Cycle 1
Health 2024-10-03 · Fire 2024-10-03
3 health deficiencies
Top issue: Infection Control (1 deficiency)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Auburn, NE
Good Samaritan Society - Auburn
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1322 U Street, Auburn, NE
(402) 274-4954
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1991-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
89 facilities
Chain averages 3 overall / 3 health / 4 staffing / 3 quality stars
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
0.58
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,125
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
51.60
Composite VBP score used to determine payment impact.
Payment multiplier
1.0060
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.39
Baseline 18.34% · Performance 19.40% · Measure score 4.39 · Achievement 4.39 · Improvement 0
Healthcare-associated infections
5.04
Baseline 5.33% · Performance 6.33% · Measure score 5.04 · Achievement 5.04 · Improvement 0
Total nurse turnover
8.66
Baseline 26.79% · Performance 28.30% · Measure score 8.66 · Achievement 8.66 · Improvement 0
Adjusted total nurse staffing
2.55
Baseline 3.94 hours · Performance 3.80 hours · Measure score 2.55 · Achievement 2.55 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.69% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 5.71% · Lower 95% interval 6.44% |
| Discharge to community | 38.76% |
50.57%
11.8 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 32% · Lower 95% interval 30.59% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 32 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 12 · Denominator 30 |
| Discharge mobility score | 40% |
50.94%
10.9 pts worse
|
Numerator 12 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 5.71% |
| Healthcare-associated infections requiring hospitalization | 6.33% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 2.7% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 78.74% |
42%
36.7 pts better
|
Numerator 100 · Denominator 127 |
| Discharge function score | 56.67% |
56.45%
0.2 pts better
|
Numerator 17 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · 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 | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.3 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.0
1.6 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 2.7 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
92.8%
4.8 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.1% · Q3 98.0% · Q4 96.3% · 4Q avg 97.6% |
| 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 | 6.6% |
4.5%
2.1 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.7% · Q3 8.0% · Q4 5.6% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.4%
1.9 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
5.3%
3.6 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.5% · Q3 2.3% · Q4 0.0% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
19.5%
1.9 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 19.0% · Q3 15.6% · Q4 14.6% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
21.6%
13 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.4% · Q3 10.0% · Q4 13.6% · 4Q avg 8.6% · 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 | 19.7% |
20.4%
0.7 pts better
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q4 18.7% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
19.9%
5.2 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 31.0% · Q3 14.0% · Q4 34.0% · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.6%
1.2 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
2.9%
0.5 pts better
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 2.0% · Q3 2.1% · Q4 1.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.5% |
26.6%
0.1 pts better
|
19.8%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 31.4% · Q3 26.5% · Q4 23.6% · 4Q avg 26.5% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
4.3%
0.3 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.3% · Q3 5.7% · Q4 6.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
80.5%
6.2 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 87.8% · Q3 88.6% · Q4 95.8% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.2% |
11.6%
6.6 pts worse
|
12.0%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 16.0% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.4% |
2.4%
3 pts worse
|
1.6%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.1% |
75.9%
37.8 pts worse
|
79.7%
41.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.6% |
20.9%
10.3 pts better
|
23.9%
13.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 8.0% · Expected 18.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-02 · Fire 2023-08-02
0 health deficiencies
No concentrated health issue counts in this cycle.
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-03-08 · Fire 2022-03-08
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-03
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2024-11-01
F · Potential for more than minimal harm
2023-08-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-02
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-02
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-08-02
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-08-31
F · Potential for more than minimal harm
2022-03-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-27
F · Potential for more than minimal harm
2022-03-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-03-27
F · Potential for more than minimal harm
2022-03-08
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-03-27
F · Potential for more than minimal harm
2022-03-08
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 2022-03-27
E · Potential for more than minimal harm
2022-03-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-27
E · Potential for more than minimal harm
2022-03-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-03
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 2024-10-14
E · Potential for more than minimal harm
2024-10-03
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-10-14
D · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-14
E · Potential for more than minimal harm
2022-03-08
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-03-27
E · Potential for more than minimal harm
2022-03-08
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 2022-03-27
D · Potential for more than minimal harm
2022-03-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-03-27
D · Potential for more than minimal harm
2022-03-08
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 2022-03-27
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Brown, George
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Ensz, Gary
Operational/Managerial Control · Individual
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Greene, Cassandra
Operational/Managerial Control · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Mccausland, Maureen
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
Operational/Managerial Control · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Schieffer, Kevin
Corporate Director · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
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