Cycle 1
Health 2024-10-16 · Fire 2024-10-16
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Omaha, NE
Brookestone Village
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
4330 South 144th Street, Omaha, NE
(402) 614-4000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
128
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Vetter Senior Living
Operator or chain grouping
Approved since
2001-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 4 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.88
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.28
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.83
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.26
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.94
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
34%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
192
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
78.76
Composite VBP score used to determine payment impact.
Payment multiplier
1.0255
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 13.88% · Performance 16.41% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
5.70
Baseline 4.77% · Performance 6.13% · Measure score 5.70 · Achievement 5.70 · Improvement 0
Total nurse turnover
7.69
Baseline 25.00% · Performance 32.26% · Measure score 7.69 · Achievement 7.69 · Improvement 0
Adjusted total nurse staffing
8.11
Baseline 5.40 hours · Performance 5.39 hours · Measure score 8.11 · Achievement 8.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.1% |
10.72%
3.6 pts better
|
Better than the National Rate · Eligible stays 438 · Observed rate 2.97% · Lower 95% interval 5.13% |
| Discharge to community | 65.87% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 430 · Observed rate 70.7% · Lower 95% interval 61.96% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.32% |
95.27%
4 pts better
|
Numerator 291 · Denominator 293 |
| Falls with major injury | 0.68% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 293 |
| Discharge self-care score | 32.52% |
53.69%
21.2 pts worse
|
Numerator 80 · Denominator 246 |
| Discharge mobility score | 27.24% |
50.94%
23.7 pts worse
|
Numerator 67 · Denominator 246 |
| Pressure ulcers or injuries, new or worsened | 2.73% |
2.29%
0.4 pts worse
|
Numerator 8 · Denominator 293 · Adjusted rate 3.76% |
| Healthcare-associated infections requiring hospitalization | 6.13% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 286 · Observed rate 3.5% · Lower 95% interval 4.24% |
| Staff COVID-19 vaccination coverage | 3.94% |
8.2%
4.3 pts worse
|
Numerator 11 · Denominator 279 |
| Staff flu vaccination coverage | 54.89% |
42%
12.9 pts better
|
Numerator 219 · Denominator 399 |
| Discharge function score | 32.11% |
56.45%
24.3 pts worse
|
Numerator 79 · Denominator 246 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 36 · Denominator 36 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 206 · Denominator 206 |
| Resident COVID-19 vaccinations up to date | 32.89% |
25.2%
7.7 pts better
|
Numerator 49 · Denominator 149 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
2.0
1.3 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
92.8%
6.9 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
4.5%
0.8 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 5.1% · Q3 4.1% · Q4 3.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
5.3%
3.2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 4.1% · Q3 1.5% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
19.5%
10.6 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 6.8% · Q3 4.3% · Q4 10.6% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
21.6%
13.3 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 9.4% · Q3 7.7% · Q4 8.8% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.8% |
20.4%
3.4 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 23.4% · Q3 17.8% · Q4 16.4% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
19.9%
4.7 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 8.5% · Q3 13.8% · Q4 12.9% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.6%
1.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.9%
0.6 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 1.0% · Q3 1.0% · Q4 2.1% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
26.6%
1.7 pts better
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 21.2% · Q3 21.8% · Q4 31.3% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
4.3%
0.5 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.6% · Q3 2.4% · Q4 4.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
80.5%
18.8 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 98.8% · Q3 98.8% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
11.6%
4.1 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 6.1% · Expected 9.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.4%
1.8 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.5% · Q4 0.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
75.9%
22.5 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
20.9%
3.7 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 12.5% · Expected 17.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-16 · Fire 2023-08-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-05-12 · Fire 2022-05-12
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-10-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-10-16
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-11-07
F · Potential for more than minimal harm
2023-08-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-08-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-30
F · Potential for more than minimal harm
2023-08-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-30
E · Potential for more than minimal harm
2023-08-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-30
F · Potential for more than minimal harm
2022-05-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-22
F · Potential for more than minimal harm
2022-05-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-06-01
F · Potential for more than minimal harm
2022-05-12
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-06-02
F · Potential for more than minimal harm
2022-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-01
F · Potential for more than minimal harm
2022-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-05-22
F · Potential for more than minimal harm
2022-05-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-05-12
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-05-11
E · Potential for more than minimal harm
2022-05-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-05-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-05-12
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-05-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-06-01
E · Potential for more than minimal harm
2022-05-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-05-12
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-05-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-11
F · Potential for more than minimal harm
2023-08-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-25
D · Potential for more than minimal harm
2022-05-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-06-22
D · Potential for more than minimal harm
2022-05-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-22
Penalties and ownership
What sits behind the stars
Ownership
Vetter Senior Living
5% Or Greater Direct Ownership Interest · Organization
Meredith, Abigail
Operational/Managerial Control · Individual
Meredith, Abigail
Contracted Managing Employee · Individual
Schindler, Lindsey
Operational/Managerial Control · Individual
Schindler, Lindsey
Contracted Managing Employee · Individual
Stuhr, Brian
Operational/Managerial Control · Individual
Stuhr, Brian
Corporate Officer · Individual
Stuhr, Brian
Contracted Managing Employee · Individual
Vanekeren, Glenn
Operational/Managerial Control · Individual
Vanekeren, Glenn
Corporate Officer · Individual
Vanekeren, Glenn
Contracted Managing Employee · Individual
Vetter Senior Living
Operational/Managerial Control · Organization
Vetter, Eldora
Operational/Managerial Control · Individual
Vetter, Eldora
Corporate Officer · Individual
Vetter, Eldora
Contracted Managing Employee · Individual
Vetter, Jack
Operational/Managerial Control · Individual
Vetter, Jack
Corporate Officer · Individual
Vetter, Jack
Contracted Managing Employee · Individual
Vsl Vetter Health Services LLC
Operational/Managerial Control · Organization
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#3
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