May 2, 2011—1 finding
- Feb 28, 2011—7 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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