Cycle 1
Health 2025-09-16 · Fire 2025-09-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Alma, NE
Good Samaritan Society - Colonial Villa
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
719 North Brown Street, Alma, NE
(308) 928-2128
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
53
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1996-05-01
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
0.65
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.33
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.44
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
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,915
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.66
Baseline 90.48% · Performance 69.77% · Measure score 2.66 · Achievement 0 · Improvement 2.66
Adjusted total nurse staffing
3.02
Baseline 3.80 hours · Performance 3.94 hours · Measure score 3.02 · Achievement 3.02 · Improvement 0.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 6.8% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 2.04% |
8.2%
6.2 pts worse
|
Numerator 1 · Denominator 49 |
| Staff flu vaccination coverage | 93.88% |
42%
51.9 pts better
|
Numerator 46 · Denominator 49 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.7% |
92.8%
12.1 pts worse
|
93.4%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.3% · Q2 83.9% · Q3 78.6% · Q4 80.8% · 4Q avg 80.7% |
| 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 | 8.8% |
4.5%
4.3 pts worse
|
3.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 9.7% · Q3 10.7% · Q4 0.0% · 4Q avg 8.8% · 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 | 5.9% |
5.3%
0.6 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 18.5% · Q3 3.8% · Q4 0.0% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.1% |
19.5%
4.4 pts better
|
19.6%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 13.8% · Q3 22.2% · Q4 16.0% · 4Q avg 15.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.4% |
21.6%
6.8 pts worse
|
16.7%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 25.0% · Q4 30.0% · 4Q avg 28.4% · 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 | 12.9% |
20.4%
7.5 pts better
|
16.3%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
19.9%
9.6 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 7.7% · Q3 7.7% · Q4 8.3% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.6%
0.3 pts better
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.9%
2.9 pts better
|
1.7%
1.7 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 long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
26.6%
3.7 pts better
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.3% · Q2 19.3% · Q3 14.0% · Q4 30.4% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
4.3%
3.6 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 5.5% · Q3 8.5% · Q4 6.9% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.3% |
80.5%
37.2 pts worse
|
81.7%
38.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 43.3% |
| 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 · 4Q avg 5.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-23 · Fire 2024-07-23
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-06-21 · Fire 2023-06-21
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
9 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-10-27
F · Potential for more than minimal harm
2025-09-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-27
F · Potential for more than minimal harm
2025-09-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-27
F · Potential for more than minimal harm
2025-09-16
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-27
E · Potential for more than minimal harm
2025-09-16
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 2025-10-27
F · Potential for more than minimal harm
2024-07-23
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-23
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-23
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-09-04
F · Potential for more than minimal harm
2023-06-21
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-21
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-07-28
F · Potential for more than minimal harm
2023-06-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-21
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-07-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-27
D · Potential for more than minimal harm
2025-09-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-27
D · Potential for more than minimal harm
2024-07-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-23
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-23
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 2024-09-04
D · Potential for more than minimal harm
2024-07-23
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 2024-09-04
E · Potential for more than minimal harm
2023-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-07-28
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
Fluit, Joel
Corporate Officer · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Johnson, Tamara
Operational/Managerial Control · Individual
Lundeen, Mark
Corporate Director · Individual
Mannis, Anna
Operational/Managerial Control · 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
Nearby options
Other facilities in reach
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Franklin, NE
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Christian Homes Health Care Center
Holdrege, NE
1-star overall rating with 2-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Holdrege Memorial Homes, Inc
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2-star overall rating with 2-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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