Holmes Lake Rehabilitation & Care Center

Location & what’s nearby

Open in Google Maps ↗ · Directions ↗ · Larger map ↗

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

35.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 36 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 59.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 49 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.21 therapist hours per resident per day in 2026Q1 — more than 25% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 26% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 97 beds and averages 56.2 residents a day — about 58% occupied, or roughly 41 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.24 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.28 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.39 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.88 hrs/resident/day on weekends vs 3.39 on weekdays — 15% thinner on weekends. RN hours go from 0.29 to 0.25 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 84% is well above the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

• Potential for harm · Ecited before2026-04-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility failed to ensure food was served in a safe and timely manner to prevent potential food born illnesses. This had the potential to affect all residents who ate from the kitchen. The facility census was 52.Licensure Reference Number 175 NAC 12-006.11 (E) A record review of the kitchen menu revealed the mealtimes were: 8:00 AM for breakfast, noon for lunch and 6:00 PM for supper.An interview on 4/8/26 with the Dietary Manager confirmed that the mealtimes were: 8:00 AM for breakfast, noon for lunch and 6:00 PM for supper.An observation on 4/9/26 at 7:00 AM with the Dietary Manager and the Cook-A who was preparing the lunch meal revealed, Cook-A opened two bags of chicken breast and placed them in two greased pans. Cook-A did not count how many chicken breast had been placed in the two greased pans. The Dietary Manager stated to the Cook-A that (gender) did not believe there was enough chicken breast for the residents. Cook-A stated (gender) believed there was enough chicken. An observation on 4/9/26 at noon with Cook-A serving lunch revealed: -Cook-A took the temperatures…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-04-09 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility failed to ensure Enhanced Barrier Precautions (EBP, refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.) were used during G-tube (surgically placed tube that delivers nutrition, fluids, and medications directly into the stomach) feeding and medication administration for 1 sampled resident (Resident 5). The facility census was 52. Licensure Reference Number 175 NAC 12.006.18(B) Findings are: A record review of admission record with the printed date of 4/8/26 revealed Resident 5 was admitted with nutritional problems related to dysphagia (difficulty swallowing) following cerebral infarction (stroke). A. During an observation on 04/08/2026 at 1:00 PM Licensed Practical Nurse (LPN-B) administered gastric tube medications to Resident 5 without wearing appropriate EBP. A record review of the facility's MDRO (multi-drug resistant organisms) PPE-Enhanced Barrier Precaution Policy last revised on 03/20/2024 revealed EBP is to be worn for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-06-10 · tag F0844 — widespread
  Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
  What the surveyor found here — the official record, unedited, may be distressing

  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. DHHS received notification of the DON change on 3/31/2025. Interview with DON on 6/10/25 at 3:00 PM confirmed that the 5-day notification of the DON change was not sent into the State Agency within 5 working days as required. Interview with DON on 6/10/25 at 3:05 PM confirmed that the year of service dates should have been dated 2025.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-10 · tag F0675 — failed to support quality of life — pattern
  Honor each resident's preferences, choices, values and beliefs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) Based on observations, interviews and record reviews, the facility failed to ensure prompt response to call lights to ensure resident needs were being met for 4 (Residents 1, 3, 7, and 8) out of 4 sampled residents. The facility census was 50. Findings are: A. Record review of Resident 1's admission Record dated 6/10/25 revealed admission to the facility was on 2/13/25. Record review of Resident 1's Diagnosis Form dated 6/10/25 revealed diagnoses of Cerebral Infarction (when blood flow to a part of the brain is blocked) due to embolism (a blockage-causing piece of material, inside a blood vessel) of right middle cerebral artery, hemiplegia (weakness or partial paralysis on one side of the body) affecting left nondominant side, Type II diabetes (a disease of inadequate control of blood levels of glucose), moderate persistent asthma (a condition on which a person's airway becomes inflamed, narrow and swell, and produce extra mucus, which makes it difficult to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-10 · tag F0610 — failed to investigate and act on abuse reports — isolated
  Respond appropriately to all alleged violations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.02(H) Based on interviews and record reviews, the facility failed to complete and send a 5-day written investigation of an alleged abuse to the Department of Health and Human Services (DHHS) as required for 1 (Resident 8) of 3 sampled residents. The facility census was 50. Findings are: Record review of the facility's undated investigation form Abuse, Neglect, or Misappropriation revealed: The complete form must be faxed to Health Facility investigations [PHONE NUMBER] within 5 working days from the date of the allegation/incident. Record review of Resident 8's admission Record dated 6/10/25 revealed admission to the facility was on 5/24/20. Resident 8 had diagnoses of Hemiplegia (paralysis or severe weakness on one side of the body) and Hemiparesis (weakness or partial paralysis on one side of the body), cerebrovascular disease (heart condition that include diseased vessels, structural problems, and blood clots) affecting left non-dominant side, atrial fibrillation…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-13 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Licensure Reference Number 175 NAC 12-006.04C3a(5) Based on interview and record review the facility failed to have a nursing services representative present during the care plan conferences for 4 (Residents 1, 4 and 6) of 4 sampled residents. The facility identified a census of 52. Findings are: A record review of the facility policy dated 9/2019 and titled Care Plan Process revealed that that Care Plan Conferences should include the resident, Family/Legal Representative (if the resident is not able to attend or gives approval for participations, Clinical Reimbursement Manager/ MDS (Minimum Data Set, a comprehensive assessment of each resident's physical and mental functional capabilities) Coordinator, Director of Nursing Services or Registered Nurse (RN) designee and that the signature of the DON or designee indicated knowledge of the care plan and that is appropriate for the residents's needs. A record review of the Care Plan Conference note dated 9/17/24 for Resident 6 revealed no one from nursing services attended the Care Plan Conference. A record review of the Care Plan…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-13 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.00610(D) Based on observation, record review and interview, the facility failed to ensure1 resident (Resident 3) of 5 sampled residents were free from significant medication errors. The facility census is 52. Findings are: Record review of the facility's undated policy, titled Using the Flexpen Insulin Competency revealed instructions to dial a test dose of 2 units, hold the pen upright and tap to bring any bubbles to the top. Prime the pen and dial the ordered dose before injecting dose. Record review of Diabetes Journal article titled Insulin Pen Priming dated [DATE] revealed priming an insulin pen is recommended to remove air bubbles from needle to ensure the full dose of insulin. If you do not prime the pen before each injection, you may get too much or too little insulin. An observation on 1/8/25 at 9:09 AM Registered Nurse (RN) - A completed an accucheck on Resident 3. The resident was lying in bed and stated (gender) had not eaten breakfast yet. RN - A applied gloves…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-01-13 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17D Based on observation, interview and record review the facility failed to ensure infection control procedures were followed and maintained during peri cares (the process of washing the genitals and anal area) for one (Resident 11) of two residents sampled. The facility identified a census of 52. Findings are: A record review of the document titled admission Record, printed on 1/9/25, revealed Resident 11 admitted to the facility on [DATE] with a primary diagnosis of cerebral infarct (occurs when blood flow is blocked causing brain tissue to die). An observation on 1/9/25 at 12:02 PM, accompanied by the facility's Regional Nurse Consultant, revealed Nurse Aide (NA)-F preparing to toileting Resident 11. During the observation NA-F ambulated Resident 11 to the bathroom, assisted [gender] onto the toilet, pulled down Resident 11's pants and soiled brief without gloves on. NA-F then performed hand hygiene and applied gloves. Next NA-F removed Resident 11's shoes, pants and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-10-21 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observations, interviews, and record reviews, the facility failed to ensure staff was wearing N-95 mask for Resident 1, wear the N-95 mask appropriately, not placing the Covid sample on clean surface, and washing hands between gloves changes to prevent potential for cross contamination. The facility census is 46. Findings are: A. On 10/21/24 at 9:05 AM observed Nurse Aide-A wearing N95 without one of the strings over the top of head as it is designed to wear. On 10/21/24 at 9:07 AM interview with NA-A confirmed that [gender] should have both mask strings over the head. Observation on 10/21/24 at 9:09 AM of SSD (Social Service Director) and Maintenance worker in dining room wearing their N95 mask without one of the strings over the top of their head. Interview with SSD on 10/21/24 at 9:10 AM revealed [gender] should have both mask strings over their head. Interview with Maintenance worker on 10/21/24 at 9:11 AM revealed [gender] should have both mask strings…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-10-08 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. An observation of the facility kitchen on 10/02/2024 between 7:35 AM and 8:10 AM revealed the following environmental concerns: -A ceiling exhaust fan, located directly above the walkway between the facility stove and food prep table, was coated with a fuzzy dark gray/black substance. Food was being prepared in this area and the exhaust fan was turned on. -Ceiling light panels near the facility stove and food preparation area were…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 17 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

10 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $777K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NE