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

Staffing

Hours and turnover

RN hours / resident day

0.42

Registered nurse staffing

LPN hours / resident day

0.69

Licensed practical nurse staffing

Aide hours / resident day

1.99

Nurse aide staffing

Weekend hours

2.68

Weekend nurse staffing

RN turnover

75%

Annual RN turnover

Total nurse turnover

64%

Annual nurse turnover

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
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
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
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
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
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
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
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	9.1%	21.6% 12.5 pts better	16.7% 7.6 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	14.0%	20.4% 6.4 pts better	16.3% 2.3 pts better	Long Stay · 2024Q4-2025Q3
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
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
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
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
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
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
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
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
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

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