Good Samaritan Society - Grand Island Village
4061 & 4055 Timberline Street & 2912 Good Samarita, Grand Island, NE 68803 · Non profit - Corporation · 67 certified beds · (308) 384-3535 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (23) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,033 in federal fines (most recent 2024-09-03)
- its independent health-inspection rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- nursing-staff turnover (64%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 1 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 16.6% | 19.0% | 15.4% | typical |
| Long-stay residents who lose too much weight | 2.6% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 3.4% | 1.4% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.6% | 2.8% | 2.0% | better |
| Long-stay residents with depressive symptoms | 3.3% | 4.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.3% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 8.4% | 4.5% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 28.3% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 14.3% | 19.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.9% | 4.0% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 36.7% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.1% | 20.7% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 80.0% | 75.9% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 33.4% | 20.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 17.4% | 11.4% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.12 | 1.81 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.85 | 1.92 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
32.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 97 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 32.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 59 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.20 therapist hours per resident per day in 2026Q1 — more than 23% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 32.4%CMS range 25.3–41.0 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.5%CMS range 9.0–15.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 32.2% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 27.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 27.1% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 90.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.3% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.7% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.8%CMS range 3.8–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.88 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 67 beds and averages 55.6 residents a day — about 83% occupied, or roughly 11 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.56 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.22 hrs/resident/day on weekends vs 3.69 on weekdays — 13% thinner on weekends. RN hours go from 0.59 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 64% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
23 citations, most serious first. The 11 most serious are shown; the remaining 12 are one tap away and print in full.
- Actual harm · Gcited before2024-09-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(I) Based on observation, interview, and record review; the facility failed to use the correct sling size to transfer a resident, and failed to asses and monitor a resident after a fall for 1 (Resident 6) of 3 sampled residents. The facility census was 41. Findings are: Record review of Resident 6's Census List revealed Resident 6 admitted to facility of 06/14/2024 with the following diagnoses: acquired Absence of left leg above knee (a surgical procedure that removed part of the leg), encephalopathy ( a general term for brain disorders or diseases), sepsis (a serious condition when the body's immune system overreacts to an infection or injury), Type 2 Diabetes Mellitus (condition when the body develops insulin resistance and can result in high blood sugars) with diabetic polyneuropathy (occurs when there is damage to multiple nerves in the peripheral nervous system), chronic obstructive pulmonary disease (is a common lung disease that causes breathing problems and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-06-01 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.05(D)Licensure Reference Number 175 NAC 12-006.05(E)Based on record review and interview the facility failed to ensure that consent was obtained prior to the administration of psychoactive medications (any medication that affects behavior, mood, thoughts, or perception) for 2 of 3 sampled residents (Residents 3 and 4). The facility census was 57.Findings are:A.Record review of the facility policy titled Psychotropic Medications dated 12/9/25 revealed that a psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. The policy revealed that a psychotropic medication is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include antipsychotics, antidepressants, antianxiety, and hypnotics. A consent form must be signed for the use of psychotropic medications. The Permission for Use of Psychotropic Medications form will be used to obtain consent. The Permission for Use of Psychotropic Medications consent form must be completed with a dose…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-30 · tag F0655 — patternCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09 (F)(i)Based on record review and interview the facility failed to ensure that a baseline care plan (a written plan required to be developed within 48 hours of admission detailing the instructions needed by staff to provide initial effective and person-centered quality care for a resident) was developed and reviewed with the resident/resident representative and ensure that a written summary was offered to the resident/resident representative for 3 of 3 residents reviewed (Residents 7, 2, and 9). The facility census was 46.Findings are:A.Record review of the facility policy titled Care Plan dated 12/1/25 revealed that the baseline care plan includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. A baseline care plan will be developed upon admission according to state and federal regulations. The facility must provide the resident and resident representative with a written summary of the baseline care plan. Use the Care Conference Note progress note to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-12-30 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.10(D) Based on record review, observations and interviews, the facility failed to ensure that the medication error rate was not 5% or higher. This affected 4 of 8 residents (Residents 21, 26, 40, and 58). The facility census was 46. Findings were:Record review of the facility policy Medication: Administration Including Scheduling and Medication Aides dated 4/08/2025 revealed the policy purpose was to administer medications correctly and in a timely manner and to provide direction regarding medications aides among other purposes. This policy also stated the medications are administered to the resident according tot he Six Rights; right medication, right dose, right time, right resident, right route, and right documentation. All employees passing medications are familiar with action and adverse reactions of medications. Record review of the Certified Medication Aide; Trained Medication Aide competency training for Medication Aide (MA) A which was completed on 11/4/2025 at the time of new hire orientation. The skills testing revealed that MA-A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.05 (D)Licensure Reference Number 175 NAC 12-006.05 (E)Based on record review and interview the facility failed to be inform the resident/resident representative of the risks and benefits of proposed care, or treatment and treatment alternatives or treatment options and to choose the alternative or option they prefer prior to administering psychotropic medications (any medication that affects behavior, mood, thoughts, or perception) for 2 (Resident 3 and Resident 4) of 5 residents. The facility census was 46.Findings are:A. Record review of the facility policy titled Psychotropic Medications dated 12/9/25 revealed that before the administration of non-emergency psychotropic medications a consent form must be signed for the use of psychotropic medications. The Permission for Use of Psychotropic Medications will be used to obtain consent. Record review of the admission Record for Resident 3 dated 12/22/25 revealed that Resident 3 admitted into the facility on 5/16/23.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-30 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.02 (H)State Statute 28-372Based on record review and interview, the facility failed to report all allegations of mistreatment and abuse within the regulatory reporting parameters. This affected 1 (Resident 4) of 1 sampled resident. The facility census was 46.Findings are:Review of a facility policy titled Abuse and Neglect dated 04/07/2025 revealed the location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse. Results of all investigations will be reported to officials in accordance with state law including to the state survey and certification agency with in five working days of the event or sooner as designated.A review of a admission Record indicated the facility admitted Resident 4 on 05/23/2025 with diagnoses of major depressive disorder (a mood disorder causing persistent sadness and loss of interest, affecting how one feels, thinks, and acts), and generalized anxiety disorder (a condition characterized by excessive anxiety and worry about a variety of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-30 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09 (G)(i)Based on record review and interviews, the facility failed to provide evidence that the required information was conveyed to the hospital at the time of transfer and failed to notify the resident or responsible party of the facility bed hold policy at the time of transfer for 1 Resident (Resident 5) of 1 sample resident. Facility census was 46Findings are:A.Review of a facility policy titled Discharge and Transfer dated 12/18/2025 revealed when a transfer or discharge occurs, the location must ensure that the transfer or discharge is documented in the medical record and appropriate information is communicated to the receiving healthcare center or provider.Review of Resident 5's medical record revealed an admission date of 09/30/2025 and a discharge date of 12/19/2025.Review of Resident 5's Progress Notes revealed a late entry with effective date of 12/19/2025 stating that Resident 5's primary care physician was notified of the resident's condition and the resident's power of attorney and spouse wished for the resident to be…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.09(H) (iii)(2)Based on observation, record review, and interview the facility failed to ensure that pressure ulcer (A localized wound of the skin and/or underlying tissue, usually over a bony area. A bedsore.) assessments including wound size were documented as required to determine healing or worsening of the pressure ulcers for 1 of 1 residents reviewed (Resident 2). The facility census was 46.Findings are:A.Record review of the facility policy titled Pressure Ulcers dated 2/17/25 revealed that the purpose is to provide assessment and prevention of pressure ulcers as well as treatment when necessary. The facility will use prevention and assessment interventions to ensure that residents entering the facility without pressure ulcers do not develop a pressure ulcer. A resident who has a pressure ulcer will receive the necessary treatment and services to promote healing. Residents will receive assessments and services to promote and maintain skin integrity. Record review of the Minimum Data Set (MDS) (a mandatory comprehensive assessment tool…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-12-30 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-006.12(D)Licensure Reference Number 175 NAC 12-006.12(D)(i)(2) Based on record review, observation, and interview, the facility failed to ensure that medications that are subject to abuse were counted correctly in order to easily account for these medications on individual resident's narcotic count sheets. This had the potential to affect one of one resident sampled (Resident 1) . The facility census was 46. Findings were:Record review of the facility policy dated 04/08/2025 Medication Administration Including Scheduling and Medication Aides revealed that the purpose of the policy is to provide direction regarding medication aides and to administer medications correctly and in a timely manner among other purposes. Record review of the Individual Resident's Narcotic Record with a start date of 12/29/2025 revealed that the count sheet was for Tramadol illegible (50) milligrams (mg) to be given by mouth 1 tab po q qid (one tablet orally every 4 times a day). The first count was completed and revealed on 12/29/2025 the beginning total was 6 tablets…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(E)Based on observation, record review and interviews, the facility failed to ensure the dishwashing machine achieved the manufacturer designated temperature during the rinse cycle to ensure sanitization of dishes used by the residents and kitchen staff. This had the potential to affect all the residents' receiving food from the kitchen. The facility census was 46.Findings are:Review of a document titled [NAME] Service dishwasher Manual revealed hot water sanitization wash cycle temperature of 150 degrees Fahrenheit and rinse temperature 180 degrees Fahrenheit. In an observation completed on 12/22/2025 at 8:36 AM of the facility dishwashing machine the following was observed.-Activation of a washing cycle wash cycle temperature was 152 degrees Fahrenheit. The rinse cycle temperature was 172 degrees Fahrenheit.-In the bottom right hand corner of the dish machine clearly visible was a manufacturer label stating wash temperature of 150 degrees Fahrenheit and rinse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-12-30 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 1-005.06(D)Licensure Reference Number 175 NAC 1-005.06(F)Licensure Reference Number 175 NAC 12-006.18Based on observation, record review, and interview the facility failed to ensure that staff performed disinfection of mechanical lifts between resident use to prevent cross-contamination, failed to ensure that staff performed hand hygiene (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) before putting on gloves and after removing gloves, and failed to perform hand washing to prevent the potential for cross contamination for 1 resident (Resident 22) during resident transfers and cares. The facility census was 46.Findings are:A.Record review of the facility policy titled Safe Resident Handling Program dated 7/7/25 revealed that there are basic responsibilities for every employee to ensure that the work environment is safe. Staff follow infection control practice to clean lifts after each use. Record review of the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 12 citations
- Potential for harm · D2025-05-05 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.04(F)(i) Based on record reviews and interview, the facility failed to ensure the licensed nurse had the knowledge and training to provide care for a Pleurex catheter for Resident 9. This affected 1 of 3 residents reviewed for use of a Pleurex catheter. The facility's census was 55. Findings are: A review of Resident 9's Clinical Census printed 05/05/2025 revealed the resident was admitted to the facility on [DATE] and was hospitalized on [DATE]. A review of Resident 9's admission Record printed 05/05/2025 revealed the resident had diagnoses of an infection to the left arm, kidney failure, heart disease, irregular heart rate, chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and a pleural effusion (a buildup of extra fluid in the space around your lungs). A review of Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-05-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.17 The facility failed to ensure that staff perform hand washing between glove changes and to wear EBP for Resident #5 while performing wound cares to prevent the potential for cross contamination. The facility census was 55. Record review of Resident 5's admission record dated 5/5/25 revealed admission to the facility was 3/31/22. Record Review of MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 4/2/25 revealed: Section C - BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) was 15 indicating the resident was cognitively intact. -Section GG - dependent assist with footwear and maximum assist with repositioning. Physicians Orders dated 5/5/25 revealed: -Wound care to left heel: cleanse with saline/wound cleanser, apply betadine moistened gauze, cover with ABD pad and secure with kerlix and tape. Change daily and as needed for drainage every day shift for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-27 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(I) Based on observation, interview, and record review, the facility failed to implement interventions to prevent accidents for 1 (Resident 1) of 3 sampled residents. The facility census was 44. Findings are: A record review of the facility's Fall Prevention And Management policy dated 07/29/2024 revealed a fall is an unintentional coming to rest on the ground. An accident is any unexpected or unintentional incident which may result in injury or illness to a resident. Root cause analysis is a method for identifying the cause or problem so that the best solutions can be identified and put into place. Following a fall, the staff should complete a falls tool, document if teaching was done, communicate the fall to administration, provider, and family, and review and update the care plan with any new/changes to the care plan interventions. A. A record review of Resident 1's Clinical Census dated 03/26/2025 revealed the resident was admitted to the facility on [DATE]. A…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-26 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.18 Licensure Reference Number 175 NAC 12.006.18(B) Based on observation, interview, and record review; the facility failed to ensure the required isolation sign was posted and staff donned (put on) and doffed (took off) the required Personal Protective Equipment (PPE) for 1 (Resident 146) of 1 sampled residents that had been identified as positive for COVID-19, this had the potential to affect all residents in the facility. The facility failed to ensure 3 (Residents 10, 11, and 12) of 3 sampled resident's oxygen tubing was changed and dated weekly and was stored in a bag when not in use, and failed to clean and store 1 (Resident 40) of 1 sampled resident's nebulizer kit (neb)(a kit used to deliver liquid medication to the lungs) daily to prevent cross-contamination (transfer of bacteria from one surface to another). The facility census was 41. A. A record review of the facility's Surveillance and Mitigation Plan for SNFs (Skilled Nursing Facilities) dated 04/26/2024 revealed for all residents that have tested positive for COVID-19, staff are…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.12(D)(i) Based on observation, interview, and record review; the facility failed to safely store medications by leaving unattended medications at resident's bedside for 1(Resident 3) of 1 sampled residents. The facility census was 41. A record review of Resident 3's admission Record revealed Resident 3 admitted to the facility on [DATE] and was admitted to the hospital on [DATE]. An observation on 09/23/24 at 9:51 AM revealed an unattended medication cup containing 12 medications varying in size and color sitting on a bedside table in Resident 3's room. An interview with Licensed Practical Nurse (LPN)-G on 09/23/2024 at 9:52 AM was conducted. LPN-G revealed that These (the pills in the medication cup) look like Resident 3's morning pills. LPN-G further revealed [gender] did not leave those medications at Resident 3's bedside and that the medications must be from the weekend. A record review of Resident 3's September 2024's Medication Record revealed that on 9/22/24 the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-09-03 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17B Based on observation, interview, and record review, the facility failed to follow infection control guidelines to prevent cross contamination related to peri cares and catheter cares for 1 (Resident 4) of 3 sampled residents. The facility identified a census of 41. Findings are: A record review of the document titled admission Record revealed Resident 4 had been accepted into the facility on [DATE] with a primary diagnosis of Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior) and Cognitive/communication deficit. An observation on 9/3/24 at 3:37 PM of peri-cares for Resident 4, being accompanied by the DON and completed by MA-A and MA-B revealed that MA-A had gathered supplies to perform peri-cares (a bottle of spray skin cleanser, a hand towel and a container of wet wipes) and placed the supplies directly on Resident 4's bed with no barrier placed throughout the procedure. The observation revealed that Resident 4 had a catheter in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-11-16 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — the official record, unedited, may be distressing
Licensure Reference Number 175 NAC 12.006.04B2c Based on observation, interview and record review, the facility failed to ensure the kitchen had a qualified Dietary Manager. This had the potential to affect all 47 residents that consumed food from the kitchen. The total facility census was 47. Findings are: A record review of the facility's Dietary Manager's (DM) training revealed the DM was enrolled in the Pathway III(b) - Dietary Manager Training course with a start date of 10/16/2023 and an end date of 10/16/2024 but had not successfully completed the course. A record review of the Job History for the DM confirmed the DM was hired at the previous facility 07/25/2019 and left the facility 12/31/2021 and had not completed the Dietary Manager training course at that time. In an interview on 11/15/2023 at 10:25 AM, the facility's Registered Dietician (RD) confirmed the RD was only at the facility 1 day per week and the DM had not completed the Dietary Manager training course.
- Potential for harm · Fcited before2023-11-16 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview and record review, the facility failed to ensure open food items in the kitchen were dated and/or labeled and failed to ensure the kitchen equipment was clean to prevent the potential for foodborne illness. This had the potential to affect all 47 residents that consumed food from the kitchen. The total facility census was 47. Findings are: A. A record review of the of the Food-Supply Storage - Food and Nutrition Services policy dated 05/11/2023 revealed foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly. An observation on 11/13/2023 at 8:20 AM of the reach in refrigerator on the left side as you enter the kitchen revealed: -1 white open container unknown substance not labeled or dated. -2 open clear containers of fruit not labeled or dated. -1 open container of a thick creamy white substance not labeled or dated. -1 can with a label of mandarin oranges covered with plastic wrap not sealed or dated. -1 container yellow substance covered with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-11-16 · tag F0760 — failed to prevent significant medication errors — patternEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.10D Based on observation, interview and record review, the facility failed to ensure 1 (Resident 100) of 2 sampled residents received an antibiotic (a medication used to treat an infection) as scheduled and failed to ensure food was given after sliding scale Insulin (progressive increase in pre-meal or nighttime insulin doses based on pre-defined blood glucose (sugar) ranges) was administered for 2 (Residents 100 and 107) of 3 sampled residents per manufacturer's specifications. The total facility census was 47. Findings are: A record review of the facility's Medication Errors policy dated 03/02/2023 revealed medication errors were when the observed or identified administration of medications were not in accordance (conformity) with the prescriber's order, manufacturer's specifications, or accepted professional standards. A significant medication error was one which causes the resident discomfort or jeopardizes the resident's health and safety. A. A record review of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-11-16 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.11E Based on observation, interview, and record review, the facility failed to ensure glove changes and hand hygiene were performed during wound care on 1 (Resident 2) of 4 sampled residents, failed to handle linen in a manner to prevent cross contamination for 2 (Resident's 6 and 99) of 2 sampled residents, and failed to secure catheter drainage bag in a manner to prevent cross contamination for 1 (Resident 13) of 1 sampled resident. The total facility census was 47. Findings are: A. A record review of the Wound Care policy dated 03/23/2023 revealed the following information: -washed and dried hands thoroughly -positioned the resident and placed a disposable cloth under the wound to serve as a barrier -loosened tape and removed dressing, pulled glove over dressing and discarded -washed and dried hands thoroughly -put on new gloves, wore sterile gloves when physical touching or holding a moist surface over the wound, applied treatment -dressed wound -removed gloves and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09D6(7) Based on observation, interview and record review, the facility failed to ensure 1 (Resident 100) of 6 sampled residents had a valid order for Oxygen and Positive Airway Pressure device (PAP)(a machine used to treat Obstructive Sleep Apnea (OSA). The total facility census was 47. Findings are: A. A record review of the facility's Oxygen Administration (delivery) Safety, Mask Types policy dated 06/30/2023 revealed oxygen administration was only to be carried out with a medical provider's order. A record review of Resident 100's Clinical Census dated 11/14/2023 revealed Resident 100 was admitted to the facility on [DATE]. A record review of Resident 100's Medical Diagnosis dated 11/14/2023 revealed the resident had diagnoses of Chronic Obstructive Pulmonary Disease (long term lung disease), Obstructive Sleep Apnea (periods of no breaths during sleep), Chronic Respiratory Failure with Hypoxia (long term lung disease with low oxygen), Chronic Diastolic (Congestive)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-11-16 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12.006.09D Based on Observation, Interview and Record Review the facility failed to ensure bowel medications were managed to prevent excessive bowel movements for one resident, (Resident 25). The facility census was 47. Findings are: Record Review of Resident 25's medication administration record revealed an order for Docusate Sodium Oral Liquid 50 mg/5ml (a stool softner) Give 10 ml by mouth two times a day for constipation start date 6/14/23 an order for Polyethylene Glycol (an osmotic laxative) 1450 Powder Give 17 gram by mouth one time a day for bowel management mix in 6-8 ounces of water or juice start date 6/01/23, and an order for Senna-Time, (a stimulant laxative) Oral Tablet 8.6 mg at bedtime for constipation start date11/13/23 Record Review of Resident 25's bowel movements revealed Resident 25 had 70 bowel movements between 10/17/23 to 11/15/23. Record Review of Consultant Pharmacist note dated 10/23/23 at 11:56 AM Medication Regime Review indicated that the pharmacist did not identify the excessive bowel movements and the potential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,033 in federal fines across 1 penalty.
- $10,033 — penalty dated 2024-09-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to GOOD SAMARITAN SOCIETY — 92 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 1 of 5 | 3.0 | -2.0 vs chain |
| Health inspection | 2 of 5 | 2.8 | -0.8 vs chain |
| Staffing | 3 of 5 | 4.0 | -1.0 vs chain |
| Quality measures | 1 of 5 | 2.8 | -1.8 vs chain |
The other 91 homes this chain runs (chain average 3.0★, per CMS)
Showing 40 of 91; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| SANFORD | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2019 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 01/01/2019 |
| HUSEN, STEVEN | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 11/07/2018 |
| MORRISON, TONY | Individual | W-2 MANAGING EMPLOYEE | — | since 01/01/2019 |
| MUIR, DANIELLE | Individual | W-2 MANAGING EMPLOYEE | — | since 04/29/2024 |
| CAIN, JAMES | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| DYKHOUSE, DANA | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| ENGBRECHT, WESLEY | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| GASSEN, WILLIAM | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 05/30/2024 |
| GULSVIG, NEIL | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| HERSETH SANDLIN, STEPHANIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| LUNDEEN, MARK | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| SHULKIN, DAVID | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| TEIKEN, BRENT | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| VENTLING-HERRMANN, MARNIE | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| FLUIT, JOEL | Individual | CORPORATE OFFICER | — | since 10/01/2022 |
| MIDDLETON, AIMEE | Individual | CORPORATE OFFICER | — | since 01/27/2022 |
| OLSON, NICHOLAS | Individual | CORPORATE OFFICER | — | since 04/08/2024 |
| ROGERS, MICHAEL | Individual | CORPORATE OFFICER | — | since 06/13/2022 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
CMS files one row per role, so the 23 rows in the source record cover these 22 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.4M paid to related parties — landlords or management companies under common ownership — equal to about 15% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in NE
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285285. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-30, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.