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 - George during CMS and state inspections, most recent first.
The facility did not meet staffing requirements due to inaccurate PBJ data submission, which showed excessively low weekend staffing despite reports that nurse and CNA schedules were consistent throughout the week. The Administrator was unaware of the data submission process and confirmed the absence of a PBJ policy, while the DON attributed the discrepancy to the use of corporate staffing pool personnel.
Staff failed to provide accurate meal portions to residents, with pureed meals being served in incorrect amounts and without proper measurement. Some residents received only half portions without care plan authorization, and staff relied on visual estimation rather than precise measurement, contrary to facility policy and dietary orders.
Surveyors found that food items in the kitchen and refrigerator were not labeled, dated, or stored according to facility policy and professional standards. Open containers of cereals, syrups, dairy products, juices, and dressings were observed without required labels or open dates, and some items were improperly stored, such as uncovered cake and a box of oranges on the floor. Interviews with the Dietary Manager and Administrator confirmed these practices did not meet expectations.
A resident with severe cognitive impairment was transferred to the hospital twice, and on both occasions, the facility failed to obtain the required signature from the resident's representative on the bed hold notice, relying only on verbal authorization and not following policy to mail the notice if the representative was not present.
A resident with multiple medical conditions who used a CPAP machine nightly did not have current CPAP orders or settings entered into the electronic chart, and the use of the CPAP was not included in the care plan. Staff interviews confirmed the omission occurred during a change in responsibility, and facility policy requiring documentation and care planning for respiratory devices was not followed.
A CNA allegedly slapped a cognitively impaired resident during care, but the incident was not reported immediately, allowing the CNA to continue working with residents. The facility's policy requires immediate reporting of abuse, but staff failed to follow this protocol, delaying the investigation and exposing residents to potential harm.
The facility failed to serve full food portions and did not consistently fill and empty scoop utensils during meal preparation. Meals were partially switched due to improperly thawed meat, and incorrect scoop sizes led to inconsistent food portions for residents. The facility lacked a policy on portion size and scoop usage, and the Administrator expected correct food servings as per the menu.
The facility failed to submit accurate staffing reports for the CMS PBJ Staffing Data Report, showing excessively low weekend staffing and insufficient licensed nursing coverage for four or more days. The issue arose from incorrect payroll data, as employees were not punched in for breaks, leading to inaccurate reporting.
A facility failed to ensure proper hand hygiene during urinary catheter care for a resident. A CNA was observed changing gloves multiple times without performing hand hygiene in between, contrary to the facility's policy. The Nurse Educator present acknowledged the oversight.
A resident with severe cognitive impairment was physically abused by a CNA during bedtime care, as the CNA became frustrated and swatted the resident's arm. The incident was witnessed by another CNA but was not reported immediately, delaying intervention. The facility's policy on abuse and neglect was not followed, as the incident was only reported to the DNS several days later, allowing the involved staff member to continue working with residents.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment within the required 2-hour timeframe. The incident, where a CNA allegedly swatted the resident's arm during care, was reported to the DNS on June 27, but the facility delayed notifying the authorities until later that day, violating state regulations.
Failure to Accurately Report Staffing Data in PBJ Submission
Penalty
Summary
The facility failed to meet staffing requirements in all metrics as evidenced by the CMS Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 2, 2025, which showed excessively low weekend staffing data. The facility reported a census of 31 residents during this period. Staffing schedules for nurses and CNAs were reportedly similar for both weekdays and weekends, but the PBJ data submitted indicated otherwise. The Administrator stated he was unaware of how the corporate office submitted staffing data and confirmed there was no facility policy regarding PBJ. The Director of Nursing (DON) suggested the low weekend staffing data may have resulted from the use of corporate-supplied staffing pool personnel, but maintained that actual staffing levels did not differ between weekdays and weekends and that insufficient staffing did not occur during the quarter.
Failure to Serve Proper Meal Portions to Residents
Penalty
Summary
Facility staff failed to serve proper portion sizes to residents during meal service, as observed during a meal preparation and service. Staff A prepared pureed meals by combining multiple servings of meat, potatoes, roll, and gravy, as well as spinach, but did not accurately measure the portions according to the residents' dietary requirements. Instead of providing the prescribed two #8 scoops of the pureed mixture per resident, Staff A served only one scoop of each mixture to two residents, leaving extra food in the pan. When questioned, Staff A was unable to confirm the exact measurements used and admitted to estimating portion sizes based on visual cues rather than precise measurement. Additionally, approximately ten plates were served with smaller, unmeasured portions because residents reportedly requested half servings, but only one resident was care planned for half portions. Interviews with the Dietary Manager and review of facility policies confirmed that staff are expected to serve full portions unless otherwise ordered and documented in the care plan. The Dietary Manager acknowledged that Staff A should have served the correct portions and that only one resident was authorized for half portions. Facility policy also specifies that pureed foods should not be combined unless requested and documented, and that meals should be well-balanced and provide adequate nutrition. The Administrator confirmed that staff are required to serve proper amounts as ordered.
Failure to Store and Prepare Food Under Sanitary Conditions
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation in the facility's kitchen. During an initial walkthrough, several open food items, including containers of Cheerios, rice cereal, raspberry syrup, oatmeal, and cornstarch, were found without labels or open dates. In the refrigerator, there were uncovered servings of cake, open cartons of liquid egg, heavy whipping cream, white milk, pitchers of orange and apple juice, thickened water, open containers of Greek yogurt past their expiration date, and various dressings and sauces, all lacking required labels or open dates. Additionally, a box of oranges was found sitting directly on the floor. These findings were in direct violation of the facility's policy, which requires opened or prepared foods to be placed in enclosed containers, labeled, dated, and stored properly. Interviews with the Dietary Manager and the Administrator confirmed that their expectations aligned with the facility's policy, specifically that dietary staff should date items when opened and ensure proper storage, including covering and labeling. The failure to follow these procedures was evident in the observed conditions, as numerous food items were not labeled, dated, or stored according to professional standards and facility policy. The facility had a census of 31 residents at the time of the survey.
Failure to Obtain Required Bed Hold Notice Signatures
Penalty
Summary
The facility failed to ensure that required bed hold notices were properly signed by the resident's representative when a resident with severe cognitive impairment was transferred out of the facility on two separate occasions. Clinical record review showed that the resident, who had diagnoses including hypertension, anemia, and arthritis, was hospitalized twice, and in both instances, the bed hold documentation only included verbal authorization from the resident's representative without obtaining the necessary signature. Facility policy requires that the Notice of Bed-Hold Policy be mailed if the family or representative does not come to the facility to receive a copy, but there was no evidence that this was done. Interviews confirmed that the signatures were missed and should have been obtained.
Failure to Document and Care Plan CPAP Use for Resident
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for a resident who required nightly use of a continuous positive airway pressure (CPAP) machine. The resident, who had diagnoses including renal insufficiency, diabetes, and anemia, reported using a CPAP nightly. Observations confirmed the presence of a CPAP machine at the bedside, and a faxed physician's order for the device was present. However, the facility did not enter the CPAP order or its settings into the electronic chart, and the resident's care plan did not reflect the use of the CPAP machine. The Minimum Data Set (MDS) assessment also failed to indicate the resident's use of a non-invasive mechanical ventilator. Interviews with facility staff revealed that the omission occurred during a transition of responsibility from the Director of Nursing (DON) to the MDS Coordinator. Both the MDS Coordinator and the DON confirmed that the CPAP order and care plan documentation were missing. The facility's policy required provider orders for respiratory devices to be recorded and included in the care plan, but these steps were not followed for this resident.
Failure to Report Abuse Allegation Promptly
Penalty
Summary
The facility staff failed to report an allegation of abuse involving a Certified Nurse Aide (CNA) who allegedly slapped a resident on the upper arm. This incident occurred during bedtime care when the resident, who has severe cognitive impairment due to a stroke, hypertension, and depression, yelled out. The CNA became frustrated and swatted the resident's arm. Despite witnessing the event, the staff did not report it immediately, allowing the alleged perpetrator to continue working with other residents. The incident was not reported to the Director of Nursing Services (DNS) until several days later, when a CNA confided in another staff member about witnessing the abuse. The staff member who was informed did not report the incident immediately, citing distrust in the charge nurse on duty. It was only after further discussion with another staff member that the incident was finally reported to the DNS. The facility's policy requires immediate reporting of any suspected abuse to a supervisor, and the charge nurse is responsible for assessing the situation and ensuring the safety of residents by removing the alleged perpetrator from direct care. However, this protocol was not followed, resulting in a delay in addressing the abuse allegation and exposing residents to potential harm.
Removal Plan
- The local police, resident's physician, and family/responsible party were notified of the allegation. An initial report was made to DIAL within the expected two-hour time frame.
- Staff members who failed to report immediately received immediate education and re-did the Iowa required Dependent Adult Abuse course online. Corrective action was completed as well with both staff members.
- The social services manager interviewed all residents to determine if there were any concerns by residents of care and treatment by staff members. None were identified.
- Education on abuse and neglect for all staff regarding the treatment of residents and the importance of immediately notifying leadership and/or supervisor of any allegation so steps can be immediately taken to remove/separate suspected staff from residents. A quiz for comprehension was completed by staff. Education was completed with all staff prior to any staff working another shift.
- Administrator or designee will audit through abuse and neglect questionnaires 5 team members randomly to include all shifts daily to ensure staff education on abuse and neglect investigation and reporting.
- Audits will be taken to QAPI for further review and recommendations.
- Center leadership has continued to provide daily reminders to staff on the need to report immediately any suspected abuse and/or neglect.
- Center leadership, including the Director of Nursing, Administrator, and Social Services, have ensured that their phone numbers have been made available for all staff to place in their phones to ensure the ability to call them at all times.
- A Skills Fair was completed where continuing reminders and education were again provided.
Failure to Serve Correct Food Portions
Penalty
Summary
The facility failed to serve the full portions of food to residents and did not consistently fill and empty scoop utensils when preparing meals. The Dietary Manager (DM) reported that meals were partially switched due to meat not being completely thawed, leading to a replacement meal being served. During meal service, the DM did not completely fill and empty the scoop when serving corn and minced pork, resulting in two residents receiving 1.5 ounces more pork, while the last two residents did not receive full scoops. Additionally, the incorrect scoop size used for broccoli resulted in a resident receiving 2.5 ounces less broccoli. The facility did not provide a policy specifically related to portion size and usage of food scoops when plating food. The Administrator expected staff to serve the correct amount of food as per the menu.
Inaccurate Staffing Reports Due to Payroll Errors
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of January 1 to March 31. The report indicated excessively low weekend staffing, with the facility failing to provide licensed nursing coverage 24 hours a day for four or more days within the quarter. Despite the staffing for nurses and Certified Nursing Assistants (CNAs) being scheduled similarly for weekdays and weekends, no issues were found for nursing coverage. The deficiency was attributed to incorrect payroll data, as employees were not punched in for breaks, leading to inaccurate reporting.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during urinary catheter care for a resident. During an observation, a Certified Nursing Assistant (CNA) donned personal protective equipment and retrieved a urine colander. The CNA placed the colander in the bathroom, removed and discarded gloves, but failed to perform hand hygiene before donning new gloves. The CNA then assisted the resident to sit in a recliner, again removed and discarded gloves without completing hand hygiene, and donned new gloves. The CNA continued to handle the resident's catheter drainage without performing hand hygiene between glove changes. The facility's policy, last revised in July 2024, instructed staff to perform hand hygiene after glove removal. The Nurse Educator present during the observation acknowledged the failure to perform hand hygiene after changing gloves.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who physically struck a resident. The resident, who had severe cognitive impairment due to a stroke, hypertension, and depression, was receiving bedtime care when the incident occurred. During the care, the resident yelled out due to discomfort from cold wipes, which led to the CNA becoming frustrated and swatting the resident's upper arm. This incident was witnessed by another CNA, who reported that the resident expressed pain by saying 'ouch' and questioned the action. Despite witnessing the event, the incident was not immediately reported to the Director of Nursing Services (DNS) or management, delaying appropriate intervention. The facility's policy on abuse and neglect, which emphasizes the residents' right to be free from abuse, was not adhered to in this case. The incident was only reported to the DNS several days later, on 6/27/24, after being confided to another staff member. Interviews with staff involved revealed that the incident was not immediately reported, and the resident's condition was not assessed for physical harm immediately following the event. The facility's failure to promptly report and address the incident allowed the staff member involved to continue working with residents, contrary to the facility's policy and the administrator's expectations.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 4, who had diagnoses of stroke, hypertension, and depression. On June 19, 2024, a Certified Nursing Assistant (CNA) allegedly swatted the resident's arm out of frustration during bedtime care. This incident was reported to the Director of Nursing Services (DNS) on June 27, 2024, at 10:20 p.m., but the facility did not submit a self-report to the authorities until 9:34 p.m. on the same day, which was beyond the 2-hour reporting requirement. The facility's policy mandates that any allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours after the allegation is made. Despite this policy, the DNS acknowledged the delay in reporting the incident to the state. The failure to adhere to the reporting timeline constitutes a deficiency in the facility's compliance with state regulations regarding the timely reporting of abuse allegations.
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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 George
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lyon Specialty Care | 10.3 mi | ★★★★★ | 3 | 0 |
| Parkview Manor Nursing Home | 12 mi | ★★★★★ | 10 | 0 |
| Sibley Specialty Care | 12.4 mi | ★★★★★ | 1 | 0 |
| Pleasant Acres Care Center | 13.4 mi | ★★★★★ | 14 | 0 |
| Osceola Senior Living | 13.5 mi | ★★★★★ | 10 | 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.