Good Shepherd Lutheran Home

2242 Wright Street · Blair, NE · 68008 · 4024264663

84 certified beds For profit - Limited Liability company Part of a CCRC

Why this verdict

  • Inspection results are getting worse cycle over cycle, not better.
  • No federal fines or payment denials in CMS’s 3-year window.

Red flags

Total nurse staffing below 3.0 hours per resident-day

2.97 reported hours vs the 3.48 minimum CMS's own staffing study recommends.

Score breakdown

Inspection record 30% of score 47
Serious harm & abuse 20% 100
Staffing 20% 52
Federal penalties 15% 100
Trend 10% 18
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 3 of 5

Total nurse hours / resident-day2.973.48 min · 4.1 strong
RN hours / resident-day0.470.55–0.75
Weekend hours / resident-day2.66≈ weekday level
Nursing turnover / year56%median 45%
Fines (3-yr window)none

Inspection citations (26 in the current record)

  • Potential for harm · D March 3, 2026 · found via complaint

    Keep residents' personal and medical records private and confidential.

    Corrected March 25, 2026 · Resident Rights

  • Potential for harm · D March 3, 2026 · found via complaint

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Corrected March 25, 2026 · Quality of Life and Care

  • Potential for harm · D March 3, 2026 · found via complaint

    Provide and implement an infection prevention and control program.

    Corrected March 25, 2026 · Infection Control

  • Potential for harm · D May 1, 2025

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

    Corrected May 22, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D May 1, 2025

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

    Corrected May 22, 2025 · Resident Rights

  • Potential for harm · D May 1, 2025

    Ensure medication error rates are not 5 percent or greater.

    Corrected May 22, 2025 · Pharmacy Service

  • Potential for harm · D May 1, 2025

    Ensure that residents are free from significant medication errors.

    Corrected May 22, 2025 · Pharmacy Service

  • Potential for harm · F May 1, 2025

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected May 22, 2025 · Nutrition and Dietary

  • Potential for harm · F May 1, 2025

    Provide and implement an infection prevention and control program.

    Corrected May 22, 2025 · Infection Control

  • Potential for harm · D May 1, 2025 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected May 22, 2025 · Resident Rights

  • Potential for harm · D May 1, 2025 · found via complaint

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

    Corrected May 22, 2025 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D May 1, 2025 · found via complaint

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Corrected May 22, 2025 · Resident Assessment and Care Planning

  • Potential for harm · F May 1, 2025 · found via complaint

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

    Corrected May 22, 2025 · Environmental

  • Potential for harm · E May 1, 2025 · found via complaint

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

    Corrected May 22, 2025 · Environmental

  • Potential for harm · D April 23, 2024

    Provide and implement an infection prevention and control program.

    Corrected May 15, 2024 · Infection Control

  • Potential for harm · F April 23, 2024

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

    Corrected May 15, 2024 · Infection Control

  • Potential for harm · D April 4, 2024 · found via complaint

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected April 11, 2024 · Resident Rights

  • Potential for harm · D May 3, 2023

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

    Corrected June 16, 2023 · Resident Rights

  • Potential for harm · E May 3, 2023

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

    Corrected June 16, 2023 · Freedom from Abuse, Neglect, and Exploitation

  • Potential for harm · D May 3, 2023

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    Corrected June 16, 2023 · Resident Rights

  • Potential for harm · E May 3, 2023

    Ensure each resident receives an accurate assessment.

    Corrected June 16, 2023 · Resident Assessment and Care Planning

  • Potential for harm · D May 3, 2023

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

    Corrected June 16, 2023 · Resident Assessment and Care Planning

  • Potential for harm · D May 3, 2023

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

    Corrected June 16, 2023 · Pharmacy Service

  • Potential for harm · D May 3, 2023

    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 June 16, 2023 · Pharmacy Service

  • Potential for harm · D May 3, 2023

    Provide and implement an infection prevention and control program.

    Corrected June 16, 2023 · Infection Control

Showing the 25 most recent. The Safety Report includes every citation with full findings.

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 285148 · certified since June 1, 1994. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.