16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Omaha, NE
2-star overall rating with 1-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4102 Woolworth Avenue, Omaha, NE
(402) 444-7041
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
254
Certified beds
Average residents
230
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-03-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.94
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.96
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.51
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.13
CMS adjusted RN staffing hours
Adjusted total hours
6.00
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
1,699
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.69
Composite VBP score used to determine payment impact.
Payment multiplier
1.0096
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.66
Baseline 22.78% · Performance 20.96% · Measure score 2.66 · Achievement 1.02 · Improvement 2.66
Healthcare-associated infections
0
Baseline 5.99% · Performance 8.30% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 26.57% · Performance 23.38% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
9.21
Baseline 5.48 hours · Performance 5.7 hours · Measure score 9.21 · Achievement 9.21 · Improvement 6.80
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.57% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 3.92% · Lower 95% interval 5.58% |
| Discharge to community | 43.49% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 31.48% · Lower 95% interval 31.62% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 35.71% |
53.69%
18 pts worse
|
Numerator 20 · Denominator 56 |
| Discharge mobility score | 33.93% |
50.94%
17 pts worse
|
Numerator 19 · Denominator 56 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 66 · Adjusted rate 2.76% |
| Healthcare-associated infections requiring hospitalization | 8.3% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 10.77% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 25.44% |
8.2%
17.2 pts better
|
Numerator 102 · Denominator 401 |
| Staff flu vaccination coverage | 48.35% |
42%
6.4 pts better
|
Numerator 190 · Denominator 393 |
| Discharge function score | 46.43% |
56.45%
10 pts worse
|
Numerator 26 · Denominator 56 |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 24 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 35.14% |
25.2%
9.9 pts better
|
Numerator 13 · Denominator 37 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
92.8%
7.1 pts worse
|
93.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 83.5% · Q3 88.1% · Q4 84.5% · 4Q avg 85.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
96.1%
1.1 pts worse
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
4.5%
1.6 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.6% · Q3 2.6% · Q4 3.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
4.4%
3.1 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.7% · Q3 1.0% · Q4 0.5% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.3%
0.8 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.5% · Q3 5.1% · Q4 4.2% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.3% |
19.5%
12.8 pts worse
|
19.6%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 30.7% · Q3 34.2% · Q4 33.7% · 4Q avg 32.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 46.5% |
21.6%
24.9 pts worse
|
16.7%
29.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 45.6% · Q3 47.5% · Q4 49.1% · 4Q avg 46.5% · 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 | 8.6% |
20.4%
11.8 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 10.3% · Q3 7.0% · Q4 10.9% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
19.9%
6.2 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 15.4% · Q3 16.5% · Q4 10.9% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
1.6%
1 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 2.1% · Q4 0.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.9%
1.2 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.9% · Q3 1.8% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
26.6%
0.9 pts better
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 24.9% · Q3 30.0% · Q4 22.5% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
4.3%
1 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.0% · Q3 5.0% · Q4 2.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.2% |
80.5%
34.3 pts worse
|
81.7%
35.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.9% · Q2 54.1% · Q3 36.2% · Q4 30.1% · 4Q avg 46.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
11.6%
3.2 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 9.4% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
2.4%
2.4 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.2% · Q3 3.1% · Q4 4.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 39.7% |
75.9%
36.2 pts worse
|
79.7%
40 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 39.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.8% |
20.9%
7.1 pts better
|
23.9%
10.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 14.1% · Expected 24.3% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-06-20
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-06-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-20
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-06-20
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-20
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-06-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-20
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-06-13
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 2024-06-13
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-06-13
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 2024-06-13
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-13
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-06-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-13
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-06-13
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-29
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 2023-06-29
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 2023-06-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-29
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-29
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-12
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-27
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-27
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-27
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-27
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-06-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-27
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-27
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-06-27
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-27
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-27
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-06-27
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-06-27
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-27
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-14
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-09
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-06-09
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-09
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-06-09
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-06-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-09
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-09
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-06-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-29
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-29
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-29
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-06-29
Health
Provide or obtain dental services for each resident.
Corrected 2023-06-29
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-29
Penalties and ownership
Payment Denial · denial start 2025-12-04 · 8 days
8 day denial
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
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