Cycle 1
Health 2024-11-21 · Fire 2024-11-21
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Omaha, NE
Good Samaritan Society - Millard
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
12856 Deauville Drive, Omaha, NE
(402) 895-2266
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
68
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1990-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 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
0.91
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.42
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.80
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
4.24
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,080
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.03
Performance 20.49% · Measure score 2.03 · Achievement 2.03 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.38% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.76
Baseline 70.97% · Performance 60.56% · Measure score 1.76 · Achievement 0.76 · Improvement 1.76
Adjusted total nurse staffing
1.81
Baseline 3.04 hours · Performance 3.59 hours · Measure score 1.81 · Achievement 1.81 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.92% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 6.45% |
| Discharge to community | 41.15% |
50.57%
9.4 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 28.57% · Lower 95% interval 26.93% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 61.7% |
95.27%
33.6 pts worse
|
Numerator 29 · Denominator 47 |
| Falls with major injury | 2.13% |
0.77%
1.4 pts worse
|
Numerator 1 · Denominator 47 |
| Discharge self-care score | 51.43% |
53.69%
2.3 pts worse
|
Numerator 18 · Denominator 35 |
| Discharge mobility score | 51.43% |
50.94%
0.5 pts better
|
Numerator 18 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 2.17% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 46 · Adjusted rate 2.66% |
| Healthcare-associated infections requiring hospitalization | 8.38% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 4.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 95.35% |
42%
53.3 pts better
|
Numerator 82 · Denominator 86 |
| Discharge function score | 54.29% |
56.45%
2.2 pts worse
|
Numerator 19 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 60.87% |
96.28%
35.4 pts worse
|
Numerator 14 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 19.05% |
25.2%
6.1 pts worse
|
Numerator 4 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.8% |
92.8%
10 pts worse
|
93.4%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 83.3% · Q3 84.8% · Q4 78.0% · 4Q avg 82.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.2% |
96.1%
9.9 pts worse
|
95.5%
9.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.3% |
4.5%
4.8 pts worse
|
3.3%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 11.1% · Q3 8.7% · Q4 6.0% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
4.4%
2.7 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 4.7% · Q4 0.0% · 4Q avg 1.7% |
| 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 8.9% · Q2 4.3% · Q3 0.0% · Q4 4.5% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.2% |
19.5%
12.3 pts better
|
19.6%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 8.3% · Q3 7.3% · Q4 6.7% · 4Q avg 7.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
21.6%
14.8 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 3.8% · Q3 3.6% · Q4 11.4% · 4Q avg 6.8% · 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 | 23.5% |
20.4%
3.1 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 3.8% · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.4% |
19.9%
0.5 pts better
|
14.9%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 40.0% · Q3 5.9% · Q4 2.4% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.9% |
1.6%
3.3 pts worse
|
1.0%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 8.4% · Q3 4.4% · Q4 4.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.9%
0.4 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.8% · Q3 2.2% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
26.6%
1.9 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 31.0% · Q3 32.2% · Q4 20.9% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.3%
3.2 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.2% |
80.5%
45.3 pts worse
|
81.7%
46.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.9% · Q2 31.6% · Q3 28.9% · Q4 33.0% · 4Q avg 35.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
11.6%
5 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 7.5% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
2.4%
0.4 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.6% · Q3 2.0% · Q4 1.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.3% |
75.9%
46.6 pts worse
|
79.7%
50.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
20.9%
0.8 pts worse
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 22.5% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-26 · Fire 2023-09-26
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-08-16 · Fire 2022-08-16
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-11-21
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 2024-12-31
E · Potential for more than minimal harm
2024-11-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-31
F · Potential for more than minimal harm
2023-09-26
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 2023-10-12
F · Potential for more than minimal harm
2023-09-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-09-26
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-09-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-09-26
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-09-26
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-09-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-12
F · Potential for more than minimal harm
2022-08-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-08-16
F · Potential for more than minimal harm
2022-08-16
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 2022-08-16
F · Potential for more than minimal harm
2022-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-22
F · Potential for more than minimal harm
2022-08-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-16
F · Potential for more than minimal harm
2022-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-16
F · Potential for more than minimal harm
2022-08-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-08-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-08-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-08-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-08-16
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-08-16
E · Potential for more than minimal harm
2022-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-05
D · Potential for more than minimal harm
2025-02-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-11-21
F584 · Resident Rights Deficiencies
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 2024-12-31
D · Potential for more than minimal harm
2024-11-21
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 2024-12-31
D · Potential for more than minimal harm
2024-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-31
D · Potential for more than minimal harm
2023-09-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-06-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-06
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-06
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-14
E · Potential for more than minimal harm
2022-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-30
D · Potential for more than minimal harm
2022-08-16
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 2022-08-30
D · Potential for more than minimal harm
2022-08-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-30
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Bashir Rafiq, Naureen
Contracted Managing Employee · Individual
Cain, James
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Norby, Nicklos
W-2 Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Rogers, Michael
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
Other facilities in reach
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Brookestone Village
Omaha, NE
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Hillcrest Millard LLC
Omaha, NE
2-star overall rating with 2-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Newport House
Omaha, NE
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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