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Good Samaritan Society - Hastings Village

300 S 1st Avenue, Hastings, NE 68901 · Non profit - Corporation · 108 certified beds · (402) 463-3181 Medicare & Medicaid certified

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1 immediate-jeopardy citation$39,704 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a high payroll-based staffing rating (4/5)
Worth asking about
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • 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 $39,704 in federal fines (most recent 2025-03-06)
  • its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • about 22% of its spending goes to commonly-owned related companies

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.

2/5
CMS overall
2 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
715 N Kansas Ave Ste 200 · (402) 461-5064 · Call to confirm hours
Pharmacy
705 N Burlington Ave · (402) 463-4554 · Call to confirm hours
Grocery
502 Eastside Blvd · (402) 705-2925 · Call to confirm hours
Park
847 N 4th Ave · Typically dawn to dusk
Place of worship
922 E South St · (402) 677-5030

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 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 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.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.4%19.0%15.4%worse
Long-stay residents who lose too much weight1.6%5.1%5.4%better
Long-stay residents with a catheter left in their bladder2.7%1.4%0.9%worse
Long-stay residents with a urinary tract infection2.1%2.8%2.0%typical
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury6.2%4.5%3.3%worse
Long-stay residents whose ability to walk worsened21.9%18.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication19.1%19.3%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%96.1%95.3%typical
Long-stay residents with pressure ulcers5.3%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control17.3%25.9%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table6.5%20.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.6%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine77.8%75.9%79.4%typical
Short-stay residents rehospitalized after admission19.0%20.7%22.6%better
Short-stay residents with an outpatient ER visit16.6%11.4%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.191.811.67better
Long-stay outpatient ER visits per 1,000 resident days2.191.921.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

‡ 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.

62.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 88 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

62.7%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
67.7%U.S. median 56.6%
Met the expected recovery
0.23U.S. median 0.30
Therapy hours / resident / day
0.13hours / resident / day
Physical therapy
0.08hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 67.7% 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 68 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 0.23 therapist hours per resident per day in 2025Q4 — more than 31% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF62.7%CMS range 54.1–71.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 7.1–14.310.7%Oct 2022–Sep 2024no 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 discharge67.7%56.6%Oct 2024–Sep 2025CMS 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 discharge63.2%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge38.2%50.0%Oct 2024–Sep 2025CMS 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 identified100.0%98.7%Oct 2024–Sep 2025CMS 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 setting100.0%100.0%Oct 2024–Sep 2025CMS 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.4–9.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.681.02Oct 2022–Sep 2024CMS 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

0.86
RN hours/ resident / day
0.40
LPN hours/ resident / day
2.36
Aide hours/ resident / day
3.62
Total nurse hours/ resident / day
0.57
RN hoursweekends
44.9%
Total nursing turnover
40.0%
RN turnover

How full it usually is: this home is certified for 108 beds and averages 45.3 residents a day — about 42% occupied, or roughly 63 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.86 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.36 is below 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 3.30 hrs/resident/day on weekends vs 4.02 on weekdays — 18% thinner on weekends. RN hours go from 1.00 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as 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

14 ↑
deficiencies at the latest standard inspection (2026-07-15)
4
at the previous standard inspection (2025-03-06)

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.

ABCDEFGHIJKL

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.

  • Immediate jeopardy · J2024-02-29 · tag F0678 — failed to provide CPR when needed — isolated
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    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 Based on record review and interview, the facility failed to follow the advance directive for Cardiopulmonary Resuscitation (CPR) (a lifesaving attempt combination of rescue breathing and chest compressions when someone's heart has stopped) or DNR (A type of advance directive in which a person states that health care providers should not perform cardiopulmonary resuscitation (restarting the heart) if his or her heart or breathing stops) for two residents (Resident 7 and 39) of 16 sampled residents. Facility census was 38. Findings are: A. Record review of the facility policy titled Advance Directive including Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) dated [DATE] revealed the purpose of the policy was to provide each resident the opportunity to make decisions related to medical care and to define a process to make resident decisions known. If cardiac arrest occurs, CPR must be initiated unless the resident has a valid DNR (Do Not…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-07-15 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 12-006.11(E) Based on record reviews, observations, and interviews, the facility failed to follow the 2022 Food and Drug Administration (FDA) food code. This had the potential to affect all residents eating food out of the kitchen. The facility census was 52. Findings are: A record review of a policy titled, Date Marking- Food and Nutrition dated 4/3/24. The policy revealed:Policy:Time Temperature Control for Safety Foods (TCS) items are date-marked when received, when manufacturer package is opened and when removed from freezer into refrigeration. Dates are monitored to ensure food safety and quality for all foods at the location, including TCS snacks stored outside the preparation kitchen.Procedure:When TCS food is received, employees:Observe for vendors date of delivery and if not available, date mark the item with the delivery date.Observe for USE by date or USE or Freeze by date. This is an expiration date.As much as possible, food items should remain in their original containers/packaging if that package has a receiving date clearly marked.If…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Fcited before2026-07-15 · tag F0880 — failed to prevent and control infections — widespread
    Provide 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 12-006.04(A)(ii)Licensure Reference Number 175 NAC 12-006.18Licensure Reference Number 175 NAC 12-006.09 (H)(vi)(3)(g)Based on record review and interview the facility failed to ensure that pre-employment health screens were completed for 5 of 6 sampled staff to prevent the potential for communicable disease for all facility residents; failed to ensure that reusable medical care equipment was cleansed and/or changed at a frequency to ensure it was maintained in a sanitary and usable condition for 2 residents (Resident 6 and 15); failed to ensure that staff providing direct resident cares did not have artificial nails that prevented proper hand sanitization during care for 2 residents (Resident 6 and 15); failed to ensure that all reusable oxygen equipment was thoroughly cleaned after use; and failed to ensure that disposable oxygen equipment was properly labeled and discarded for the prevention of infection for 1 resident (Resident 67). The facility census was 52.Findings 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.

    Infection Control Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · F2026-07-15 · tag F0924 — widespread
    Put firmly secured handrails on each side of hallways.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-007.03(K). Based on observations and interviews, the facility failed to affix handrails securely to the walls in resident corridors, this had the potential to affect all residents residing in the facility. The facility census was 52. Findings are: An observation and walkthrough at 3:30 PM on 7/14/26 with the Maintenance Director (MD) and Housekeeping Supervisor (HS) revealed a several foot long rounded handrail in the front corridor area of the building entrance loose. The MD and HS observed drywall falling from around the edges of the handrails, screws and attachments that were affixed to the wall. An observation and walkthrough at 3:30 PM on 7/14/26 with MD and HS revealed loose handrailing beside the bathing room on 100 hall. MD revealed they were aware of this railing being loose. An observation and walkthrough at 3:30 PM on 7/14/26 with MD and HS revealed loose handrailing beside and across from the activity room in an open corridor area where people gather. MD revealed they were unaware of this railing being loose. An observation 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.

    Environmental Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-07-15 · tag F0761 — failed to label and store drugs safely — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.12(D)(iii)Based on observation, record review, and interview the facility failed to ensure that medications and medical supplies were not expired. The facility census was 52.Findings are:Record review of the facility policy titled Medications: Acquisition, Receiving, Dispensing, and Storage dated 3/30/26 revealed that the location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. Observation on 7/13/26 at 10:11 AM in the 100 medication storage room revealed that a box of Vacuette Drawing Needles expired on 5/19/26 (sterile, single-use stainless steel needles used by medical professionals to collect venous blood samples). An unopened box of Accucheck SafeT-Pro Plus lancets expired on 2/28/25 (a sterile single-use medical device with a blade that pricks the skin to draw small drops of blood for checking blood sugar). Alginate dressings with some expired on 9/1/24 and some on 7/1/25 (a natural wound dressing that covers and absorbs wound fluid). Tubes of Remedy Cream…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · E2026-07-15 · tag F0802 — failed to prepare enough nourishing food — pattern
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    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(H) Based on record reviews, interviews and observations, the facility failed to serve meals in a timely manner based on the facility's posted time for meals. This had the potential to affect all residents who ate meals in the dining rooms. The facility census was 52. Findings are:A record review of posted mealtimes and locations reveal:Breakfast-7:30 AMLunch-11:30 AMEvening Meal-5:30 PMDining room locations:100 Avenue-Central Hub of Building400 Avenue-Between 400 Nurse Station and room [ROOM NUMBER] An observation in 100 Avenue dining room on 7/13/26 at 11:57 AM, meal service had not yet started. An observation in 100 Avenue dining room on 7/13/26 at 12:45 PM, last person was served their meal for lunch. An observation in 100 Avenue dining room on 7/14/26 at 8:00 AM, meal service had not yet started. An observation in 400 Avenue dining room on 7/14/26 at 8:10 AM, meal service had not yet started. An observation in 400 Avenue dining room on 7/14/26 at 8:55 AM, last…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.19 Based on record reviews and interviews, the facility failed to provide daily housekeeping per the Resident Agreement for 2 residents (Resident 18 and Resident 25) of 13 residents sampled. The facility census was 52. Findings are:A record review of a facility policy titled Housing with Services: Rehab/Skilled & Long-Term Care: Housekeeping Resource Packet dated 8/21/25Standard or Light Cleaning-Rehabilitation/Skilled Care & Long Term Care:Purpose: To provide procedures for the proper, daily cleaning of resident roomsBackground: Rehabilitation/skilled care setting provide care and services to residents who are often vulnerable to infections and the effects of infections due to weakened immune systems. As such, thorough, routine, and high quality cleaning procedures are necessary to minimize the prevalence of infection.Procedure:1. Standard or light cleaning should occur on a daily basis in occupied rooms. If standard or light cleaning is not scheduled daily, the scheduled should be adjusted for daily cleaning in rooms where residents 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.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0628 — isolated
    Provide 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

    The facility failed to ensure that the Ombudsman was notified of transfers and discharges; and failed to ensure that a written copy of the reason for transfer to the hospital was given to the resident or the resident representative. This affected one of one sampled residents, Resident 14. Based on record review and interview, the facility failed to ensure that the State Ombudsman was notified of all transfers and discharges; and failed to ensure that a written copy of the reason for transfer to the hospital was given to the resident or the resident representative. This affected 1 of 1 sampled residents, Resident 14. The facility Census was 52. Findings were:Record review of the facility's Admission, Transfer and Discharge Team policy dated 9/8/2025 revealed the purpose was to discuss potential admissions, transfers, and discharges and implications for the operation of the entire facility and to make decisions on admissions, transfers, or discharges balancing the needs of the resident and the facility's ability to meet those needs. Furthermore the policy procedure stated that…

    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.

    Resident Rights Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    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(F)Based on record review and interview the facility failed to ensure that care conferences (meetings) (essential team conferences held quarterly at nursing homes with multiple medical professionals in one room to update the resident's care plan, address problems and answer resident/resident representative's questions) were provided to the resident/resident representative as required for 1 resident (Resident 5) of 3 sampled residents. The facility census was 52.Findings are:Record review of the facility policy titled Comprehensive Care Plan and Care Conferences dated 12/29/25 revealed that the purpose is to develop a person-centered care plan for each resident and to provide an ongoing method of assessing, implementing, evaluating, and updating the resident's care plan to help maintain the resident's highest practicable level of function. The social worker or designated employee will establish the time and place to hold the care conference. Invite residents and their…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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(H)(i)(2)Based on interviews, observations, and record reviews, the facility failed to provide the necessary care and services to assist in maintaining a resident's level of function for 1 resident (Resident 6) of 1 sampled resident, and complete routine bathing for 1 resident (Resident 6) of 2 sampled residents. The facility census was 52.Findings are:A.Record review of a Resident Handbook on 07/15/2026 revealed Restorative Nursing care focuses on restoring and or maintaining physical function. Restorative Nursing focuses on rehabilitation and restorative interventions to maintain the resident's abilities.In an interview completed on 07/13/2026 at 10:26 AM with Resident 6, Resident 6 stated that they felt that their level of function had declined since admission from the facility. The resident stated that they had received therapy services and were able to use the sit to stand lift for transfers at the end of therapy services. The resident stated that staff were able…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide 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 observations, record review, and interviews, the facility failed to provide care in a manner to promote healing of a pressure related skin injury for 1 resident, (Resident 15), of 1 sampled resident. The facility census was 52. Findings are:A.Record review of a document titled Top tips for Best Wound Cleansing Practices and dated 06/30/2017 revealed Potable drinkable tap water can be used if there is no other alternative.In an observation completed on 07/14/2026 at 2:19 PM of wound care being provided to Resident 15 by Licensed Practical Nurse-A (LPN-A). LPN-A entered the residents' bathroom and obtained a washcloth that was hanging on the bar of the residents bathroom wall under the faucet in the bathroom and moistened the washcloth with water from the tap. The LPN rang the excess water from the cloth and then with the resident placed on their left side placed the tap water moistened wash cloth to the resident's sacrum. The LPN then allowed the resident to roll back onto their back with the washcloth present over their…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
Show the remaining 12 citations
  • Potential for harm · D2026-07-15 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.09(H)(iv)(1)Based on record review, observation, and interview, the facility failed to provide perineal care (the cleansing in the genital and anal areas to prevent infection and skin breakdown) per professional standards of practice for 2 residents (Resident 6 and Resident 15) of 2 sampled residents. The facility census was 52.Findings are:Record review of a document titled Nebraska ICAP UTI Perineal Care Procedure https://icap.nebraskamed.com/ and dated 0209/2017 revealed for female residents separate the labia and wash from front to back on each side of the labia and in the center over the urethra and vaginal opening, using a clean area of the washcloth for each stroke.Record review of a facility policy titled Perineal Care and dated 07/30/2025 revealed to separate the labia with one hand and using a disposable wipe, using downward strokes from the front to the back.A.In an observation completed on 07/14/2026 at 9:45 AM of perineal care being provided to Resident 6 by Nurse Aide N(NA-N) and Nurse Aide I(NA-I) the following was…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Dcited before2026-07-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 (H)(vi)(3)(a)Licensure Reference Number 175 NAC 12-006.09 (J)(i)(1) The facility failed to ensure that admission weights were taken for all individuals in order to monitor and assess for adequate nutrition and hydration for those who receive assisted nutrition. This affected resident 67.Record review of the facility policy dated 6/2/26 admission Documentation revealed that the policy purpose was to obtain appropriate initial information regarding the resident and family and to provide the initial documentation needed on admission. The procedures included; Greet the resident and family and escort to resident's room, assist with transfer to bed or wheelchair if needed, introduce resident to roommate, explain the call light system and request return demonstration, and take the initial vital signs, weight and height and document in the weights and vitals tab in the electronic medical record. Record review of the Baseline Care Plan dated 7/8/2026 revealed that Resident 67…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure 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 observation, record review, and interview the facility failed to maintain a medication administration error rate of less than 5%. The facility error rate was 7.61% (27 medication administrations and 2 errors). This affected 2 of 6 residents (Residents 62 and 12). The facility census was 52.Findings are:A.Record review of the facility policy titled Insulin Administration, Insulin Pens, Insulin Pumps dated 10/31/25 revealed that the purpose of the policy is to administer insulin injections correctly and allow for safe use of insulin pens. (Insulin is a medication used to regulate blood sugar levels). The section titled Insulin Pen (a device resembling an oversized ink pen that is prefilled with insulin and used with disposable pen needles for more accurate dosing) revealed that insulin pens must be clearly labeled with the name or other identifiers to verify that the correct pen is used on the correct person. Verify the provider order, the expiration date, and the number of days the pen has been open. Follow manufacturer's…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · D2026-07-15 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    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 observation, record review, and interview the facility failed to ensure that staff administered resident insulin (a medication used to regulate blood sugar levels) in a manner to prevent significant medication administration errors (errors that jeopardize the residents health or safety) for 2 of 2 residents observed (Residents 62 and 12). The facility census was 52.Findings are:A.Record review of the facility policy titled Insulin Administration, Insulin Pens, Insulin Pumps dated 10/31/25 revealed that the purpose of the policy is to administer insulin injections correctly and allow for safe use of insulin pens. (Insulin is a medication used to regulate blood sugar levels). The section titled Insulin Pen (a device resembling an oversized ink pen that is prefilled with insulin and used with disposable pen needles for more accurate dosing) revealed that insulin pens must be clearly labeled with the name or other identifiers to verify that the correct pen is used on the correct person. Verify the provider order, the expiration…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has plan of correction
  • Potential for harm · Fcited before2025-03-06 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure 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 175NAC 12-006.11(E) Based on observation, interview, and record review the facility failed to ensure sanitary conditions in the kitchen and failed to label and date leftover foods in order to prevent the potential for food borne illnesses for all residents who consumed meals prepared in the kitchen. This had to potential to affect all residents that consumed meals prepared by the facility kitchen; and the facility failed to ensure that resident room meals were served and removed in a manner to prevent the potential for foodborne illness for 2 residents (Residents 34 and 16) of 2 residents observed. The facility census was 37. Findings are: A. Record review of the undated Resident Handbook states under Food and Nutrition Services the facility serves nutritious, well-balanced meals and the registered dietician routinely reviews menus, food preparation, sanitation, and dining services. Record review of the undated policy Date Marking; Food and Nutrition revealed the purpose of the policy…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-03-06 · tag F0850 — failed to provide social-work services — widespread
    Hire a qualified full-time social worker in a facility with more than 120 beds.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews and record reviews, the facility failed to employ a qualified social worker on a full-time basis. The facility census was 37. Findings are: A review of the Long Term Care Bed Count Record provided by the facility dated 03/03/2025 revealed the facility had a census of 37 and a licensed bed count of 175. An interview on 03/03/2025 at 12:43 PM with Resident 32's Power of Attorney (POA; a legal document that allows someone else to act on your behalf) revealed that the Social Services Department does not always provide updates on Resident 32. The POA further states the social services director is not always available when needed. An interview on 03/04/2025 at 3:28 PM with the Social Services Director (SSD) revealed that they are responsible for all duties within the department and works on a full-time basis. SSD was asked about qualifications for obtaining the role, the SSD revealed they moved into the position from the kitchen and activities department, then obtained an online certification as a social services designee in long term care. A record review of the SSD…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-06 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Title 175 NAC Chapter 12-006.05 (E) Based on interviews and record reviews, the facility failed to provide bathing as required for 1 resident (Resident 5). The facility census was 37. Findings are: An interview on 03/03/2025 at 10:24 AM with Resident 5 revealed that they are scheduled for weekly baths and did not get a bath last week. According to Resident 5, they were told the bath chair was not working, however told the bath aide they would like a shower and need at least one a week. Record review of Resident 5's admission Record dated 03/03/2025 reveals an admission date on 05/18/2023. Record review of Resident 5's Care Plan Report with an initiation date of 05/18/2023, reveals: -RESIDENT ADL PREFERENCES: Resident prefers a whirlpool bath one time per week during the day. -BATHING: Prefers whirlpool. -BATHING: Resident requires bed bath 1 staff assist. Record review of Resident 5's Plan of Care (POC) Response History dated 03/04/2025 reveals 30 day look back for questions: Type of Bath reveals on 02/07/2025, 02/12/2025, 02/19/2025 a whirlpool bath was provided, and on 02/26/2025…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-06 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 175NAC 12-006.18(B) Licensure Reference Number 175NAC 1-005.06(E) Based on observation, interview, and record review the facility failed to ensure that staff wore gown and gloves as required during high contact resident care (activities with the highest risk for transfer of germs to hands and clothing) for 1 resident (Resident 33) of 2 residents observed to prevent the potential for cross contamination and infection. The facility census was 37. Findings are: Record review of the facility policy titled Standard and Transmission Based Precautions dated 4/2/24 revealed that the purpose of the policy is to prevent the spread of infection and to provide appropriate personnel with protective equipment when necessary. The section titled Enhanced Barrier Precautions (EBP) revealed that it refers to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDROs (Multi-Drug Resistant organisms -microorganisms (primarily bacteria) that…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 12-006.10A1 Based on observation, record review, and interview; the facility failed to implement a process to access residents for self-administration of medications. This affected 2 (Resident #4 and Resident #24) of 5 sampled residents. Facility stated census of 38. Findings are: A. A review of Resident #4's admission Record dated 02/26/2024 Resident #4 admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis which is a loss of strength on one side of the body, affecting the right dominant side. The Quarterly Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), dated 12/20/2023 revealed Resident #4 had a Brief Interview for Mental Status (BIMS) which is a screening tool that aids in detecting cognitive impairment, score of 15 indicating resident was cognitively intact. The resident was independent of Activities of Daily Living (ADLs) of bed mobility, eating, toileting,…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure 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 12-006.09D7a Based on observation, record review, and interview; the facility failed to implement interventions to prevent accidents for 1 (Resident #20) of 5 sampled residents. Facility census was 38. Findings are: Review of Resident #20's admission Record revealed the resident was admitted on [DATE] with the diagnoses of: Pneumonia (which is an infection that inflames the air sacs in one or both lungs) and Congestive Heart Failure (which is a condition when your heart can not pump blood well enough to give your body a normal supply resulting in fluids collecting in your lungs and legs). The admission Minimum Data Set (MDS, a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning), dated 01/09/2024 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 11(moderately impaire cognition) and staff provided partial to moderate assistance with Activities of Daily Living (ADL's). 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 12-006.09D8a Based on observation, record review, and interview; the facility failed to provide the physician ordered diet to 1 (Resident #20) of 5 sampled residents. The facility census was 38. Findings are: Review of Resident #20's admission Record revealed the resident admitted on [DATE] with the diagnoses of: Pneumonia which is an infection that inflames the air sacs in one or both lungs and Congestive Heart Failure which is a condition when your heart can not pump blood well enough to give your body a normal supply resulting in fluids collecting in your lungs and legs. The admission Minimum Data Set (which is a mandatory comprehensive assessment tool that measures the health status of nursing home residents and is used for care planning (MDS)) dated 01/09/2024 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 11 and staff provided partial to moderate assistance with Activities of Daily Living (ADL's). Resident #20 was also indicated to have 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-02-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 12006.17 Based on observation, record review, and interview; the facility failed to perform hand hygiene during resident perineal care (cleansing of a residents private areas between the legs), and failed to clean respiratory care equipment after resident use. This affected 2 (Resident #4 and Resident #13) of 5 sampled residents. Facility census was 38. Findings are: A. In an observation on 02/28/2024 at 3:23 PM catheter cares were observed by Nurse Aide (NA)-C and NA-D to Resident #13 in their room. NA-C and NA-D were standing at Resident #13's bed side. On Resident #13's bedside table beside NA-C was a basin with 2 wash clothes which were submerged with visible bubbles present in the water. NA-C had gloved hands and obtained a washcloth from the basin and wrung out the excess water. NA-C then used the washcloth to cleanse Resident #13 perineal area and catheter. NA-C discarded the washcloth into a clear plastic bag. Then NA-C obtained another washcloth from the basin and wrung it out. NA-C then repeated the cleansing of the perineal area with 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$39,704 in federal fines across 2 penalties.

  • $22,903 — penalty dated 2025-03-06
  • $16,801 — penalty dated 2024-02-29

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 →

RatingThis homeChain avg
Overall 2 of 53.1-1.1 vs chain
Health inspection 2 of 52.9-0.9 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 4 of 52.8+1.2 vs chain
The other 91 homes this chain runs (chain average 3.1★, per CMS)
1 of 5Edgebrook Care CenterEdgerton, MN 1 of 5Good Samaritan - IndianolaIndianola, IA 1 of 5Good Samaritan - Red OakRed Oak, IA 1 of 5Good Samaritan Society - AtkinsonAtkinson, NE 1 of 5Good Samaritan Society - BlackduckBlackduck, MN 1 of 5Good Samaritan Society - Grand Island VillageGrand Island, NE 1 of 5Good Samaritan Society - LakotaLakota, ND 1 of 5Good Samaritan Society - Mary Jane BrownLuverne, MN 1 of 5Good Samaritan Society - MillardOmaha, NE 1 of 5Good Samaritan Society - St Luke's VillageKearney, NE 1 of 5Good Samaritan Society - WindomWindom, MN 1 of 5Good Samaritan Society De SmetDe Smet, SD 1 of 5Good Samaritan Society MillerMiller, SD 1 of 5Salem Lutheran HomeElk Horn, IA 1 of 5Souris Valley Care CenterVelva, ND 1 of 5Sunset Drive - a Prospera CommunityMandan, ND 2 of 5Good Samaritan - AtwoodAtwood, KS 2 of 5Good Samaritan - Decatur CountyOberlin, KS 2 of 5Good Samaritan - OttumwaOttumwa, IA 2 of 5Good Samaritan - WaukonWaukon, IA 2 of 5Good Samaritan Society - BottineauBottineau, ND 2 of 5Good Samaritan Society - OakesOakes, ND 2 of 5Good Samaritan Society - Park RiverPark River, ND 2 of 5Good Samaritan Society - Specialty Care CommunityRobbinsdale, MN 2 of 5Good Samaritan Society - St John'sKearney, NE 2 of 5Good Samaritan Society - SuperiorSuperior, NE 2 of 5Good Samaritan Society - Waconia And Westview AcreWaconia, MN 2 of 5Good Samaritan Society Luther ManorSioux Falls, SD 2 of 5Good Samaritan Society New UnderwoodNew Underwood, SD 2 of 5Good Samaritan Society Sioux Falls CenterSioux Falls, SD 2 of 5Good Samaritan Society Sioux Falls VillageSioux Falls, SD 2 of 5St Vincent's - A Prospera CommunityBismarck, ND 3 of 5Good Samaritan - AlgonaAlgona, IA 3 of 5Good Samaritan - DavenportDavenport, IA 3 of 5Good Samaritan - EsthervilleEstherville, IA 3 of 5Good Samaritan - HolsteinHolstein, IA 3 of 5Good Samaritan - Loveland VillageLoveland, CO 3 of 5Good Samaritan - VilliscaVillisca, IA 3 of 5Good Samaritan - West UnionWest Union, IA 3 of 5Good Samaritan Society - AuburnAuburn, NE

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 / managerTypeRoleShareSince
SANFORDOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2019
BROWN, GEORGEIndividualCORPORATE DIRECTOR—since 01/01/2025
DYKHOUSE, DANAIndividualCORPORATE DIRECTOR—since 05/30/2024
ENGBRECHT, WESLEYIndividualCORPORATE DIRECTOR—since 05/30/2024
GASSEN, WILLIAMIndividualCORPORATE DIRECTOR; CORPORATE OFFICER—since 05/30/2024
GULSVIG, NEILIndividualCORPORATE DIRECTOR—since 05/30/2024
HERSETH SANDLIN, STEPHANIEIndividualCORPORATE DIRECTOR—since 05/30/2024
LUNDEEN, MARKIndividualCORPORATE DIRECTOR—since 05/30/2024
MCCAUSLAND, MAUREENIndividualCORPORATE DIRECTOR—since 01/01/2025
MOLBERT, LAURISIndividualCORPORATE DIRECTOR—since 05/30/2024
NORTH, ANDREWIndividualCORPORATE DIRECTOR—since 05/30/2024
SCHIEFFER, KEVINIndividualCORPORATE DIRECTOR—since 01/01/2025
SHULKIN, DAVIDIndividualCORPORATE DIRECTOR—since 05/30/2024
TEIKEN, BRENTIndividualCORPORATE DIRECTOR—since 05/30/2024
VENTLING-HERRMANN, MARNIEIndividualCORPORATE DIRECTOR—since 05/30/2024
WENZEL, THOMASIndividualCORPORATE DIRECTOR—since 01/01/2025
FLUIT, JOELIndividualCORPORATE OFFICER—since 10/01/2022
MIDDLETON, AIMEEIndividualCORPORATE OFFICER—since 01/27/2022
OLSON, NICHOLASIndividualCORPORATE OFFICER—since 04/08/2024
SCHEMA, NATHANIndividualCORPORATE OFFICER—since 01/01/2022
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETYOrganizationOPERATIONAL/MANAGERIAL CONTROL—since 01/01/2019
LEACH, SHAWNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF—since 06/17/2018
MORRISON, TONYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF—since 01/01/2019
NITZEL, GRANTIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF—since 12/01/2020

CMS files one row per role, so the 28 rows in the source record cover these 24 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.

$5.6M
Net patient revenuemost recent cost report
-108.3%
Operating marginrevenue minus expenses
$2.6M
Related-party expense22% of expenses
Who pays — share of resident-days
Medicaid 34%Medicare 5%Other / private 62%

This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 22% 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

$420per resident / day
operating cost
$12,782per month
≈ monthly operating cost
$202per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Nebraska
$8,377/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,350/mo
Assisted living

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 2026-09-01 — CMS provider number 285072. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-15, 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.

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