Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Good Samaritan Society - Millard
Omaha, NE · 106 certified beds · Last Life Safety survey November 21, 2024
CMS Certification Number 285098 · first certified July 1990
Ownership
Operated by GOOD SAMARITAN SOCIETY · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NE
22 citations — more than 74% of the 180 certified nursing homes in NE. Compared within NE rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 9.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (November 2025 to January 2026), and past the point by which nine in ten NE facilities have been surveyed. This facility’s last Life Safety survey was November 2024. Facilities in NE are typically surveyed 12–14 months after the last one (median 13), measured over 271 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 22 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 22 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in NE, and nationally. Surveyors differ markedly between states, so the NE figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 22 |
| Median facility in NE | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 16, 2022 | 11 |
| September 26, 2023 | 8 |
| November 21, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2024-11-21 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-09-26 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-09-26 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-11-21 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2024-11-21 |
| K-0161 | Use approved construction type or materials. | 1 | 2022-08-16 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2023-09-26 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2022-08-16 |
What the citations cover
- Smoke Deficiencies 12
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 2
- Egress Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 21, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 31, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 31, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 31, 2024) |
September 26, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 12, 2023) |
August 16, 2022 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (September 22, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0922 | Meet requirements for the use and maintenance of medical gas equipment. | Deficient, Provider has date of correction (August 16, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 16, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.