Cycle 1
Health 2025-02-11 · Fire 2025-02-11
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
13 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Milford, NE
Sunrise Country Manor
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
610 224th Street, Milford, NE
(402) 761-3230
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1998-09-01
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
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.82
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.68
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.08% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 96 |
| Staff flu vaccination coverage | 8.94% |
42%
33.1 pts worse
|
Numerator 11 · Denominator 123 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.8 · 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 1.3 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.8% |
96.1%
3.3 pts worse
|
95.5%
2.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
4.5%
1.1 pts better
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.1% · Q3 3.0% · Q4 4.6% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.5% |
4.4%
0.9 pts better
|
11.4%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.6% · Q3 0.0% · Q4 7.0% · 4Q avg 3.5% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
5.3%
2.7 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 1.7% · Q4 3.4% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 49.2% |
19.5%
29.7 pts worse
|
19.6%
29.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.4% · Q2 50.8% · Q3 45.9% · Q4 46.6% · 4Q avg 49.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 48.6% |
21.6%
27 pts worse
|
16.7%
31.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 51.4% · Q3 50.0% · Q4 48.6% · 4Q avg 48.6% · 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 | 10.1% |
20.4%
10.3 pts better
|
16.3%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 18.3% · Q3 0.0% · Q4 3.6% · 4Q avg 10.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
19.9%
11.9 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 8.9% · Q3 3.4% · Q4 7.3% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.1% |
1.6%
4.5 pts worse
|
1.0%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 6.0% · Q3 5.4% · Q4 4.9% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
26.6%
3.4 pts better
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 26.9% · Q3 20.5% · Q4 22.8% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.3%
1.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 1.8% · Q4 6.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
80.5%
16.4 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 96.9% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-02 · Fire 2024-04-02
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2023-05-16 · Fire 2023-05-16
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
16 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-11
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 2025-03-28
F · Potential for more than minimal harm
2025-02-11
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 2025-03-28
F · Potential for more than minimal harm
2025-02-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-11
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 2025-03-28
F · Potential for more than minimal harm
2025-02-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-11
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-02-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-11
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-03-28
F · Potential for more than minimal harm
2024-04-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-17
F · Potential for more than minimal harm
2024-04-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-02
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-05-17
E · Potential for more than minimal harm
2024-04-02
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-05-17
F · Potential for more than minimal harm
2023-05-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
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 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-30
F · Potential for more than minimal harm
2023-05-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-16
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-02-11
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 2025-03-28
F · Potential for more than minimal harm
2025-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-11
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 2025-03-28
D · Potential for more than minimal harm
2025-02-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-05-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-04-02
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 2024-05-17
E · Potential for more than minimal harm
2024-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
E · Potential for more than minimal harm
2023-05-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Stauffer, Lemar
5% Or Greater Direct Ownership Interest · Individual
Stauffer, Lemar
Corporate Director · Individual
Stauffer, Seth
Operational/Managerial Control · Individual
Stauffer, Seth
Corporate Director · Individual
Sunrise Country Inc
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
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Tabitha Nursing Center at Crete
Crete, NE
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Ridgewood Rehabilitation & Care Center
Seward, NE
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Emerald Nursing & Rehab Lancaster LLC
Lincoln, NE
1-star overall rating with 1-star inspections with Special Focus status with $79,725 in total fines with 15 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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