Good Samaritan Society - St Luke's Village
2201 East 32nd Street, Kearney, NE 68847 · Buffalo County · 60 certified beds · avg 40 residents/day · certified since Jun 1, 1996
Part of chain: GOOD SAMARITAN SOCIETY (92 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Apr 16, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 9, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 16, 2025 · F-0755 · triggered by a complaint
The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Why it matters: Weak pharmacy services lead to medication mistakes, delays, and missed drug interactions that can seriously harm residents.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 9, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (28)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 14, 2026 | F · Potential for harm, facility-wide | The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 14, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Apr 16, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 16, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 28, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Jan 28, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 28, 2025 | F · Potential for harm, facility-wide | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jan 28, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 5, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 5, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 5, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 5, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Feb 5, 2024 | C · Minimal risk, facility-wide | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 5 | 0 | F |
| 2025 | 14 | 2 | J ▲ |
| 2026 | 9 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $11,654.
| Date | Type | Amount / length |
|---|---|---|
| Apr 16, 2025 | Fine | $11,654 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.61 | 4.33 | 3.95 | bottom 21% in Nebraska; bottom 42% in the U.S. |
| Registered Nurse hours | 0.71 | 0.72 | 0.69 | top 44% in Nebraska; top 35% in the U.S. |
| Weekend total nurse staffing | 3.11 | 3.79 | 3.50 | bottom 19% in Nebraska; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.47 | 0.48 | top 47% in Nebraska; top 45% in the U.S. |
| Total nursing staff turnover (%) | 64.7 | 48.7 | 45.8 | bottom 19% in Nebraska; bottom 10% in the U.S. |
| RN turnover (%) | 66.7 | 44.1 | 42.9 | bottom 23% in Nebraska; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.52, RN 0.69, weekend 3.04. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 1/5 · short-stay residents: 2/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sanford | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/2019 |
| The Evangelical Lutheran Good Samaritan Society | Organization | 5% or Greater Indirect Ownership Interest | 100% | 01/01/2019 |
| Cain, James | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Dykhouse, Dana | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Engbrecht, Wesley | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Fluit, Joel | Individual | Corporate Officer | NOT APPLICABLE | 10/01/2022 |
| Foster, James | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/04/2022 |
| Gassen, William | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Gassen, William | Individual | Corporate Officer | NOT APPLICABLE | 05/30/2024 |
| Gulsvig, Neil | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Herseth Sandlin, Stephanie | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Lundeen, Mark | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Middleton, Aimee | Individual | Corporate Officer | NOT APPLICABLE | 01/27/2022 |
| Molbert, Lauris | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Morrison, Tony | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2019 |
| Murray, Chadd | Individual | Contracted Managing Employee | NOT APPLICABLE | 10/31/2018 |
| North, Andrew | Individual | Corporate Director | NOT APPLICABLE | 05/30/2024 |
| Olson, Nicholas | Individual | Corporate Officer | NOT APPLICABLE | 04/08/2024 |
| Rogers, Michael | Individual | Corporate Officer | NOT APPLICABLE | 06/13/2022 |
| Schema, Nathan | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can I see a sample menu, and how do you handle special diets like low-sodium or diabetic meals?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mother Hull Home | 1.5 mi | Kearney, NE | ★★☆☆☆ | 2/5 | |
| Good Samaritan Society - St John's | 1.5 mi | Kearney, NE | ★★☆☆☆ | 2/5 | |
| Mt Carmel Home - Keens Memorial | 2.1 mi | Kearney, NE | ★★★★☆ | 4/5 | |
| Brookestone Gardens | 3.7 mi | Kearney, NE | ★★★★★ | 3/5 | |
| Bethany Home, INC | 15.4 mi | Minden, NE | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 285192.