Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Lakeview during CMS and state inspections, most recent first.
The facility failed to maintain a clean and homelike environment, with issues such as cobwebs, peeling paint, missing light fixture covers, and unsecured materials in the ceiling. A rocking chair lacked a cushion, exposing frayed material. The Facility Administrator confirmed these deficiencies and acknowledged the absence of a written action plan to address them, affecting 11 of 69 residents.
The facility failed to follow the written menu by serving meals with incorrect portion sizes, specifically using a 6-ounce scoop instead of the required 8-ounce for chicken pot pie. This affected the nutritional intake of 13 residents, as confirmed by staff interviews and observations.
The facility failed to ensure proper infection control during laundry delivery, as laundry aides did not perform hand sanitization between resident room visits, risking cross-contamination. Despite knowing the protocol, aides repeatedly handled clothing without sanitizing hands, and clothing was carried against uniforms. Interviews with the DON and IP confirmed the expectation for hand hygiene, highlighting a deficiency in infection prevention practices.
A resident with a history of Allergic Rhinitis and Chronic Sinusitis received Mucinex for a cough without a nurse's assessment. The resident's cough worsened, but no respiratory assessment was conducted. The LPN was unaware of the resident's concerns, and the DON confirmed the lack of policies for follow-up on as-needed medications and focused assessments for acute conditions.
A facility failed to routinely assess and monitor a pressure ulcer in a resident with multiple health issues, including spastic quadriplegic cerebral palsy and severe intellectual disabilities. Despite having wound care orders, the facility did not document wound descriptions or measurements in the Weekly Skin Assessment for November. A wound consultation revealed concerns about the right knee ulceration, leading to the resident being started on antibiotics for cellulitis. The facility's policy required detailed documentation of pressure ulcers, which was not followed, resulting in the deficiency.
A facility failed to implement interventions for a resident with contractures in the left hand, leading to pain and interference with daily activities. Despite previous occupational therapy and recommendations for self-care, the facility did not provide necessary assistance or interventions after unsuccessful Botox treatments.
A facility failed to maintain a medication error rate below 5%, with errors affecting two residents. One resident received eye drops routinely instead of as needed, contrary to the label instructions. Another resident had Diclofenac Gel applied to their back instead of their knees, as per the physician's order. These discrepancies were confirmed by the DON.
A resident with severe protein-calorie malnutrition did not receive the physician-ordered double protein servings at meals. Despite the care plan and dietary orders specifying increased protein, the dietary aide served only one portion of protein. Interviews confirmed the resident received less than prescribed, and the facility administrator acknowledged the dietary order for double protein servings.
Facility Environment Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations made during a walkthrough. Cobwebs with debris were found in the windows of the Activities room in the secured care unit. Additionally, chipped and peeling paint exposing unsealed wood was observed on the door frames of multiple resident rooms, including rooms 411, 404, 405, 403, 207, 209, 102, 107, and 108. A missing light fixture cover was noted in the ceiling of the Activities room, and various pieces of material in different shades of white were attached with black screws to the ceiling surrounding the vent in a bathroom. In the hallway of the secured care unit, multiple pieces of white material were secured to the ceiling, with one piece being wavy and warped. Further issues included a wooden rocking chair in the Activities Room without a cushion, exposing frayed brown cloth material. An interview with the Facility Administrator confirmed these observations, including the peeling paint, improperly sealed ceiling areas, absence of a cushion on the rocking chair, and the presence of cobwebs. The Facility Administrator also confirmed that there was no current written action plan to address these issues of disrepair and cleanliness, affecting 11 of the 69 residents in the facility.
Deficiency in Meal Portion Sizes
Penalty
Summary
The facility failed to ensure that the menus were followed as written, specifically regarding the portion sizes of meals served to residents. During an observation, it was noted that the chicken pot pie, which was supposed to be served in an 8-ounce portion, was instead served using a 6-ounce scoop. This discrepancy in portion size resulted in residents receiving less than the required caloric intake. The issue affected 13 out of 15 residents who were served meals, with the facility census being 69. Interviews with facility staff revealed that the cook had reviewed the menu for the week and discussed the serving spoons used in the facility. The serving spoons were color-coded and stored according to size, with the 8-ounce spoons being orange and green. However, during the meal service, a white 6-ounce scoop was used, as confirmed by the dietary aide and the facility representative. This improper use of serving utensils led to the deficiency in meeting the nutritional needs of the residents as outlined in the menu.
Infection Control Deficiency in Laundry Delivery
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the delivery of laundry to residents, as observed by surveyors. The report highlights that laundry aides did not perform hand sanitization between resident room visits, which is a critical step in preventing cross-contamination. This deficiency was observed with two laundry aides, identified as LA-D and LA-E, who repeatedly handled clothing and hangers without sanitizing their hands after exiting each resident's room. The facility's infection prevention and control program mandates hand hygiene between resident contacts, but this protocol was not followed. During the observations, LA-D was seen delivering clothing to multiple residents' rooms without performing hand sanitization after each visit. The clothing was often carried against the aide's uniform, which further increased the risk of cross-contamination. Despite being aware of the hand hygiene protocol, LA-D continued to neglect hand sanitization, even after being questioned by the surveyor. Similarly, LA-E was observed on a different hall, also failing to sanitize hands between room visits, despite acknowledging the requirement to do so. Interviews with the facility's Director of Nursing (DON) and Infection Preventionist (IP) confirmed that the expectation is for all staff to perform hand sanitization after exiting a resident's room. The IP also emphasized that clothing should not be carried against uniforms to prevent cross-contamination. The facility's failure to adhere to these infection control protocols resulted in a deficiency, as it compromised the safety and sanitary conditions necessary to prevent the spread of infections among residents.
Failure to Assess Resident's Respiratory Condition
Penalty
Summary
The facility failed to provide an assessment by a licensed professional nurse for a resident with symptoms of a potential respiratory infection. The resident, who had diagnoses of Allergic Rhinitis and Chronic Sinusitis, had an order for Mucinex to be administered as needed for a cough. The Medication Administration Record indicated that the resident received Mucinex 22 out of 30 days in November, with follow-ups on its effectiveness conducted by a Medication Aide. However, there was no documentation of respiratory assessments or nursing attention directed towards the resident's cough in the progress notes. Observations revealed the resident had a deep, productive cough, which had worsened over the past two weeks. The resident reported informing nursing staff about the worsening condition but could not recall specific staff members. An LPN, who was the full-time day shift nurse for the resident, was unaware of the resident's concerns and confirmed that no respiratory assessment had been completed. The Director of Nursing acknowledged the absence of a policy on follow-up for as-needed medications and procedures for focused assessments related to acute conditions, confirming that it is best practice to perform such assessments.
Failure to Document and Monitor Pressure Ulcer Care
Penalty
Summary
The facility failed to routinely assess and monitor the effectiveness of treatment for a pressure ulcer in a resident who was fully dependent on nursing staff for all activities of daily living. The resident had multiple diagnoses, including spastic quadriplegic cerebral palsy, contractures, severe intellectual disabilities, and a pressure ulcer of unspecified stage. Despite having specific wound care orders for the right knee and left foot, the facility did not document wound descriptions or measurements in the Weekly Skin Assessment for November 2024. This lack of documentation was confirmed by the Director of Nursing, who stated that wound measurements and descriptions were not being recorded on skin assessment days or at any other time, except monthly with the wound care nurse. A wound consultation on November 1, 2024, revealed concerns about the right medial knee ulceration, which was slightly larger and had seropurulent drainage, indicating possible infection or inflammation. The provider started the resident on oral antibiotics for cellulitis of the wound. The facility's policy on Skin and Wound Management required nursing staff to assess and document significant risk factors for pressure ulcers, including a full assessment of the sore's location, stage, dimensions, and presence of exudates or necrotic tissue. However, these assessments were not being conducted as per the policy, leading to the deficiency.
Failure to Implement Interventions for Contractures
Penalty
Summary
The facility failed to implement necessary interventions to prevent the worsening of contractures in a resident's left hand. The resident, who was admitted with a diagnosis of contractures, experienced pain and discomfort due to the condition, which also interfered with activities of daily living. Despite the presence of contractures prior to admission, the care plan lacked documentation and interventions for managing the condition. Observations revealed that the resident's fingers were bent inward, and the facility staff did not assist with cleaning under the fingers or placing a towel roll between the fingers and palm, as recommended. The resident had previously received occupational therapy services, which were discontinued after reaching maximum potential. The occupational therapy discharge note indicated that the resident could not tolerate range of motion exercises or a splint but could use a small towel roll as a barrier in the left hand. Training was provided to the resident and caregivers on exercises, compensatory strategies, and self-care. However, after unsuccessful Botox injections in early 2024, no further interventions were implemented by the facility, despite the resident's ongoing needs.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 7.41%. This deficiency affected two residents out of a sample of ten. The first incident involved Resident 17, where a medication aide administered Ultra Eye Preservative Free Drops routinely instead of on an as-needed basis, as indicated on the pharmacy label. The physician's order, however, directed the drops to be administered four times a day. This discrepancy between the label and the physician's order was confirmed by the Director of Nursing. The second incident involved Resident 14, where Diclofenac Gel was applied to the resident's back instead of the knees, as per the physician's order. The medication aide offered the resident a choice of application site, which was not in accordance with the physician's directive. The Director of Nursing confirmed that the order specified application to the knees only, and there was no order for application to the back.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to provide a physician-ordered therapeutic diet with increased protein for a resident, identified as Resident 22, who was part of a sample in a facility with a census of 69. The resident had a cognitive score indicating intact mental status and was diagnosed with severe protein-calorie malnutrition, among other conditions. The care plan specified the need for double portions of protein with meals, as well as snacks and supplements, based on the registered dietician's recommendations. However, during an observation, it was noted that the dietary aide served only one scoop of meat and one sandwich to the resident, contrary to the dietary orders. Interviews conducted with the dietary aide and the resident confirmed that the resident did not receive the prescribed double protein servings. The dietary aide initially claimed that two sandwiches were served but later admitted that the resident had not been given the double servings of protein. The resident, who only speaks Spanish, confirmed through an activity aide that only one sandwich was received. The facility administrator also confirmed the order for double protein servings, highlighting the failure to adhere to the prescribed dietary plan.
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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 Grand Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eventide Prairie Commons Care Center | 1.6 mi | — | 0 | 0 |
| Chi Health St. Francis | 2.6 mi | — | 0 | 0 |
| Adept Nursing & Rehab Of Grand Island | 2.8 mi | — | 0 | 0 |
| Tiffany Square | 2.8 mi | — | 7 | 0 |
| Good Samaritan Society - Grand Island Village | 3 mi | — | 16 | 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 August 2026) and official state health department websites.