Cycle 1
Health 2025-02-10 · Fire 2025-02-10
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Callaway, NE
Callaway Good Life Center, Inc
2-star overall rating with 2-star inspections with $34,608 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
600 West Kimball Street, Callaway, NE
(308) 836-2267
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
38
Certified beds
Average residents
29
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.93
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,710
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9890
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.63
Baseline 6.59% · Performance 6.75% · Measure score 3.63 · Achievement 3.63 · Improvement 0
Total nurse turnover
6.94
Performance 35.29% · Measure score 6.94 · Achievement 6.94 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 4.06 hours · Performance 2.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 5.36% · Lower 95% interval 6.85% |
| Discharge to community | 43.94% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 37 · Observed rate 37.84% · Lower 95% interval 33.57% |
| Medicare spending per beneficiary | 0.71 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 23.26% |
8.2%
15.1 pts better
|
Numerator 10 · Denominator 43 |
| Staff flu vaccination coverage | 67.21% |
42%
25.2 pts better
|
Numerator 41 · Denominator 61 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
92.8%
3.4 pts better
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 86.2% · Q4 100.0% · 4Q avg 96.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
4.5%
3.5 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.4%
4.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.3%
3 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
19.5%
7.5 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 10.0% · Q3 14.8% · Q4 12.5% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.0% |
21.6%
8.6 pts better
|
16.7%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.5% · Q4 10.0% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.6% |
20.4%
4.2 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 18.2% · Q4 34.7% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
19.9%
6.8 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q3 38.5% · Q4 29.2% · 4Q avg 26.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
2.9%
1.1 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 7.7% · Q4 3.7% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
26.6%
7.7 pts better
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q3 23.4% · Q4 10.5% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.3%
4.3 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.6% |
80.5%
12.9 pts worse
|
81.7%
14.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 54.2% · 4Q avg 67.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.2% |
11.6%
7.4 pts better
|
12.0%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.2% · Observed 4.2% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
2.4%
2.4 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 44.0% |
75.9%
31.9 pts worse
|
79.7%
35.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 44.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.8% |
20.9%
10.1 pts better
|
23.9%
13.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 8.3% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-01-10 · Fire 2023-01-10
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-02-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-02-10
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-02-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-04-01
F · Potential for more than minimal harm
2024-02-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-02-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-02-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-02-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-01-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-01
F · Potential for more than minimal harm
2023-01-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-01-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-05-19
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-06-27
F · Potential for more than minimal harm
2025-02-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-02-10
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-02-10
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-01
D · Potential for more than minimal harm
2025-02-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-04-01
G · Actual harm
2024-03-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-27
G · Actual harm
2024-02-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-08
D · Potential for more than minimal harm
2024-02-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-04-01
D · Potential for more than minimal harm
2024-02-29
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-04-01
G · Actual harm
2023-01-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-10
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-01-10
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-10
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-13
E · Potential for more than minimal harm
2023-01-10
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-01-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-13
Penalties and ownership
What sits behind the stars
$17,148
2024-02-29
Fine
Fine · fine $17,148
Fine
$17,460
2024-02-29
Fine
Fine · fine $17,460
Fine
$0
2024-02-29
Payment Denial
Payment Denial · denial start 2024-04-03 · 2 days
2 day denial
Ownership
Keeney, Marcia
Corporate Officer · Individual
Ross, Mary
Corporate Officer · Individual
Sutherland, Todd
Corporate Director · Individual
Sutherland, Todd
W-2 Managing Employee · Individual
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