Average — CMS composite of the measures below.
The next survey window likely opens around December 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 - Villisca during CMS and state inspections, most recent first.
Controlled substances were not safely secured because an LPN stored scheduled clonazepam in the same drawer as routine medications while only PRN controlled meds were double locked. The DON said the facility had only been double locking PRN controlled meds, and record review showed several residents received scheduled clonazepam. The facility policy defined controlled meds and required a separate access system for locking Schedule II meds.
The facility failed to ensure safe food storage when surveyors found opened food items in the kitchen without opened dates, including shredded cheese, cauliflower, and a crock pot of cheese. The DM said staff were expected to date items when opened and that opened items were good for no longer than 3 days, while the facility policy required clear date and time labeling for food kept in storage.
Failure to follow BP parameters and repeat low readings: A resident with HTN, respiratory failure, and fluid/electrolyte imbalance had several low BP readings documented, including one with no repeat BP or MD consult and another with no BP documented for a period afterward. The MAR showed metoprolol orders with hold parameters, yet the resident still received a dose when the BP was below the ordered threshold. The DON and an LPN stated staff should retake BP readings when they are outside the normal range.
Failure to Serve Ordered Texture-Modified Diets: Three residents did not receive meals prepared in the ordered texture and consistency. One resident with dementia and psychotic disturbance was served a regular stir fry meal with an egg roll that was not minced or pureed, another resident with kidney disease and malnutrition received noodles and stir fry without gravy despite a soft and bite-sized, mildly thick diet order, and a third resident was served only a partial portion of noodles because that was all that remained in the pan. The DM acknowledged one meal should have included gravy, and the menu called for minced or soft and bite-sized items with thick gravy and pureed components.
A resident with a recent below-the-knee amputation and severe cognitive impairment was admitted with physician orders for PT and OT, but these services were not initiated until nearly a month later due to missed orders. Staff and DON confirmed the delay, which was not in accordance with facility policy requiring timely implementation of therapy orders.
A resident with severe cognitive impairment and stage 2 pressure ulcers did not receive the required weekly wound assessments with measurements as ordered, due to gaps in documentation and staff absence. Although a contracted wound nurse provided some care, facility RNs did not complete the necessary weekly assessments, contrary to facility policy.
A resident with multiple medical conditions did not consistently receive physician-ordered compression stockings for lower extremity edema, with documentation showing frequent unavailability and staff admitting to possible inaccurate charting. The resident reported not having the correct stockings, and staff interviews confirmed a lack of follow-up with providers when the ordered supplies were not available or used as directed.
A resident with severe cognitive impairment and total dependence for transfers was moved multiple times using a mechanical lift by only one CNA, contrary to the care plan and facility policy requiring two staff for such procedures. Staff interviews and facility documentation confirmed that two staff should be present for safety during these transfers, but the CNA performed the tasks alone, placing the resident at risk.
A facility failed to provide a resident and their family with adequate notification of financial responsibility when Medicare Part A services were scheduled to be discontinued. The resident, who had severe cognitive deficits and multiple diagnoses, required assistance with daily activities. The absence of a required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 in the resident's chart highlighted the deficiency, as the facility's policy mandates issuing the ABN before service delivery to inform beneficiaries of potential non-coverage and financial liability.
A resident with epilepsy and profound intellectual disabilities was observed using foot straps on her wheelchair without proper consent or physician orders. The facility's care plan and consent documents only referenced a seatbelt, not the foot restraints. Staff acknowledged the oversight, as the facility's policy requires consent and orders for any device restricting movement.
The facility failed to obtain bed hold notifications for two residents transferred to a hospital after suffering hip fractures. The facility's policy requires informing residents or their representatives of the bed hold policy before and upon transfer, but this was not done. Staff indicated that the necessary documentation was not completed due to the absence of the social worker and lack of clarity on who should complete the forms after hours.
A resident with severe cognitive deficits and a history of falls was transferred without a gait belt by a CNA, contrary to the care plan and facility policy. The resident required partial assistance and had limited weight-bearing ability. The DON confirmed that staff were expected to use gait belts for transfers, highlighting a deficiency in following safety protocols.
A resident in an LTC facility reported that a staff member refused to transfer him to bed until he used the bathroom, attempting to pry his hand off a mechanical lift. The resident, who required assistance with daily activities, experienced distress due to the staff member's actions. Despite grievances from the resident and family, the facility's administration did not promptly address the issue, and the staff member continued to provide care until the matter was investigated. Interviews revealed inadequate investigation and communication by the facility's administration.
A resident with moderate cognitive impairment was subjected to rough handling by a CNA during a shower, resulting in multiple injuries. The CNA, who had a history of behavioral issues, used inappropriate language and did not adhere to the facility's policies on abuse and resident dignity. Despite previous interventions, the incident led to the CNA's termination.
Controlled substances not securely double locked
Penalty
Summary
The facility failed to safely secure controlled substances for 13 of 13 residents reviewed. During medication administration, Staff A, an LPN, was observed preparing medications for Resident #33 and removed clonazepam from the same drawer as the scheduled medication. When asked why the controlled substance was not under a double lock, she said she did not know and stated that the PRN controlled substances were under a double lock. An observation of the narcotic drawer later showed that the PRN lorazepam and clonazepam were double locked, but the scheduled controlled medications were not. Record review showed that four residents received scheduled clonazepam, and the facility’s DON stated that while she had worked there, only PRN controlled medications were double locked and scheduled controlled medications were not. The DON later said she contacted the pharmacy, which directed the facility to double lock both scheduled and PRN controlled substances, and she reported that staff were educated and all controlled substances were moved. The facility policy stated that controlled medications are substances with accepted medical use and potential for abuse or dependence, and that the access system used to lock Schedule II medication could not be the same access system used to lock non-controlled medications.
Food Items Left Undated in Kitchen Storage
Penalty
Summary
The facility failed to ensure safe food storage when an initial kitchen observation on 1/26/26 at 10:00 AM found opened food packages without dates when opened. Surveyors observed a bag of shredded cheese, a bag of cauliflower, and a crock pot of cheese with no opened date. On 1/27/26 at 3:00 PM, the Dietary Manager stated staff were expected to date food items when they were opened, that unopened items in the refrigerator were good for 7 days, and that opened items were good for no longer than 3 days. The Dietary Manager also stated the crock pot of cheese was from a staff party over the weekend and was not used by residents. A facility policy titled Date Marking, dated 4/4/25, instructed staff to date time/temperature control food items with the received date and to clearly label the date and time when containers were opened and kept in storage.
Failure to Follow Blood Pressure Parameters and Retake Low Readings
Penalty
Summary
The nursing facility failed to follow physician orders for blood pressure parameters and failed to retake blood pressure measurements when readings were outside the normal range for Resident #38. Resident #38’s MDS showed an admission date of 12/13/25, a BIMS score of 14, and diagnoses including hypertension, respiratory failure, and disorder of electrolyte and fluid balance. The care plan identified hypertension and directed staff to monitor for disorientation, lethargy, and difficulty breathing. The Blood Pressure Exceptions Report showed multiple low blood pressure readings, including 75/56 on 12/14/25, 64/34 on 12/15/25, and 84/70 on 12/20/25. The chart lacked documentation of a repeat blood pressure or physician consultation after the 75/56 reading, lacked blood pressure measurements on 12/16/25 after the 64/34 reading, and showed no documented blood pressure until later on 12/15/25. The MAR included metoprolol 25 mg twice daily, later changed to hold if systolic blood pressure was less than 100 or heart rate less than 50, yet documentation showed the resident received metoprolol with a blood pressure of 84/70. The DON stated nurses should retake blood pressure when results are outside the normal range, and an LPN stated she would hold metoprolol, retake the blood pressure, and call the doctor.
Failure to Serve Ordered Texture-Modified Diets
Penalty
Summary
The facility failed to serve therapeutic menus as ordered for 3 of 34 residents reviewed. Resident #25 had diagnoses including muscle weakness, dementia, psychotic disturbance, and anxiety, and had a diet order for a regular diet with regular texture, thin consistency, and ground meat. Resident #23 had diagnoses including kidney disease, malnutrition, and vitamin deficiency, and had a diet order for a no added salt diet with soft and bite-sized texture and mildly thick consistency. Resident #20 had diagnoses including hypertension, vascular dementia, anxiety, and muscle weakness, and had a diet order for a regular texture diet. During the lunch meal observation, Resident #25 was served a regular stir fry meal with an egg roll, but the meat was not minced and the egg roll was not pureed. Resident #23 was served ground noodles and stir fry with no gravy. Resident #20 was served only a half scoop of noodles because that was all that remained in the pan. The Dietary Manager stated Resident #23 should have received gravy on the meal, especially because the noodles were sticky. The facility's Week at a Glance Menu for Week 4 listed texture-modified items for the #5 and #6 diets, including minced or soft and bite-sized beef and broccoli stir fry with thick gravy, modified noodles, pureed egg rolls, and a pureed brownie. The facility policy on Texture-Modification Diets directed food and nutritional services to provide prescribed texture-modified diets ordered by the attending physician and to use a standardized process for prepared texture-modified menu items.
Failure to Initiate Physician-Ordered Therapy Services Upon Admission
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not initiating physician-ordered physical therapy (PT) and occupational therapy (OT) for a resident following admission. The resident, who had a right below-the-knee amputation and severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3, was admitted with physician orders for PT and OT on 8/4/25. However, these therapy services were not started until nearly a month later, despite the orders being present in the electronic health record. Staff interviews confirmed that the therapy department did not receive the order until 8/27/25, and therapy services began in early September. The Director of Nursing acknowledged that the initial orders from 8/4/25 were missed and not followed, resulting in a delay in therapy services. Facility policy required timely and accurate implementation of physician orders, including therapy, upon admission, but this was not adhered to in this case.
Failure to Complete Required Weekly Pressure Ulcer Assessments
Penalty
Summary
A resident with severe cognitive impairment and a diagnosis of two stage 2 pressure ulcers did not receive the required weekly wound assessments with measurements as ordered by the physician and outlined in facility policy. The resident's treatment orders included daily wound observation and dressing changes, as well as weekly skin observation and wound measurements. However, review of the electronic health record and treatment administration records showed that no measurements of the right sacral wound were documented from early May to the end of May. The facility's wound nurse was on medical leave during this period, and although a contracted wound nurse visited the resident and performed some assessments, there were gaps in the documentation of wound measurements and descriptions. Interviews with staff confirmed that the required weekly wound assessments with measurements were not completed by facility RNs during the wound nurse's absence. The Director of Nursing acknowledged that assessments with measurements should have been performed weekly and that this did not occur between the specified dates. Facility policy required licensed nurses to record the location, measurements, and characteristics of any pressure ulcer at least weekly, but this standard was not met for the resident in question.
Failure to Follow Physician Orders for Compression Stockings and Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with diagnoses including quadriplegia, seizure disorder, anxiety, and respiratory failure. Physician orders required daily and evening wound care to the lower extremities and the use of compression stockings in the morning and removal in the evening to address edema. Documentation and interviews revealed that the resident did not consistently receive the ordered compression stockings, with records showing they were unavailable on 30 occasions, refused 25 times, and applied only 6 times over a period of more than a month. The resident reported not having the correct stockings, and when stockings were received, they were the wrong size and returned. Staff interviews confirmed that the resident did not have the appropriate stockings and that there was a lack of follow-up with the physician or provider when the ordered supplies were not available or not being used as directed. Further, staff admitted to possible inaccuracies in documentation, with one LPN stating that staff may document treatments as completed when they were not, including the application of compression stockings. The facility's policy emphasized the importance of accurate and timely processing of physician orders, but this was not followed in practice. The outside provider noted that the resident's wounds would likely be healing better if the compression stockings had been used as ordered. Observations confirmed the resident was not wearing compression stockings, and multiple staff acknowledged the lack of follow-up and communication regarding the unavailability and non-use of the ordered medical supplies.
Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfers
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including cerebrovascular accident and dementia, was not provided adequate supervision and assistance during transfers and toileting. The resident required total staff assistance for activities of daily living, including transfers and toileting, as documented in the care plan, which specified the use of a dependent non-weight bearing mechanical lift with two staff members present. Despite these requirements, a single Certified Nurse Assistant (CNA) performed three separate movements using the mechanical lift without the assistance of a second staff member. During observation, the CNA completed the transfer and toileting tasks alone, including moving the resident from a recliner to a wash basin, then to a wheelchair, using the mechanical lift. Staff interviews confirmed that the expectation and facility policy required two staff to be present and engaged when operating the mechanical lift for dependent residents. The CNA acknowledged performing the tasks alone and stated this was the usual practice for this resident, despite the care plan and facility policy. Further interviews with other staff, including CNAs, the Clinical Care Coordinator, the Director of Nursing (DON), and the Administrator, all confirmed that two staff should be present for such transfers to ensure safety. The facility's Safe Resident Handling Program also outlined the need for a 'TIME OUT' safety stop and two staff for full weight-bearing support with the total lift. The failure to follow these protocols resulted in the resident not being adequately protected from possible accidents and injury during transfers.
Failure to Provide Adequate Notification of Financial Responsibility
Penalty
Summary
The facility failed to provide adequate notification of financial responsibility to a resident and their family when Medicare Part A services were scheduled to be discontinued. This deficiency was identified for one resident out of three reviewed, with the facility having a total census of 42 residents. The resident in question had a severe cognitive deficit, as indicated by a Brief Interview for Mental Status (BIMS) score of 1, and was diagnosed with conditions including cancer, anemia, renal insufficiency, and cerebrovascular accident (CVA). The resident required assistance with ambulation, toileting, and transfers due to self-care performance deficits related to acute transverse myelitis in demyelinating disease of the central nervous system. The facility's failure was highlighted by the absence of a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 in the resident's chart. The social worker confirmed that the resident was not cognitive enough to participate in decision-making and that the necessary form was not located or signed by the family. According to the facility's policy, the ABN must be issued before the delivery of the service in question, allowing the beneficiary enough time to make an informed decision about receiving the service and accepting potential financial liability. The lack of this documentation indicates a failure to comply with the policy, potentially leaving the resident or their family unaware of their financial responsibilities after the discontinuation of Medicare Part A services.
Failure to Obtain Consent and Physician Orders for Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints without proper consent and physician orders. The resident, who had epilepsy and profound intellectual disabilities with limited mobility, was observed using bilateral foot straps on her wheelchair for safety. However, the facility did not obtain consent from the family or a physician's order for these foot restraints. The resident's care plan and physician orders only referenced the use of a seatbelt, not the foot restraints, and the consent documents signed by the resident's Power of Attorney also did not include the foot restraints. During observations, staff were seen fastening both the seatbelt and foot straps when transferring the resident to her wheelchair. The Director of Nursing and MDS Coordinator acknowledged that the foot straps were considered restraints and should have required consent and physician orders. The facility's policy on restraints indicated that any device restricting movement, such as leg or ankle restraints, required consent, a physician's order, and regular documentation in the care plan. Despite this, the necessary procedures were not followed for the foot restraints used on the resident.
Failure to Obtain Bed Hold Notifications for Hospital Transfers
Penalty
Summary
The facility failed to obtain bed hold notifications for two residents who were transferred to a hospital, as required by their policy. Resident #3 was transferred to a hospital after falling at home and suffering a right hip fracture. The resident was on a paid hospital leave from 5/11/24 to 5/14/24, but the facility did not have a signed bed hold notification. Staff E, a social worker, indicated that she was not present when the resident left the facility, and therefore, the document was not completed. Similarly, Resident #20 was transferred to a hospital after being found on the floor with a right hip fracture. The resident was on a no-pay hospital leave from 10/19/24 to 10/24/24, but again, the facility did not have a signed bed hold notification. Staff E stated that a nurse was supposed to complete the document, but it was not done. The Director of Nursing acknowledged that bed holds should have been completed and mentioned that charge nurses could be trained to complete them. The facility's bed-hold policy requires that the resident or their representative be informed of the bed hold policy before and upon transfer, and in emergencies, the notice should be sent with the resident to the hospital and provided to a family member within 24 hours.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to practice safe transfer techniques for a resident with severe cognitive deficits and a history of falls. The resident required partial assistance for transfers and had limited weight-bearing ability due to a right patella fracture. Despite the care plan directing staff to use assistive devices during transfers, a Certified Nurse Aide (CNA) was observed transferring the resident to and from the toilet without using a gait belt. Instead, the CNA used the resident's arm and clothing to assist with standing, which was not in accordance with the facility's policy. The facility's policy on gait-transfer belts, last reviewed in May 2024, stated that gait belts should be used to stabilize transfers and aid residents in maintaining balance. The Director of Nursing (DON) confirmed that staff were expected to follow the care plan and use a gait belt for any resident requiring assistance with transfers. However, the observation of the CNA's actions indicated a failure to adhere to these guidelines, leading to a deficiency in providing adequate supervision and safety during resident transfers.
Resident's Rights Violated by Staff Member
Penalty
Summary
The facility failed to treat a resident with respect and dignity during care, as evidenced by an incident involving a staff member and a resident. The resident, who had intact cognitive ability and required substantial assistance with daily activities, reported that a staff member refused to transfer him to bed until he went to the bathroom. The staff member attempted to pry the resident's hand off a mechanical lift, causing distress to the resident. The resident's family member also reported the incident, expressing concern that the resident's rights had been violated. The incident occurred when the resident put on his call light for assistance, but the staff member delayed responding and insisted on the resident using the bathroom before being transferred to bed. The resident, who experienced swelling in his legs and needed to elevate them, was distressed by the staff member's actions. Despite the resident's and family member's grievances, the facility's administration did not promptly address the issue, and the staff member continued to provide care to the resident until the matter was investigated. Interviews with various staff members revealed that the facility's administration, including the Director of Nursing (DON) and the Administrator, did not adequately investigate the incident or communicate with the resident and family member about the allegations. The DON did not report the incident to state authorities or complete an incident report, as they did not believe it rose to the level of abuse. The Social Worker, responsible for handling grievances, also delayed addressing the issue and did not interview the resident until several days after the incident.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) identified as Staff A. The resident, who had a history of moderate cognitive impairment and required assistance with activities of daily living, was reportedly subjected to rough handling during a shower. The resident sustained multiple injuries, including abrasions and bruising on the face, chest, and hand, which were documented in the facility's records and observed by staff. The resident reported that Staff A was rough during the shower and did not stop when asked, although the resident later denied being hit or harmed in other ways. Staff A had a documented history of behavioral issues, including previous disciplinary actions for inappropriate tone and approach with residents. On the day of the incident, another staff member overheard the resident yelling in the shower and Staff A responding with inappropriate language. After the shower, the resident was observed with visible injuries, prompting an assessment and subsequent transfer to the emergency room for evaluation. The facility's investigation included interviews with staff and residents, revealing that Staff A had been previously counseled on her behavior and approach to resident care. The facility's policies on abuse and resident dignity were not adhered to, as evidenced by the rough handling and inappropriate language used by Staff A. Despite previous interventions and education provided to Staff A, the incident occurred, leading to the resident's injuries and the eventual termination of Staff A's employment. The facility's failure to ensure the resident's safety and dignity resulted in a deficiency related to abuse prevention and resident care.
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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 Villisca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Stanton | 6.9 mi | ★★★★★ | 1 | 0 |
| Red Oak Rehab And Care Center | 13.4 mi | ★★★★★ | 8 | 0 |
| Corning Specialty Care | 13.8 mi | ★★★★★ | 9 | 0 |
| Good Samaritan - Red Oak | 14.3 mi | ★★★★★ | 23 | 1 |
| Azria Health Clarinda | 14.4 mi | ★★★★★ | 0 | 0 |
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