Cycle 1
Health 2025-12-11 · Fire 2025-12-11
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Ellis, KS
Good Samaritan Society - Ellis
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1101 Spruce Street, Ellis, KS
(785) 726-3101
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
38
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1994-12-01
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
0.69
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,396
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0040
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
5.64
Baseline 47.62% · Performance 40.62% · Measure score 5.64 · Achievement 5.64 · Improvement 2.57
Adjusted total nurse staffing
4.35
Baseline 4.05 hours · Performance 4.32 hours · Measure score 4.35 · Achievement 4.35 · Improvement 1.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 6.34% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.15% |
95.27%
0.9 pts better
|
Numerator 25 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 7.69% |
2.29%
5.4 pts worse
|
Numerator 2 · Denominator 26 · Adjusted rate 6.13% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 79.37% |
42%
37.4 pts better
|
Numerator 50 · Denominator 63 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.8 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
91.8%
4.7 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 97.2% · Q3 97.1% · Q4 94.3% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
95.5%
1.9 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
4.4%
1.3 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 5.6% · Q3 2.9% · Q4 2.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 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 | 9.9% |
5.0%
4.9 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.4% · Q3 12.9% · Q4 9.4% · 4Q avg 9.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.4% |
23.2%
5.2 pts worse
|
19.6%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 31.4% · Q3 25.8% · Q4 23.5% · 4Q avg 28.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.1% |
19.8%
3.3 pts worse
|
16.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 23.1% · Q3 19.2% · Q4 16.0% · 4Q avg 23.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 16.4% |
18.4%
2 pts better
|
16.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 17.4% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
18.8%
1.8 pts worse
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 26.5% · Q3 6.5% · Q4 30.3% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.5% |
1.8%
1.7 pts worse
|
1.0%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 6.7% · Q3 0.0% · Q4 3.2% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.1% |
3.1%
2 pts worse
|
1.7%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 11.1% · Q3 2.9% · Q4 3.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.1% |
23.2%
8.9 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 34.8% · Q3 32.6% · Q4 34.3% · 4Q avg 32.1% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
4.6%
0.3 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 7.3% · Q3 3.0% · Q4 2.8% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.0% |
75.6%
12.6 pts worse
|
81.7%
18.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 63.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
11.7%
1.5 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 9.4% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
23.0%
3.4 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 21.9% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-11 · Fire 2024-03-11
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-29 · Fire 2022-08-29
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-24
F · Potential for more than minimal harm
2025-12-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-02-23
F · Potential for more than minimal harm
2025-12-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-23
E · Potential for more than minimal harm
2025-12-11
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 2026-01-30
E · Potential for more than minimal harm
2025-12-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-30
E · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-30
E · Potential for more than minimal harm
2025-12-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-30
E · Potential for more than minimal harm
2025-12-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-01-30
E · Potential for more than minimal harm
2024-03-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-17
E · Potential for more than minimal harm
2024-03-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-03-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-24
F · Potential for more than minimal harm
2022-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-14
F · Potential for more than minimal harm
2022-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-29
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-14
E · Potential for more than minimal harm
2022-08-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-14
Inspection history
Recent health citations
G · Actual harm
2026-01-06
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 2025-12-22
D · Potential for more than minimal harm
2025-12-11
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 2026-01-23
D · Potential for more than minimal harm
2025-12-11
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 2026-01-23
D · Potential for more than minimal harm
2025-12-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-23
F · Potential for more than minimal harm
2024-03-11
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 2024-04-05
F · Potential for more than minimal harm
2024-03-11
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-05
F · Potential for more than minimal harm
2024-03-11
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 2024-04-05
E · Potential for more than minimal harm
2024-03-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-05
E · Potential for more than minimal harm
2024-03-11
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 2024-04-05
D · Potential for more than minimal harm
2024-03-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-04-05
F · Potential for more than minimal harm
2022-08-29
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 2022-09-30
E · Potential for more than minimal harm
2022-08-29
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
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 2022-09-30
D · Potential for more than minimal harm
2022-08-29
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 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
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 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-09-30
D · Potential for more than minimal harm
2022-08-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-09-30
Penalties and ownership
What sits behind the stars
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
Brown, George
Corporate Director · Individual
De Andrade, Paulo
Operational/Managerial Control · 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
Haselhorst, Dacia
Operational/Managerial Control · 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
The Evangelical Lutheran Good Samaritan Society
Operational/Managerial Control · Organization
Ventling-Herrmann, Marnie
Corporate Director · Individual
Wenzel, Thomas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Hays
Hays, KS
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Via Christi Village Hays Ks LLC
Hays, KS
1-star overall rating with 1-star inspections with $15,593 in total fines with 20 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Trego Co-Lemke Memorial Hospital Ltcu
Wakeeney, KS
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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