Your report for Hillcrest Millard LLC
Overall Score
CMS Five-Star Quality RatingBelow averageCMS Five-Star overall rating
- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- NebraskaAbove only 26% of peers178 rated homes · average 2.9★
- Douglas CountyAbove only 23% of peers23 rated homes · average 2.8★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs NE avg
- StaffingCan add or remove a star3★−0.4 vs NE avg
- Quality measuresCan add or remove a star4★+1.0 vs NE avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersNE avg2.8★U.S. avg2.8★
What is health inspection rating?
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
Why it matters
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 24% of peersNE avg3.4★U.S. avg2.9★
What is staffing rating?
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
Why it matters
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above 61% of peersNE avg3.0★U.S. avg3.6★
What is quality measures rating?
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
Why it matters
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff4.30hrsAbove 61% of peersNE avg4.17Benchmark4.10
What is total nurse hours?
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Why it matters
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.75hrsAbove 64% of peersNE avg0.71Benchmark0.75
What is rn hours?
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
Why it matters
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better71%Above only 10% of peersNE avg49%RN turnover60%
What is nursing staff turnover?
The share of nursing staff who left within the past year, from the same payroll data.
Why it matters
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 25% of peersNE avg$10,100Fines · denials0 · 0
What is fines in the last three years?
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Why it matters
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cycles28citations
6inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Sep 12, 2024most recent
Citations by monthMay 2022 – Sep 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Click to filter the findings below
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Sep 12, 2024Cycle 1worst F · no actual harm
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 23, 2024
- F584Honor 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.Resident RightsD · isolatedCorrected Oct 23, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Oct 23, 2024
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Oct 23, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryF · widespreadCorrected Oct 23, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 23, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Oct 23, 2024
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Oct 23, 2024
Apr 18, 2024Cycle 2worst D · no actual harm
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 29, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 29, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 29, 2024
Feb 29, 2024Cycle 2worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 10, 2024
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 10, 2024
Aug 3, 2023Cycle 2worst E · no actual harm
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Sep 12, 2023
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningE · patternCorrected Sep 12, 2023
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Sep 12, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Sep 12, 2023
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Sep 12, 2023
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Sep 12, 2023
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 12, 2023
Jun 13, 2023Cycle 3worst D · no actual harm
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 25, 2023
May 3, 2022Cycle 3worst E · no actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 15, 2022
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jun 15, 2022
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Jun 15, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 15, 2022
- F758Implement 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.Pharmacy ServiceE · patternCorrected Jun 15, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Jun 15, 2022
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jun 15, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.30hrs
- Registered nursesRN hours only0.75hrs
- Licensed practical nursesLPN hours0.88hrs
- Nurse aidesCNA hours2.66hrs
- Weekend nursingAll staff on Saturdays and Sundays3.94hrs
- Nebraska average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better71%Above only 10% of peersNE avg 49%
- RN turnoverRegistered nurses only60%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy76 certified beds · ~59 residents a day78%Above 61% of peersNE avg 73%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $10,100NE avg in fines
Above only 25% of peersFewer fines than 25% of rated homes in Nebraska
Actions on record
No fines or payment denialsNothing on record in the current reporting window. Nebraska facilities average 0.6 penalties.
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Independent
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
Direct owners (5%+)
- Hillcrest Operating Ventures, LLC
Operational or managerial control
- Hillcrest Health Systems INC
- Debra Aswege-Mezenberg
- James Janicki
- Kevin Mulhearn
- Matthew Oestmann
Corporate officers
- James Janicki
- Kevin Mulhearn
- Matthew Oestmann
Managing employees
- Amber Kendall
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 285302 · 13225 Westwood Lane, Omaha, NE, 68144.
- Percentiles compare this facility with every rated nursing home in Nebraska and Douglas County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
