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
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing
LPN hours / resident day
0.45
Licensed practical nurse staffing
Aide hours / resident day
2.94
Nurse aide staffing
Weekend hours
3.48
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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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