Cycle 1
Health 2025-01-28 · Fire 2025-01-28
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Kearney, NE
Good Samaritan Society - St Luke's Village
1-star overall rating with 1-star inspections with $11,483 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2201 East 32nd Street, Kearney, NE
(308) 237-3108
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Good Samaritan Society
Operator or chain grouping
Approved since
1996-06-01
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
0.85
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
89%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,369
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
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
0.61
Baseline 6.71% · Performance 7.65% · Measure score 0.61 · Achievement 0.61 · Improvement 0
Total nurse turnover
0
Baseline 60.53% · Performance 75.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.21
Baseline 3.44 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.78% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 45 · Observed rate 6.67% · Lower 95% interval 6.72% |
| Discharge to community | 47.04% |
50.57%
3.5 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 41.94% · Lower 95% interval 32.69% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.56% |
95.27%
0.3 pts better
|
Numerator 43 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 43.33% |
53.69%
10.4 pts worse
|
Numerator 13 · Denominator 30 |
| Discharge mobility score | 43.33% |
50.94%
7.6 pts worse
|
Numerator 13 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.22% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 45 · Adjusted rate 2.13% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 47 |
| Staff flu vaccination coverage | 79.45% |
42%
37.5 pts better
|
Numerator 58 · Denominator 73 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 15 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10.34% |
25.2%
14.9 pts worse
|
Numerator 3 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
92.8%
5.2 pts worse
|
93.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 97.0% · Q3 89.5% · Q4 67.6% · 4Q avg 87.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
96.1%
4.4 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.3% |
4.5%
2.8 pts worse
|
3.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 13.2% · Q4 8.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
4.4%
3.6 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 14.4% |
5.3%
9.1 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 13.8% · Q3 24.2% · Q4 13.8% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
19.5%
0.6 pts better
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 13.3% · Q3 26.5% · Q4 16.7% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.3% |
21.6%
6.7 pts worse
|
16.7%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 31.8% · Q3 25.0% · Q4 29.2% · 4Q avg 28.3% · 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 | 37.0% |
20.4%
16.6 pts worse
|
16.3%
20.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
19.9%
1.8 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 27.3% · Q3 4.3% · Q4 19.2% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.6%
0.1 pts better
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 3.3% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.9%
0.1 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 2.7% · Q4 6.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
26.6%
2.6 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 32.6% · Q3 23.8% · Q4 30.5% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
4.3%
1.2 pts worse
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 8.9% · Q3 2.2% · Q4 1.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.3% |
80.5%
14.2 pts worse
|
81.7%
15.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 72.3% · Q3 68.8% · Q4 57.1% · 4Q avg 66.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 30.6% |
11.6%
19 pts worse
|
12.0%
18.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 27.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
75.9%
4.5 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| 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 30.2% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-05 · Fire 2024-02-05
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-19 · Fire 2022-12-19
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-01-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-01-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-01-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-03-12
E · Potential for more than minimal harm
2025-01-28
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-03-12
F · Potential for more than minimal harm
2024-02-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-15
F · Potential for more than minimal harm
2024-02-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-15
F · Potential for more than minimal harm
2022-12-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-19
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 2023-01-20
Inspection history
Recent health citations
J · Immediate jeopardy
2025-04-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
J · Immediate jeopardy
2025-04-16
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 2025-05-09
F · Potential for more than minimal harm
2025-01-28
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 2025-03-12
F · Potential for more than minimal harm
2025-01-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-12
F · Potential for more than minimal harm
2025-01-28
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-28
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 2025-03-12
D · Potential for more than minimal harm
2025-01-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-28
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 2025-03-12
D · Potential for more than minimal harm
2025-01-28
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-28
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 2025-03-12
D · Potential for more than minimal harm
2025-01-28
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-03-12
D · Potential for more than minimal harm
2025-01-28
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 2025-03-12
D · Potential for more than minimal harm
2025-01-28
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 2025-03-12
F · Potential for more than minimal harm
2024-02-05
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 2024-03-15
E · Potential for more than minimal harm
2024-02-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-05
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 2024-03-15
C · Minimal harm
2024-02-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-03-15
F · Potential for more than minimal harm
2022-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-20
E · Potential for more than minimal harm
2022-12-19
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 2023-01-20
D · Potential for more than minimal harm
2022-12-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-19
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 2023-01-20
D · Potential for more than minimal harm
2022-12-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-20
D · Potential for more than minimal harm
2022-12-19
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 2023-01-20
Penalties and ownership
What sits behind the stars
$11,483
2025-04-16
Fine
Fine · fine $11,483
Fine
Ownership
Sanford
5% Or Greater Direct Ownership Interest · Organization
The Evangelical Lutheran Good Samaritan Society
5% Or Greater Indirect Ownership Interest · Organization
Cain, James
Corporate Director · Individual
Dykhouse, Dana
Corporate Director · Individual
Engbrecht, Wesley
Corporate Director · Individual
Fluit, Joel
Corporate Officer · Individual
Foster, James
W-2 Managing Employee · Individual
Gassen, William
Corporate Director · Individual
Gassen, William
Corporate Officer · Individual
Gulsvig, Neil
Corporate Director · Individual
Herseth Sandlin, Stephanie
Corporate Director · Individual
Lundeen, Mark
Corporate Director · Individual
Middleton, Aimee
Corporate Officer · Individual
Molbert, Lauris
Corporate Director · Individual
Morrison, Tony
W-2 Managing Employee · Individual
Murray, Chadd
Contracted Managing Employee · Individual
North, Andrew
Corporate Director · Individual
Olson, Nicholas
Corporate Officer · Individual
Rogers, Michael
Corporate Officer · Individual
Schema, Nathan
Corporate Officer · Individual
Shulkin, David
Corporate Director · Individual
Teiken, Brent
Corporate Director · Individual
Ventling-Herrmann, Marnie
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Mother Hull Home
Kearney, NE
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Good Samaritan Society - St John's
Kearney, NE
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Mt Carmel Home - Keens Memorial
Kearney, NE
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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