Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - St Luke's Village during CMS and state inspections, most recent first.
A resident who was non-verbal, dependent for care, and reliant on a PEG tube did not receive ordered Dilantin doses on multiple occasions due to the medication being unavailable, and there was no documentation that the alternative Phenytoin was administered or that the physician was notified within 24 hours as required. The resident was later hospitalized for a seizure with low Dilantin levels, and facility records and interviews confirmed the lack of medication administration and required notifications.
A resident with Down's Syndrome, non-verbal status, and full PEG-tube dependence did not receive prescribed Dilantin and Phenytoin due to pharmacy supply issues, with multiple missed doses and inadequate documentation in the MAR. The pharmacy confirmed the medications were unavailable for several days, and there was no timely physician notification as required by policy. The resident was later hospitalized for a seizure with low Dilantin levels.
The facility did not employ a full-time RD, and the DM lacked the necessary qualifications, affecting all 41 residents consuming food prepared in the facility's kitchen.
A facility failed to ensure proper infection control during laundry delivery, as a laundry aide did not perform hand hygiene between delivering clean laundry and handling potentially soiled hangers. This was observed across multiple rooms, involving 21 residents, and was inconsistent with the facility's policy, posing a potential risk for cross-contamination.
A facility failed to ensure a RN completed their initial orientation within the required 30 days of hire, as per policy. Discrepancies in the RN's start date were noted, and it was confirmed that essential training on emergency procedures and abuse and neglect was completed well beyond the 30-day requirement. This oversight had the potential to affect all 41 residents.
A resident with dementia and a history of falls suffered a fall resulting in a major injury, which was not reported to the state or regulatory agency as required by the facility's policy. The resident, who required substantial assistance and used a wheelchair, returned from the hospital with sutures. The DON confirmed the failure to report the incident.
A facility failed to accurately complete the MDS for a resident regarding psychotropic medication use. The resident, with a primary diagnosis of hemiplegia and a BIMS score indicating no cognitive impairment, was receiving several mood-affecting medications. However, the MDS inaccurately reported that no antipsychotic medications were received. The DON confirmed the error and noted the absence of a specific MDS policy, relying instead on the RAI manual.
The facility failed to develop care plans with measurable goals and interventions for two residents with dementia, leading to deficiencies in addressing their care and treatment needs. One resident, with dementia, had no goals or interventions related to their antipsychotic medication, while another resident, cognitively intact, lacked a care plan addressing their antipsychotic and antidepressant medications. Staff confirmed the absence of specific target behaviors and interventions in the care plans.
A resident with heart failure, who had expressed a desire for CPR, was found unresponsive and not provided with life-saving measures by the nursing staff. Despite the absence of a DNR order and the resident's documented wishes, CPR was not initiated, leading to a deficiency in care.
A facility failed to provide proper bowel care management for a resident with severe cognitive impairment and chronic respiratory failure. Despite a care plan outlining interventions for constipation, no bowel movements were documented for five days, and no PRN medications were administered. The DON confirmed the absence of a bowel protocol policy and that staff did not follow the facility's expectations for bowel management.
A resident with urinary retention and incontinence experienced multiple falls while attempting to reach the bathroom independently. The facility failed to implement a scheduled toileting plan or update the care plan with interventions to prevent these falls, despite the resident's cognitive awareness and need for assistance.
The facility failed to ensure timely physician visits for two residents, as required by federal guidelines. One resident was not seen every 30 days during the initial 90-day period, and another was not seen every 60 days thereafter. The deficiency was confirmed by the DON and Administrator.
A resident's medication administration was not in accordance with facility policy, as the medication cassette label did not match the MAR. The discrepancy arose because the provider sent the order directly to the pharmacy, bypassing the facility, resulting in the MAR not being updated. The issue was confirmed by the DON and a pharmacist, who noted inconsistencies in the order communication process.
A facility failed to properly document and monitor behaviors to support the use of psychotropic medications for a resident with hemiplegia and no cognitive impairment. The resident was on multiple psychotropic medications, but the Treatment Administration Record showed incomplete documentation. Despite observed behaviors, there were no correlating progress notes, and a Gradual Dose Reduction was declined without clinical rationale. The Director of Nursing confirmed the lack of documentation and rationale, indicating a deficiency in medication management.
Failure to Administer Ordered Anticonvulsant Medication and Notify Physician
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for a resident who was non-verbal, had Down's Syndrome, was dependent for all care needs, and relied on a PEG tube for nutrition and medication administration. The resident had physician orders for Dilantin Oral Suspension to be given twice daily via PEG tube, and for Phenytoin Oral Tablet to be given via PEG tube every 12 hours as needed if the liquid Dilantin was unavailable. Record reviews revealed that there were multiple instances in March and April where Dilantin was not administered as ordered, with documentation on the Medication Administration Record (MAR) indicating 'drug not available' or referencing nurse notes, and with no documentation that Phenytoin was administered as an alternative during these periods. Communication with the pharmacy confirmed that neither Dilantin nor Phenytoin was available for several days, and there was no evidence that the physician was notified within 24 hours of the medication being unavailable, as required by facility policy. Progress notes and MARs lacked documentation of administration or physician notification for the missed doses. The resident was subsequently hospitalized due to a seizure, with hospital records indicating low Dilantin levels and a new order to increase the medication. Interviews with the DON and Administrator confirmed the lack of documentation for medication administration and physician notification during the periods when the medication was unavailable. Facility policy required provider notification and completion of a SAFE Event Report for medication errors, but these actions were not documented as completed.
Failure to Provide and Document Essential Anticonvulsant Medication
Penalty
Summary
The facility failed to ensure that pharmacy services provided necessary medications for a resident with Down's Syndrome, who was non-verbal, dependent for all care needs, and fully reliant on PEG-tube feedings. The resident was prescribed Dilantin Oral Suspension to be administered twice daily via PEG-tube, with Phenytoin Oral Tablet as an alternative if the liquid form was unavailable. Review of the Medication Administration Record (MAR) and progress notes revealed multiple instances in March and April where Dilantin was not available or not administered, and there was a lack of documentation for both Dilantin and Phenytoin on several dates. Communication records showed that the pharmacy confirmed Dilantin and Phenytoin were not available for delivery over several days. Although a nurse contacted the pharmacy regarding the medication shortage, there was no evidence that the physician was notified within 24 hours as required by facility policy. Additionally, there was insufficient documentation in the MAR and progress notes regarding the administration or non-administration of the medications during the identified periods. The resident was subsequently hospitalized due to a seizure, with hospital records indicating low Dilantin levels and a new order to increase the medication dosage. Facility interviews confirmed the absence of documentation for medication administration and the lack of timely physician notification about the unavailability of the prescribed medications.
Non-Compliance in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to ensure compliance with regulatory requirements for food and nutrition services staffing. Specifically, the facility did not employ a full-time Registered Dietitian (RD) and the Director of Food and Nutritional Services, referred to as the Dietary Manager (DM), did not possess the necessary educational degree or certification. The DM had completed 270 contact hours in a nutrition and food service professional training program, but there was no evidence of certification from this training. An interview with the DM confirmed the lack of required qualifications, and an interview with the RD confirmed their part-time status and the DM's non-compliance with educational requirements. This deficiency had the potential to affect all 41 residents consuming food prepared in the facility's kitchen.
Inadequate Hand Hygiene During Laundry Delivery
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the delivery of laundry services. Observations revealed that a laundry aide, identified as LA-L, did not perform hand hygiene between delivering clean laundry to residents' rooms and handling potentially soiled hangers. The aide was seen pushing a covered cart, retrieving clothing items from the cart, and entering multiple residents' rooms to deliver these items. Upon exiting the rooms, the aide collected empty hangers and placed them back into the covered cart without performing hand hygiene, as required by the facility's policy. This deficiency was observed across multiple rooms and involved 21 residents, indicating a systemic issue in the facility's infection control practices. The facility's policy mandates that clean linen carts be covered at all times and that hand hygiene be performed between laundry passes to prevent cross-contamination. However, the aide's actions were inconsistent with these requirements, as confirmed by the facility administrator during an interview. The failure to adhere to these infection prevention procedures posed a potential risk for cross-contamination among the residents.
Failure to Complete Staff Orientation Within Required Timeframe
Penalty
Summary
The facility failed to ensure that a staff member, specifically a Registered Nurse (RN), completed their initial orientation within the required 30 days of hire, as per the facility's policy. The orientation policy, dated July 21, 2023, mandates completion within 30 days of the employee's start date. However, records show discrepancies in the RN's start date, with one document listing it as June 25, 2024, and another as May 31, 2025. Despite these inconsistencies, it was confirmed through interviews with the Director of Nursing Services and the facility Administrator that the RN did not complete the orientation within the stipulated timeframe. The orientation included essential training on emergency procedures and abuse and neglect, which were completed on September 18, 2024, well beyond the 30-day requirement. This oversight had the potential to affect all 41 residents residing in the facility.
Failure to Report Resident Fall with Major Injury
Penalty
Summary
The facility failed to report an accident with a major injury within the required time frames for a resident. The resident, who was admitted with diagnoses of dementia, a history of falls, and atrial fibrillation, suffered a fall and was taken to the hospital for care. Upon returning to the facility on the same day, the resident had sutures to the right hand. Despite the facility's policy on Fall Prevention and Management, which mandates reporting such incidents to the state and regulatory agency, the incident was not reported. The resident's quarterly Minimum Data Set (MDS) indicated moderate cognitive impairment, requiring substantial assistance with daily activities and using a wheelchair for mobility. The Director of Nursing Services confirmed that the facility did not adhere to its policy or regulatory guidelines by failing to report the fall with injury. This oversight was identified through record review, observation, and interview during the survey process.
Inaccurate MDS Assessment for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident regarding the use of psychotropic medications. Specifically, the MDS for a resident with a primary diagnosis of hemiplegia and a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, inaccurately reported the use of antipsychotic medications. The resident was receiving several medications affecting mood and behavior, including Clonazepam, Escitalopram Oxalate, Mirtazapine, and Olanzapine, yet the MDS section N0450 was incorrectly coded to indicate that no antipsychotic medications were received. The Director of Nursing (DON) confirmed the coding error upon review of the MDS and acknowledged that the facility did not have a specific MDS policy but followed the Resident Assessment Instrument (RAI) manual. The RAI manual requires that assessments accurately reflect the resident's status, as per federal regulations. This deficiency was identified through record review and an interview with the DON, highlighting a lapse in the facility's assessment process.
Deficiency in Care Plan Development for Residents with Dementia
Penalty
Summary
The facility failed to develop care plans with measurable goals and interventions for two residents with dementia, leading to deficiencies in addressing their care and treatment needs. Resident 31, admitted with dementia, was found to have no measurable goals or interventions related to their antipsychotic medication on their care plan. Interviews with staff, including a nurse aide and an LPN, confirmed that specific target behaviors were not documented in the resident's treatment administration record or care plan, despite the resident exhibiting repetitive behaviors. Similarly, Resident 35, who was cognitively intact and admitted with type 2 diabetes, hypertension, and urinary retention, also lacked a care plan with measurable goals or interventions for their antipsychotic and antidepressant medications. Staff interviews revealed that the resident displayed impatience and short-tempered behavior when waiting for assistance, yet these behaviors were not addressed in the care plan. The Director of Nursing Services confirmed the absence of specific target behaviors and interventions in the care plans for both residents.
Failure to Initiate CPR for Resident Requesting Resuscitation
Penalty
Summary
The facility failed to provide life-saving measures to a resident who had expressed a desire for cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. Resident 39, who was admitted with acute on chronic diastolic heart failure, had documented wishes for CPR to be performed. However, when the resident was found unresponsive, cool to the touch, and with blue discoloration around the mouth, CPR was not initiated by the nursing staff on duty. The incident occurred when two Nursing Assistants (NAs) reported to the Registered Nurse (RN) on duty that Resident 39 was unresponsive. The RN, who was occupied with another deceased resident's family and mortician, delayed attending to Resident 39. Upon checking the resident, the RN found no pulse and noted the resident's cold extremities and discoloration. Despite the resident's documented wishes for CPR, the RN did not initiate resuscitation efforts and instead contacted the Director of Nursing Services (DNS) to discuss the situation. The DNS confirmed that the staff was not re-educated on the facility's CPR policy following the incident. The facility's policy mandates the initiation of CPR unless there is a valid Do Not Resuscitate (DNR) order or obvious signs of clinical death, neither of which applied to Resident 39. The failure to perform CPR was a deviation from the resident's expressed wishes and the facility's policy, resulting in a deficiency in the standard of care provided.
Failure in Bowel Care Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure proper bowel care management for a resident with severe cognitive impairment and chronic respiratory failure with hypoxia. The resident was at risk of constipation due to decreased mobility and medication side effects. The Comprehensive Care Plan outlined specific interventions to monitor and manage constipation, including observing for signs and symptoms of complications and ensuring a bowel movement at least every three days. However, a review of the resident's records revealed no documented bowel movements for five consecutive days, and no PRN medications for bowel care were administered during this period. An interview with the Director of Nursing (DON) revealed that the facility lacked standing orders or a bowel protocol policy to prevent constipation. The facility's process required the evening nurse to review the bowel report and administer PRN medications if no bowel movement occurred in three days. If PRN medications were unavailable, the nurse was to contact the physician for orders. Despite these expectations, the DON confirmed that staff did not follow the facility's bowel management protocol for the resident, as evidenced by the lack of documentation and administration of PRN medications during the specified timeframe.
Failure to Prevent Falls Due to Inadequate Toileting Interventions
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident, identified as Resident 35, who was admitted with diagnoses including type 2 diabetes, hypertension, and urinary retention. The resident, who was cognitively intact and required supervision for toilet use and transfers, experienced multiple falls while attempting to reach the bathroom independently. Despite these incidents, the resident's care plan lacked any focus or interventions related to urinary incontinence, urinary retention, or falls due to the need to toilet. Interviews with the resident and staff revealed that the resident frequently fell due to the urgency of needing to use the bathroom and not waiting for staff assistance. The staff confirmed that the resident was not on a scheduled toileting plan, which contributed to the falls. The Director of Nursing Services acknowledged that the falls were associated with the resident's toileting needs and confirmed the absence of appropriate interventions in the care plan to address these issues.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits for two residents were conducted within the federal guidelines. According to the facility's policy, physician visits are required every 30 days for the first 90 days after admission and every 60 days thereafter. The policy also allows for a 10-day grace period for visits to be considered timely. However, the records for Resident 35 showed that the resident was not seen by their physician every 30 days during the initial 90-day period. Similarly, Resident 31 was not seen by their physician every 60 days as required. The deficiency was confirmed through interviews with the Director of Nursing Services and the Administrator, who acknowledged the failure to meet the required frequency of physician visits for both residents. The facility's policy also states that if a physician is continually late in completing required visits, the Director of Nursing Services, Administrator, and/or Medical Director should communicate with the physician to address the issue. However, the report does not mention any corrective actions taken to address the deficiency.
Medication Administration Discrepancy
Penalty
Summary
The facility failed to ensure that medications were administered according to its policy for one resident, identified as Resident 28. The facility's policy requires adherence to the Six Rights of medication administration and performing three checks to ensure accuracy. However, an observation revealed that the medication cassette for Resident 28 contained a label for Calcium Carbonate with Vitamin D, which did not match the order on the Medication Administration Record (MAR). The MAR indicated an order for Calcium Carbonate 600 mg tablets, two tablets daily, without mention of Vitamin D3, highlighting a discrepancy between the medication cassette and the MAR. The deficiency was further confirmed through interviews with the Director of Nursing Services and a pharmacist. The Director of Nursing Services acknowledged the mismatch between the medication cassette and the MAR, attributing it to the provider faxing the order directly to the pharmacy without informing the facility. This resulted in the facility not updating the MAR to reflect the new order. The pharmacist also noted inconsistencies in the process of receiving medication orders, with some physicians sending orders directly to the pharmacy, leading to changes in medication cassettes without corresponding updates to the facility's records.
Deficiency in Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure proper behavior monitoring and documentation to support the use of psychotropic medications for Resident 13, who was admitted with a primary diagnosis of hemiplegia and no cognitive impairment. Resident 13 was receiving multiple psychotropic medications, including Clonazepam, Escitalopram Oxalate, Mirtazapine, and Olanzapine, which required behavior monitoring. However, the Treatment Administration Record (TAR) for November 2024 through January 2025 showed numerous instances where documentation was incomplete or marked as not applicable, with several opportunities left blank or documented as zero without correlating progress notes. The facility's policy on behavior management required documentation of ongoing and repetitive behaviors by CNAs and social services or nursing staff. Despite this, there were multiple instances where target behaviors such as sad statements about the resident's spouse's death and self-isolation were not documented in progress notes, even when they were observed. Interviews with staff confirmed that Resident 13 exhibited these behaviors but had been attending more activities and meals outside of their room, indicating some improvement. Additionally, a Gradual Dose Reduction (GDR) form signed by the physician on December 19, 2024, declined a dose reduction for the antipsychotic medications without providing a clinical rationale. The Director of Nursing Services confirmed the lack of documentation to support the continued use of psychotropic medications and the absence of a clinical rationale for not attempting a dose reduction, highlighting a deficiency in the facility's medication management and documentation practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kearney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mother Hull Home | 1.5 mi | — | 14 | 0 |
| Good Samaritan Society - St John's | 1.5 mi | — | 18 | 0 |
| Mt Carmel Home - Keens Memorial | 2.1 mi | — | 9 | 0 |
| Brookestone Gardens | 3.7 mi | — | 8 | 0 |
| Bethany Home, Inc | 15.4 mi | — | 0 | 0 |
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