Cycle 1
Health 2025-02-24 · Fire 2025-02-24
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hays, KS
Good Samaritan Society - Hays
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2700 Canal Blvd, Hays, KS
(785) 625-7331
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
43
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
0.77
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.47
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.52
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.47
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
4.21
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,296
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
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
2.23
Baseline 55.56% · Performance 54.55% · Measure score 2.23 · Achievement 2.23 · Improvement 0
Adjusted total nurse staffing
5.87
Baseline 4.31 hours · Performance 4.75 hours · Measure score 5.87 · Achievement 5.87 · Improvement 2.49
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.28% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 13.24% · Lower 95% interval 7.19% |
| Discharge to community | 46.85% |
50.57%
3.7 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 42.86% · Lower 95% interval 33.53% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 11 · 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 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0.97% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 103 |
| Staff flu vaccination coverage | 53.66% |
42%
11.7 pts better
|
Numerator 88 · Denominator 164 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · 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 1 · 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 |
|---|---|---|---|---|
| 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 1.4 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
2.2
0.8 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.8% |
95.5%
2.3 pts better
|
95.5%
2.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
4.4%
0.9 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.1% · Q3 4.8% · Q4 2.4% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.6% |
5.6%
1 pts worse
|
11.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 11.8% · Q3 2.7% · Q4 8.1% · 4Q avg 6.6% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.0%
3.9 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 0.0% · Q3 18.8% · Q4 10.8% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
23.2%
5.6 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 30.8% · Q3 29.7% · Q4 24.3% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
19.8%
0.9 pts better
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 12.5% · Q3 23.3% · Q4 22.2% · 4Q avg 18.9% · 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 | 15.2% |
18.4%
3.2 pts better
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 19.2% · Q4 10.5% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.3% |
18.8%
10.5 pts worse
|
14.9%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 15.8% · Q3 25.7% · Q4 22.9% · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
3.1%
1.3 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 2.5% · Q3 2.7% · Q4 2.4% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.5% |
23.2%
10.3 pts worse
|
19.8%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.4% · Q2 41.8% · Q3 32.6% · Q4 17.3% · 4Q avg 33.5% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.6%
1 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 2.8% · Q3 2.0% · Q4 4.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
75.6%
13 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 88.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-15 · Fire 2023-05-15
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-10-21 · Fire 2021-10-21
12 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-08
E · Potential for more than minimal harm
2025-02-24
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 2025-05-08
E · Potential for more than minimal harm
2025-02-24
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 2025-05-08
E · Potential for more than minimal harm
2025-02-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-08
E · Potential for more than minimal harm
2025-02-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-08
E · Potential for more than minimal harm
2025-02-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-08
E · Potential for more than minimal harm
2025-02-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-08
E · Potential for more than minimal harm
2023-05-15
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 2023-02-15
E · Potential for more than minimal harm
2023-05-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-05-15
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 2023-02-15
D · Potential for more than minimal harm
2023-05-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-05-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-15
F · Potential for more than minimal harm
2021-10-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-03
F · Potential for more than minimal harm
2021-10-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-03
F · Potential for more than minimal harm
2021-10-21
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 2021-12-03
F · Potential for more than minimal harm
2021-10-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-03
E · Potential for more than minimal harm
2021-10-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-24
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-24
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 2025-03-28
D · Potential for more than minimal harm
2025-02-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-24
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-03-28
E · Potential for more than minimal harm
2023-07-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-23
E · Potential for more than minimal harm
2023-07-12
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 2023-08-23
E · Potential for more than minimal harm
2023-05-15
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 2023-06-28
D · Potential for more than minimal harm
2023-05-15
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 2023-06-28
D · Potential for more than minimal harm
2023-05-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-28
D · Potential for more than minimal harm
2023-05-15
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 2023-06-28
D · Potential for more than minimal harm
2023-05-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-28
C · Minimal harm
2023-05-15
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-06-28
F · Potential for more than minimal harm
2021-10-21
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 2021-11-19
E · Potential for more than minimal harm
2021-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-10-21
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 2021-11-19
D · Potential for more than minimal harm
2021-10-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-10-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-10-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-10-21
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 2021-11-19
D · Potential for more than minimal harm
2021-10-21
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 2021-11-19
D · Potential for more than minimal harm
2021-10-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-10-21
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 2021-11-19
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
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
Gillespie, Jose
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
Sandgren, Deeandra
Operational/Managerial Control · Individual
Sanford
Operational/Managerial Control · Organization
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
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
#2
Good Samaritan Society - Ellis
Ellis, KS
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Redbud Village
Plainville, KS
0-star overall rating with 0-star inspections with 8 fire-safety deficiencies in the latest cycle
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