Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Forest City during CMS and state inspections, most recent first.
A resident with an indwelling catheter was repeatedly observed with the urine bag either lying on the floor or touching the floor while attached to the bed rail, and the bag was not covered with a dignity bag. The care plan lacked specific instructions for catheter bag placement, and these practices were not in line with CDC guidelines or facility policy, as confirmed by the DON.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, as the facility failed to ensure adequate safeguards against physical, mental, and sexual abuse, physical punishment, and neglect by any individual.
A resident with multiple medical conditions required two-person assistance for transfers at night, as per their care plan. However, a CNA attempted a transfer alone, resulting in the resident losing balance and sustaining a fracture. The incident highlighted a failure to follow the care plan, leading to the resident's hospitalization and surgery.
The facility failed to develop comprehensive care plans for three residents, omitting crucial details about high-risk medications, their side effects, and monitoring requirements. One resident with intact cognition was on Coumadin for atrial fibrillation, another with moderate cognitive impairment was on a diuretic for heart failure, and a third was on antipsychotics for mental health conditions. These omissions were confirmed through record reviews and staff interviews.
The facility failed to obtain food temperatures for a resident's meal substitutions and neglected regular cleaning of the kitchen ice machine. Surveyors found residue on the ice machine, and the CDM acknowledged the lack of scheduled cleaning. During lunch service, staff did not check temperatures of reheated meals before serving, contrary to facility policy.
A facility failed to provide necessary assessments and interventions for a resident with cardiovascular issues, including congestive heart failure and hypertension. Despite orders for ted hose application and removal, documentation was lacking, and significant weight gain and edema were not properly addressed. The resident developed a venous wound and severe edema, but there was insufficient documentation and communication with the physician regarding these changes.
Failure to Maintain Proper Catheter Bag Placement and Adherence to Infection Control Policy
Penalty
Summary
A deficiency was identified regarding the care of a resident with an indwelling urinary catheter. The resident, who had a diagnosis of benign prostatic hyperplasia and was dependent on staff for toileting hygiene, had a care plan that did not specify instructions for proper placement of the catheter urine bag and tubing to prevent them from touching the floor. Despite documentation indicating the resident had been educated to keep the urine bag lower than the bladder and off the floor, multiple observations showed the catheter urine bag either lying on the floor or attached to the bed rail but still touching the floor. Additionally, the urine bag was not covered with a dignity bag during these observations. Staff interviews confirmed that the expectation was for the catheter urine bag not to touch the floor while attached to the bed. Review of CDC guidelines and the facility's own policy both directed that catheter bags and tubing should not be allowed to touch the floor and should be covered. The lack of clear care plan direction and repeated failure to maintain proper catheter bag placement led to noncompliance with both facility policy and national infection prevention guidelines.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect residents from all forms of abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, indicating lapses in the facility's protective measures and oversight.
Inadequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident, resulting in a significant incident. The resident, who had a history of various medical conditions including anemia, atrial fibrillation, hypertension, deep venous thrombosis, diabetes mellitus, and chronic kidney disease, required specific levels of assistance for transfers as outlined in their care plan. The care plan specified that the resident needed extensive assistance from two staff members for transfers during the night hours due to increased fatigue. On the night of the incident, a certified nursing assistant (CNA) did not adhere to the care plan and attempted to transfer the resident alone, despite the requirement for two-person assistance after 6 PM. During the transfer from the commode to the wheelchair, the resident experienced a sudden loss of strength in her left knee, leading to a loss of balance. The CNA assisted the resident to the floor, but the resident sustained a fracture that required hospitalization and surgical intervention. The incident report and subsequent interviews revealed that the CNA was aware of the care plan's requirements but failed to follow them, resulting in the resident's injury. The CNA admitted to transferring the resident alone and acknowledged the mistake. The facility's policies on fall prevention and care planning emphasize the importance of following care plans to ensure resident safety, but these were not adhered to in this instance, leading to the deficiency.
Failure to Develop Comprehensive Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which did not address the risk factors and necessary interventions related to their high-risk medications. Resident #87, with intact cognition, was diagnosed with conditions including anemia, atrial fibrillation, hypertension, deep venous thrombosis, diabetes mellitus, and chronic kidney disease. Despite receiving anticoagulant medication, Coumadin, for atrial fibrillation, the care plan did not include information on the medication, its potential side effects, or monitoring requirements. This oversight was confirmed by the MDS Coordinator. Resident #8, with moderate cognitive impairment, had diagnoses of atrial fibrillation, heart failure, hypertension, anxiety, and depression. The resident was prescribed a diuretic medication, hydrochlorothiazide, for congestive heart failure, but the care plan failed to address the medication, its side effects, or monitoring needs. Similarly, Resident #30, also with moderate cognitive impairment, had diagnoses of anxiety, depression, PTSD, and schizophrenia. The resident was on antipsychotic medications, including Abilify and Quetiapine, yet the care plan did not cover these medications, their side effects, or necessary monitoring. These deficiencies were identified through clinical record reviews, staff interviews, and policy reviews.
Food Safety and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to food safety standards by not obtaining food temperatures for a resident's meal substitutions and neglecting regular cleaning of the kitchen ice machine. During a kitchen tour, surveyors observed a line of pink/yellow residue along the rim of the ice machine, indicating a lack of regular cleaning. The Certified Dietary Manager (CDM) acknowledged the oversight and explained that there were no scheduled spot checks or regular wiping down of the ice machine, although monthly deep cleaning was tracked separately. Additionally, during a lunch service observation, kitchen staff reheated a serving of tomato soup and a frozen portion of macaroni and cheese in the microwave but did not check the temperatures before serving them to a resident. The CDM confirmed that temperatures should have been obtained to meet food safety standards, as outlined in the facility's policy, which requires reheated or cooked foods in the microwave to reach a minimum temperature of 165 degrees.
Failure to Provide Adequate Assessment and Intervention for Resident with Cardiovascular Issues
Penalty
Summary
The facility failed to provide necessary assessments and interventions for Resident #21, who had a history of cardiovascular issues including atrial flutter, congestive heart failure, hypertension, anemia, and chronic kidney disease. Despite a physician's order for the application and removal of ted hose, the facility did not document compliance with this order from June through September 2024. Additionally, there was a significant weight gain and increased edema in Resident #21, but the facility did not conduct or document appropriate nursing assessments or interventions related to these symptoms. On August 8, 2024, a progress note indicated a significant weight gain and 3+ edema, yet Resident #21 was not on any diuretic medication at that time. Although the ARNP recommended an evaluation for heart failure, there was a lack of follow-up documentation regarding this appointment. When the physician evaluated Resident #21 on August 21, 2024, new orders for Lasix were given, but subsequent progress notes lacked documentation of nursing assessments and interventions related to fluid retention and diuretic usage. Further issues arose when Resident #21 developed a full-thickness venous wound and 4+ edema with weeping and open areas on the legs. Despite these developments, there was no documentation of physician orders for the use of ace wraps, and communication with the physician regarding these changes was insufficient. The facility's documentation was sparse and missing critical details about assessments and interventions, as acknowledged by the Director of Nursing.
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What surveyors actually found near you
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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 Forest City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Concord Care Center | 11.7 mi | ★★★★★ | 7 | 0 |
| Westview Care Center | 14.3 mi | ★★★★★ | 0 | 0 |
| Oakwood Care Center | 14.9 mi | ★★★★★ | 5 | 0 |
| Lake Mills Care Center | 16.7 mi | ★★★★★ | 5 | 0 |
| Timely Mission Nursing Home | 18 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.