Cycle 1
Health 2025-04-10 · Fire 2025-04-10
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Omaha, NE
Old Mill Rehabilitation
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1131 Papillion Parkway, Omaha, NE
(402) 934-7500
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
44
Certified beds
Average residents
36
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Promontory Healthcare
Operator or chain grouping
Approved since
2014-06-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.85
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
2.11
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
4.60
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.30
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
2,359
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.01
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.88
Baseline 15.49% · Performance 19.17% · Measure score 4.88 · Achievement 4.88 · Improvement 0
Healthcare-associated infections
6.43
Baseline 4.43% · Performance 5.91% · Measure score 6.43 · Achievement 6.43 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.69
Baseline 4.29 hours · Performance 4.13 hours · Measure score 3.69 · Achievement 3.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.59% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 640 · Observed rate 7.5% · Lower 95% interval 7.96% |
| Discharge to community | 50.61% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 670 · Observed rate 50.6% · Lower 95% interval 47.68% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.75% |
95.27%
4.5 pts better
|
Numerator 402 · Denominator 403 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 403 |
| Discharge self-care score | 51.61% |
53.69%
2.1 pts worse
|
Numerator 160 · Denominator 310 |
| Discharge mobility score | 46.45% |
50.94%
4.5 pts worse
|
Numerator 144 · Denominator 310 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 6 · Denominator 402 · Adjusted rate 1.92% |
| Healthcare-associated infections requiring hospitalization | 5.91% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 394 · Observed rate 4.31% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 2.9% |
8.2%
5.3 pts worse
|
Numerator 2 · Denominator 69 |
| Staff flu vaccination coverage | 56.6% |
42%
14.6 pts better
|
Numerator 60 · Denominator 106 |
| Discharge function score | 46.45% |
56.45%
10 pts worse
|
Numerator 144 · Denominator 310 |
| Transfer of health information to provider | 99.19% |
95.95%
3.2 pts better
|
Numerator 122 · Denominator 123 |
| Transfer of health information to patient | 97.82% |
96.28%
1.5 pts better
|
Numerator 269 · Denominator 275 |
| Resident COVID-19 vaccinations up to date | 47.92% |
25.2%
22.7 pts better
|
Numerator 92 · Denominator 192 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
80.5%
17.4 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 98.1% · Q3 97.1% · Q4 97.1% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.6% |
11.6%
1 pts worse
|
12.0%
0.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 11.3% · Expected 10.0% · 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 0.5% · Q2 0.0% · Q3 0.5% · Q4 1.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
75.9%
11.6 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
20.9%
3.2 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 19.2% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-16 · Fire 2024-04-16
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-21 · Fire 2023-03-21
3 health deficiencies
Top issue: Environmental (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-04-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-23
F · Potential for more than minimal harm
2024-04-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-16
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 2024-05-22
F · Potential for more than minimal harm
2024-04-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-16
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-22
F · Potential for more than minimal harm
2024-04-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-04-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-22
F · Potential for more than minimal harm
2023-03-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
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 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-03-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-10
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 2025-05-23
E · Potential for more than minimal harm
2025-04-10
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-10
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 2025-05-23
C · Minimal harm
2025-04-10
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-05-23
E · Potential for more than minimal harm
2024-11-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-11-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-07-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-04-16
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 2024-05-22
D · Potential for more than minimal harm
2024-04-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-04-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-22
D · Potential for more than minimal harm
2024-03-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-19
D · Potential for more than minimal harm
2023-07-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-07-24
E · Potential for more than minimal harm
2023-03-21
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-03-21
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
Ownership
Dein, Michele
Operational/Managerial Control · Individual
Haynes, Anna
Operational/Managerial Control · Individual
Haynes, Anna
Corporate Officer · Individual
Promontory Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Banyan at Montclair
Omaha, NE
0-star overall rating with 0-star inspections with Special Focus status with $159,083 in total fines with 20 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Keystone Ridge Post Acute Nursing and Rehabilitati
Omaha, NE
1-star overall rating with 1-star inspections with $70,103 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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