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
Staffing
Hours and turnover
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
0.68
Licensed practical nurse staffing
Aide hours / resident day
2.82
Nurse aide staffing
Weekend hours
2.96
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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
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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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