Good Samaritan Society - Syracuse
1622 Walnut Street, Syracuse, NE 68446 · Non profit - Corporation · 88 certified beds · (402) 269-2251 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (36% vs 45% nationally) — better care continuity
- about 18% 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 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 | 3 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 2 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 3 to 4 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 | 23.3% | 19.0% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.4% | 5.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.1% | 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 | 1.3% | 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 | 3.1% | 4.5% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 21.6% | 18.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 26.1% | 19.3% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 97.6% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.7% | 4.0% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 34.6% | 25.9% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 22.0% | 20.7% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 2.0% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 58.1% | 75.9% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 20.4% | 20.7% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 20.9% | 11.4% | 12.0% | 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.
40.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 40 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.07 therapist hours per resident per day in 2026Q1 — more than 4% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 | 40.1%CMS range 28.8–55.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 7.6–16.0 | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality 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 | not 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 stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.3%CMS range 3.7–11.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 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 88 beds and averages 46.7 residents a day — about 53% occupied, or roughly 41 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 3.34 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.32 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 2.79 hrs/resident/day on weekends vs 3.57 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.55 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 36% is below the national median of 45%. 1 administrator has left in the past year.
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.
9 citations, most serious first — scroll within the box to see all.
- Potential for harm · Fcited before2025-01-16 · 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 Based on observation, interview and record review the facility staff failed to ensure hand hygiene and gloving techniques were followed during wound care for 1( Resident 34) and tube feeding for 1( Resident 17), failed to ensure wound care supplies were not contaminated for 1 (Resident 34), failed to implement interventions to prevent the spread of Covid-19 and failed to ensure the facility had a Legionella water management plan. The facility failure had the potential to effect all residents in the facility. The facility had a census of 42. Findings are: A. A record review of Resident 34's hospice wound care order dated 12/16/2024 revealed the following instructions: -Wash left heel with wound wash, dry with gauze, apply layer of Vaseline gauze to wound and cover with dry gauze dressing and secure with Medi pore tape. Hospice nurse to complete twice a week. If dressing becomes soiled or is removed, apply dry dressing and secure as needed (PRN). An observation on 01/15/2025 at 10:47 AM of wound care performed by the Clinical Care Lead…
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 before2025-01-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
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 NAC 175 12-006.04(F)(i)5 Based on record review and interview the facility staff failed to notify the physician and responsible party regarding missed/unavailable doses of medication for 1 (Resident 18) of 8 resident's reviewed. The facility staff identified a census of 42. Findings are: Record review of Resident 18's Face Sheet dated 01/15/2025 revealed Resident 18 was admitted to the facility on [DATE]. Record review of Resident 18's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 11/04/2024 revealed the facility staff assessed the resident's use of anticonvulsant medication. This MDS also assessed Resident's mental status and documented severe impairment. Record review of Resident 18's Medication Administration Record (MAR, a record of how the Resident's medications are administered) for Phenytoin (an anticonvulsant medication) Oral Suspension 125 MG/ML (Milligram/Milliliter), give 8 ML by mouth two times a day revealed 19…
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 · D2025-01-16 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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, record review and interview; the facility failed to ensure the MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) was coded to reflect the resident used a wander guard system (a medical alert device used to send an alert to staff or sound an alarm to prevent elopement for wandering residents)for 1 (Resident 6) of 11 residents that utilized a wander guard system. The facility census was 42. Findings are: Observation on 01/16/25 at 8:34 AM revealed Resident 6 seated in a recliner in their room. Resident 6 had a wander guard system bracelet present on the right wrist. Interview on 01/15/25 at 3:18 PM with the facility Social Worker confirmed that the wander guard was placed on Resident 6 on 12/19/24. The Social Worker further confirmed that Resident 6 was at risk for elopement. Record review of Resident 6's CCP (Comprehensive Care Plan, a individualized plan of care which identifies care needs for the resident) dated revised 12/19/24 revealed that Resident 6 had 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.
- Potential for harm · D2025-01-16 · 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 re-evaluate elopement risk and monitor the functioning of the wander guard system (a medical alert device used to send an alert to staff or sound an alarm to prevent elopement for wandering residents) for 1 (Resident 6) of 11 residents that utilized a wander guard system. The facility census was 42. Findings are: Record review of a facility policy entitled Elopement- Rehab/Skilled & Adult Day Services, dated 8/16/24 revealed the following: - During the stay: 1. Residents will be assessed and monitored in the following ways: a. The Elopement Risk UDA (assessment) will be completed for all residents with the quarterly, annual and significant change MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) assessments. The Elopement Risk UDA can also be triggered PRN (as needed) when elopement risk is identified (i.e. change in resident's medical condition…
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 · D2025-01-16 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure 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 record review and interview; the facility failed to ensure 1 Resident (#18) of 9 Resident's reviewed were free from significant medication errors. The facility staff identified a census of 42. Findings are: Record review of Resident 18's Face Sheet dated 01/15/2025 revealed a diagnosis of Epilepsy and an admission date of 12/08/2022. Record review of Resident 18's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) signed as completed on 11/04/2024 revealed the facility staff assessed the resident's use of anticonvulsant medication, used to treat Epilepsy. This MDS also assessed Resident's mental status and documented severe impairment. Record review of Resident 18's MAR (Medication Administration Record) revealed Phenytoin Oral Suspension 125 MG/ML (Milligram/Milliliter), give 8 ML by mouth two times a day, related to Epilepsy. Record review of the MAR revealed in November 2024, the medication was unavailable for a total of 16 doses. Further review revealed 3 doses were unavailable in December…
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 before2024-01-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — the official record, unedited, may be distressing
Licensure Reference Number 175 NAC 12.006.04C3a(6) Based on record review and interview, the facility failed to notify the practitioner of a change in condition for 1 (Resident 48) of 3 sampled residents. The facility census was 45. Findings are: Record Review of Resident 48's Electronic Health Record (EHR) revealed a progress note dated 11-11-2023 at 2:17 PM revealing Resident 48 did not go to lunch, was sleepy and Resident 48's skin was pale and cool to the touch. Record Review of Resident 48's EHR revealed a progress note dated 11-11-2023 at 2:34 PM revealing Resident 48's family representative was notified that there had been a change in Resident 48's condition and options were discussed about going to the emergency room or staying at the facility. Record Review of Resident 48's EHR revealed the absence of physician notification of a change in condition on 11-11-2023. Interview with the Director of Nursing (DON) on 01-10-2024 at 12:22 PM confirmed that there was no additional documents in Resident 48's EHR that the physician was notified of a change of condition.
- Potential for harm · Fcited before2023-01-09 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.17 Based on observation, record review and interview, the facility staff failed to wear and clean Personal Protective Equipment [PPE, protective clothing designed to protect the wearer from infection, including gowns, gloves, face masks and eye protection] in a manner to prevent the potential spread of COVID 19. This had the potential to affect all the residents that resided in the facility. The facility census was 46. Findings are: A. Interview on 01/03/23 at 8:30 AM, upon entrance to the facility, with the facility Administrator revealed that staff were expected to wear an N95 mask [a particulate filtering face mask] and eye protection [goggles or face shield] to cover the eyes in the facility because there were residents that were positive for COVID 19 that resided in the facility. Observation on 01/04/23 at 2:30 PM revealed a sign posted on the door between the COVID 19 positive unit and the other areas of the nursing home that read: You are exiting a Yellow Zone [an…
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 · E2023-01-09 · tag F0552 — patternEnsure 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(3) Based on record review and interview; the facility staff failed to give a choice for COVID-19 treatment upon a positive COVID-19 diagnosis for 3 (Resident 3, 27 and 37) of 3 sampled residents. The facility staff identified a census of 46. The findings are: A. Record review of an email dated 12/31/22 from ICAP (Infection Control Assessment Promotion Program) to the Administrator regarding recommendations for the COVID-19 outbreak with residents that occurred on 12/31/22 revealed a recommendation for COVID-19 therapeutic treatment for as many residents as eligible. B. Record review of Resident 3's progress note dated 12/31/22 revealed Resident 3 had a positive COVID-19 test. Review of Resident 3's MDS (Minimum Data Set; a federally mandated comprehensive assessment tool used for care planning) dated 12/5/22 revealed a BIMS (Brief Interview for Mental Status) score of 14. According to the MDS [NAME] a score of 13-15 indicates a resident is cognitively intact. On…
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 · E2023-01-09 · tag F0923 — patternHave enough outside ventilation via a window or mechanical ventilation, or both.
What the surveyor found here — an excerpt from the official record, may be distressing
Licensure Reference Number 175 NAC 12-007.04D Based on observation and interview, the facility failed to ensure a working ventilation system in 9 resident bathrooms (rooms 101, 109, 110, 115, 201, 205, 211, 212, and 301) of 44 occupied resident rooms. The facility census was 46 at the time of survey. Findings are: In an interview on 1/9/23 at 07:19 AM with the Manager of Ancillary Services (MAS) confirmed the facility was unable to find ventilation check log books. During observations of the facility environment on 1/9/23 beginning at 08:20 AM with the MAS revealed observations that the ventilation system in the resident bathrooms of rooms 101, 109, 110, 115, 201, 205, 211, 212, and 301 did not draw a 1 ply square of tissue to the surface of the ventilation covers in the resident bathrooms. In an interview on 1/9/23 at 08:40 AM with the MAS confirmed the ventilation check logs did not exist and that the ventilation in rooms 101, 109, 110, 115, 201, 205, 211, 212, and 301 were not functioning. It was also confirmed by the MAS that MAS had not been doing any bathroom ventilation…
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
No federal fines in the current CMS record.
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 | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 4 of 5 | 2.8 | +1.2 vs chain |
| Staffing | 4 of 5 | 4.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 2.8 | +0.2 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 | 100% | since 01/01/2019 |
| BROWN, GEORGE | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| 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 |
| MCCAUSLAND, MAUREEN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| MOLBERT, LAURIS | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| NORTH, ANDREW | Individual | CORPORATE DIRECTOR | — | since 05/30/2024 |
| SCHIEFFER, KEVIN | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| 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 |
| WENZEL, THOMAS | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| 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 |
| SCHEMA, NATHAN | Individual | CORPORATE OFFICER | — | since 01/01/2022 |
| THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 01/01/2019 |
| MORRISON, TONY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2019 |
| SHELL, STEPHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/30/2015 |
| TEMPELMEYER, ZACHARIAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2014 |
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.
This home reported $1.0M paid to related parties — landlords or management companies under common ownership — equal to about 18% 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.
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 285138. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-01-16, 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.