16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Omaha, NE
1-star overall rating with 1-star inspections with $36,170 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2305 South 10th Street, Omaha, NE
(402) 345-5683
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
184
Certified beds
Average residents
154
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Delmar Gardens
Operator or chain grouping
Approved since
1987-07-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 3 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
RN hours / resident day
0.35
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
3.09
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
1,635
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.14
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.64
Baseline 18.68% · Performance 18.82% · Measure score 5.64 · Achievement 5.64 · Improvement 0
Healthcare-associated infections
7.45
Baseline 5.34% · Performance 5.61% · Measure score 7.45 · Achievement 7.45 · Improvement 0
Total nurse turnover
5.64
Baseline 43.97% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 1.25
Adjusted total nurse staffing
3.33
Baseline 4.10 hours · Performance 4.03 hours · Measure score 3.33 · Achievement 3.33 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.02% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 9.18% · Lower 95% interval 6.54% |
| Discharge to community | 47.54% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 40% · Lower 95% interval 37.02% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 1.92% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 52 |
| Discharge self-care score | 37.14% |
53.69%
16.5 pts worse
|
Numerator 13 · Denominator 35 |
| Discharge mobility score | 37.14% |
50.94%
13.8 pts worse
|
Numerator 13 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 52 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 1.79% · Lower 95% interval 2.88% |
| Staff COVID-19 vaccination coverage | 26.05% |
8.2%
17.9 pts better
|
Numerator 56 · Denominator 215 |
| Staff flu vaccination coverage | 49.25% |
42%
7.2 pts better
|
Numerator 99 · Denominator 201 |
| Discharge function score | 45.71% |
56.45%
10.7 pts worse
|
Numerator 16 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 59.09% |
25.2%
33.9 pts better
|
Numerator 13 · Denominator 22 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
92.8%
1.4 pts better
|
93.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 94.5% · Q3 95.1% · Q4 97.9% · 4Q avg 94.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.1%
1.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
4.5%
1.5 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.5% · Q3 4.2% · Q4 4.2% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.2% |
4.4%
4.2 pts better
|
11.4%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.3%
0.4 pts worse
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.0% · Q3 5.8% · Q4 7.3% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.1% |
19.5%
7.6 pts worse
|
19.6%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 27.6% · Q3 28.3% · Q4 25.0% · 4Q avg 27.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.7% |
21.6%
15.1 pts worse
|
16.7%
20 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.2% · Q2 36.8% · Q3 34.4% · Q4 38.4% · 4Q avg 36.7% · 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 | 20.9% |
20.4%
0.5 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 19.5% · Q3 25.8% · Q4 22.2% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.1% |
19.9%
11.2 pts worse
|
14.9%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 26.8% · Q3 28.6% · Q4 40.4% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.6%
0.8 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 0.0% · Q4 0.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.9%
1.6 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.2% · Q3 4.9% · Q4 4.3% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
26.6%
0.4 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 25.1% · Q3 25.6% · Q4 30.2% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.3%
2.6 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.2% · Q3 2.8% · Q4 0.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.4% |
80.5%
12.1 pts worse
|
81.7%
13.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.3% · Q2 77.4% · Q3 75.4% · Q4 56.9% · 4Q avg 68.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
11.6%
7.5 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 4.1% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
75.9%
10.8 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
20.9%
0.4 pts worse
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 20.4% · Expected 22.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-21
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 2024-09-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-21
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-21
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-21
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-21
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-16
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-16
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-08-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-05
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-05
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-05
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 2023-08-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-05
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 2022-07-07
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-07
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-07-07
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-07
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-07-07
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-07
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 2022-07-07
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-07-07
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-07
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-07-07
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-07
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-07-07
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Not marked corrected
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Not marked corrected
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-15
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2025-08-15
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-21
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 2024-09-21
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-09-21
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-21
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-21
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-21
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-21
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-09-21
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-16
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-16
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-16
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-16
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-08-16
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 2022-07-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-07
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 2022-07-07
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-07
Health
Assess the resident when there is a significant change in condition
Corrected 2022-07-07
Penalties and ownership
Fine · fine $12,048
Fine
Fine · fine $24,122
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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