Blair, NE

Good Shepherd Lutheran Home

1-star overall rating with 2-star inspections with 11 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

2242 Wright Street, Blair, NE

(402) 426-4663

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1994-06-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.42

Registered nurse staffing · state 0.71 · national 0.68

LPN hours / resident day

0.69

Licensed practical nurse staffing · state 0.71 · national 0.87

Aide hours / resident day

1.99

Nurse aide staffing · state 2.76 · national 2.35

Total nurse hours

3.11

All reported nurse hours · state 4.17 · national 3.89

Licensed hours

1.12

RN + LPN hours · state 1.41 · national 1.54

Weekend hours

2.68

Weekend nurse staffing · state 3.61 · national 3.43

Weekend RN hours

0.46

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.44

CMS adjusted RN staffing hours

Adjusted total hours

3.26

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

75%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

64%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,487

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

20.22

Composite VBP score used to determine payment impact.

Payment multiplier

0.9823

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

1.71

Performance 7.32% · Measure score 1.71 · Achievement 1.71 · This facility did not have sufficient data to calculate a baseline period measure result.

Total nurse turnover

2.58

Baseline 62.34% · Performance 53.12% · Measure score 2.58 · Achievement 2.58 · Improvement 1.96

Adjusted total nurse staffing

1.77

Baseline 3.41 hours · Performance 3.58 hours · Measure score 1.77 · Achievement 1.77 · Improvement 0.24

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.85%	10.72% 0.9 pts better	No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 6.48%
Discharge to community	45.13%	50.57% 5.4 pts worse	No Different than the National Rate · Eligible stays 34 · Observed rate 41.18% · Lower 95% interval 33.24%
Medicare spending per beneficiary	1.07	1.02 0.1 pts worse
Drug regimen review with follow-up	96.15%	95.27% 0.9 pts better	Numerator 25 · Denominator 26
Falls with major injury	3.85%	0.77% 3.1 pts worse	Numerator 1 · Denominator 26
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 26 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.32%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.78%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 69
Staff flu vaccination coverage	12.94%	42% 29.1 pts worse	Numerator 11 · Denominator 85
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 16 · 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	2.7	1.8 0.9 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.6 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	5.8	2.0 3.8 pts worse	1.8 4 pts worse	Long Stay · 20240701-20250630 · Adjusted 5.8 · Observed 5.5 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	93.3%	92.8% 0.5 pts better	93.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 96.8% · Q3 93.7% · Q4 91.2% · 4Q avg 93.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	80.6%	96.1% 15.5 pts worse	95.5% 14.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 80.6%
Percentage of long-stay residents experiencing one or more falls with major injury	4.3%	4.5% 0.2 pts better	3.3% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 4.8% · Q4 5.9% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.1%	4.4% 2.7 pts worse	11.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 8.5% · Q3 5.5% · Q4 5.0% · 4Q avg 7.1%
Percentage of long-stay residents who lose too much weight	3.6%	5.3% 1.7 pts better	5.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.5% · Q3 5.4% · Q4 0.0% · 4Q avg 3.6%
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 13.0% · Q2 10.5% · Q3 11.9% · Q4 13.1% · 4Q avg 12.1%
Percentage of long-stay residents who received an antipsychotic medication	9.1%	21.6% 12.5 pts better	16.7% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 9.1% · Q3 9.8% · Q4 6.2% · 4Q avg 9.1% · 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	14.0%	20.4% 6.4 pts better	16.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 44.1% · Q2 4.7% · Q3 3.8% · Q4 3.5% · 4Q avg 14.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	8.0%	19.9% 11.9 pts better	14.9% 6.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 8.9% · Q3 5.4% · Q4 3.4% · 4Q avg 8.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.1%	1.6% 0.5 pts worse	1.0% 1.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.2% · Q3 1.6% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.4%	2.9% 1.5 pts worse	1.7% 2.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.9% · Q3 1.7% · Q4 1.5% · 4Q avg 4.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	32.1%	26.6% 5.5 pts worse	19.8% 12.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 31.5% · Q3 32.0% · Q4 25.9% · 4Q avg 32.1%
Percentage of long-stay residents with pressure ulcers	5.0%	4.3% 0.7 pts worse	5.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.0% · Q3 6.6% · Q4 4.5% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	64.8%	80.5% 15.7 pts worse	81.7% 16.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q3 57.1% · Q4 61.9% · 4Q avg 64.8%
Percentage of short-stay residents who had an outpatient emergency department visit	9.3%	11.6% 2.3 pts better	12.0% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 10.7% · Expected 12.9% · 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 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.3%	20.9% 0.4 pts worse	23.9% 2.6 pts better	Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 21.4% · Expected 24.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-01 · Fire 2025-05-01

11 health deficiencies

Top issue: Environmental (2 deficiencies)

11 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2024-04-23 · Fire 2024-04-23

3 health deficiencies

Top issue: Infection Control (2 deficiencies)

10 fire-safety deficiencies

Top issue: Miscellaneous (4 deficiencies)

Cycle 3 Health 2023-05-03 · Fire 2023-05-03

9 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-01

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-01

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 2025-05-22

F · Potential for more than minimal harm 2025-05-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-01

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-22

E · Potential for more than minimal harm 2025-05-01

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-05-22

E · Potential for more than minimal harm 2025-05-01

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 2025-05-22

E · Potential for more than minimal harm 2025-05-01

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-05-22

E · Potential for more than minimal harm 2025-05-01

K922 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use and maintenance of medical gas equipment.

Corrected 2025-05-22

F · Potential for more than minimal harm 2024-04-23

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 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-05-15

F · Potential for more than minimal harm 2024-04-23

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-05-15

E · Potential for more than minimal harm 2024-04-23

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-05-15

F · Potential for more than minimal harm 2023-05-03

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-06-16

F · Potential for more than minimal harm 2023-05-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-06-16

F · Potential for more than minimal harm 2023-05-03

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-06-16

F · Potential for more than minimal harm 2023-05-03

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-06-16

F · Potential for more than minimal harm 2023-05-03

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-06-16

E · Potential for more than minimal harm 2023-05-03

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-06-16

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-05-01

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 2025-05-22

F · Potential for more than minimal harm 2025-05-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-05-22

F · Potential for more than minimal harm 2025-05-01

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2025-05-22

E · Potential for more than minimal harm 2025-05-01

F923 · Environmental Deficiencies

Health

Have enough outside ventilation via a window or mechanical ventilation, or both.

Corrected 2025-05-22

D · Potential for more than minimal harm 2025-05-01

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 2025-05-22

D · Potential for more than minimal harm 2025-05-01

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-05-22

D · Potential for more than minimal harm 2025-05-01

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 2025-05-22

D · Potential for more than minimal harm 2025-05-01

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-05-22

D · Potential for more than minimal harm 2025-05-01

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 2025-05-22

D · Potential for more than minimal harm 2025-05-01

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-05-22

D · Potential for more than minimal harm 2025-05-01

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-05-22

F · Potential for more than minimal harm 2024-04-23

F882 · Infection Control Deficiencies

Health

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-23

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-04

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 2024-04-11

E · Potential for more than minimal harm 2023-05-03

F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Corrected 2023-06-16

E · Potential for more than minimal harm 2023-05-03

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

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 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-06-16

D · Potential for more than minimal harm 2023-05-03

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 2023-06-16

D · Potential for more than minimal harm 2023-05-03