Cycle 1
Health 2025-12-30 · Fire 2025-12-30
12 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Grand Island, NE
Good Samaritan Society - Grand Island Village
1-star overall rating with 2-star inspections with $10,033 in total fines with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4061 & 4055 Timberline Street & 2912 Good Samarita, Grand Island, NE
(308) 384-3535
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
67
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
2010-09-01
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
0.55
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.94
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.28
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,287
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.86% · Performance 23.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.49
Baseline 6.08% · Performance 6.79% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Total nurse turnover
0
Baseline 67.35% · Performance 67.24% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.72
Baseline 3.54 hours · Performance 3.57 hours · Measure score 1.72 · Achievement 1.72 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.49% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 16.07% · Lower 95% interval 8.99% |
| Discharge to community | 32.35% |
50.57%
18.2 pts worse
|
Worse than the National Rate · Eligible stays 97 · Observed rate 24.74% · Lower 95% interval 25.3% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 59.72% |
95.27%
35.5 pts worse
|
Numerator 43 · Denominator 72 |
| Falls with major injury | 2.78% |
0.77%
2 pts worse
|
Numerator 2 · Denominator 72 |
| Discharge self-care score | 28.57% |
53.69%
25.1 pts worse
|
Numerator 14 · Denominator 49 |
| Discharge mobility score | 32.65% |
50.94%
18.3 pts worse
|
Numerator 16 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 2.78% |
2.29%
0.5 pts worse
|
Numerator 2 · Denominator 72 · Adjusted rate 3.11% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 6.15% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 82 |
| Staff flu vaccination coverage | 57.92% |
42%
15.9 pts better
|
Numerator 106 · Denominator 183 |
| Discharge function score | 36.73% |
56.45%
19.7 pts worse
|
Numerator 18 · Denominator 49 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 24.39% |
25.2%
0.8 pts worse
|
Numerator 10 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.8 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 3.0 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.0% |
92.8%
6.8 pts worse
|
93.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 68.6% · Q2 90.2% · Q3 94.7% · Q4 88.4% · 4Q avg 86.0% |
| 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 | 12.1% |
4.5%
7.6 pts worse
|
3.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.2% · Q3 13.2% · Q4 11.6% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
4.4%
2.2 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.9% · Q4 2.8% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.3%
0.2 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 11.4% · Q3 3.1% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
19.5%
7.4 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 5.3% · Q3 8.8% · Q4 15.4% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.2% |
21.6%
5.4 pts better
|
16.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 13.8% · Q3 21.4% · Q4 12.9% · 4Q avg 16.2% · 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 | 35.4% |
20.4%
15 pts worse
|
16.3%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.4% |
19.9%
5.5 pts worse
|
14.9%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.7% · Q2 23.7% · Q3 12.5% · Q4 17.9% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.6%
1.1 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.9%
1.6 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.1% |
26.6%
12.5 pts worse
|
19.8%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.8% · Q2 41.6% · Q3 37.6% · Q4 32.0% · 4Q avg 39.1% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
4.3%
3.9 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 8.7% · Q3 8.4% · Q4 6.6% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.2% |
80.5%
12.3 pts worse
|
81.7%
13.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.9% · Q2 64.4% · Q3 86.3% · Q4 78.3% · 4Q avg 68.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.4% |
11.6%
10.8 pts worse
|
12.0%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.4% · Observed 20.5% · Expected 10.2% · 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 · Q1 6.5% · Q2 8.7% · Q3 2.6% · Q4 0.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
75.9%
4.1 pts better
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.6% |
20.9%
9.7 pts worse
|
23.9%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 27.4% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2024-09-26
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-11-16 · Fire 2023-11-16
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-12-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-12-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2026-02-06
F · Potential for more than minimal harm
2024-09-26
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-26
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-26
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-09-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-26
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 2024-10-21
E · Potential for more than minimal harm
2024-09-26
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-10-21
F · Potential for more than minimal harm
2023-11-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-12-31
F · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-31
F · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-31
F · Potential for more than minimal harm
2023-11-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-12-31
E · Potential for more than minimal harm
2023-11-16
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2023-12-31
E · Potential for more than minimal harm
2023-11-16
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 2023-12-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-30
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-30
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-30
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 2026-02-06
D · Potential for more than minimal harm
2025-12-30
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-30
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 2026-02-06
D · Potential for more than minimal harm
2025-12-30
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 2026-02-06
D · Potential for more than minimal harm
2025-12-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-05-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-05-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-09
D · Potential for more than minimal harm
2025-03-27
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 2025-05-09
G · Actual harm
2024-09-26
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 2024-10-21
F · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-26
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 2024-10-21
D · Potential for more than minimal harm
2024-09-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
F · Potential for more than minimal harm
2023-11-16
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 2023-12-22
F · Potential for more than minimal harm
2023-11-16
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 2023-12-22
E · Potential for more than minimal harm
2023-11-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-22
E · Potential for more than minimal harm
2023-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-22
Penalties and ownership
What sits behind the stars
$10,033
2024-09-03
Fine
Fine · fine $10,033
Fine
Ownership
Cain, James
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
Husen, Steven
Contracted Managing Employee · Individual
Lundeen, Mark
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
W-2 Managing Employee · Individual
Muir, Danielle
W-2 Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Rogers, Michael
Corporate Officer · Individual
Sanford
5% Or Greater Direct Ownership Interest · Organization
Schema, Nathan
Corporate Officer · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Direct Ownership Interest · Organization
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Tiffany Square
Grand Island, NE
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Cedars at Broadwell
Grand Island, NE
1-star overall rating with 1-star inspections with $16,801 in total fines with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
CHI Health St. Francis
Grand Island, NE
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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