Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 - West Union during CMS and state inspections, most recent first.
Failure to Timely Report Allegation of Abuse: A resident with moderate cognitive impairment, dementia, and PTSD reported that a CNA inappropriately touched her during an incontinence check. The DON investigated and an LPN was noted to have witnessed the brief check without inappropriate contact, but the facility did not file the abuse allegation report until nearly a month after the incident, and the DON acknowledged the report was not timely.
Failure to Update Time-Limited PASRR: The facility failed to submit an updated PASRR before a resident’s short-term Level II approval expired. The resident had serious mental illness diagnoses, moderate cognitive impairment, and required specialized behavioral health services, but the MDS Coordinator/RN acknowledged the update was not submitted on time and that psych appts or med management were not yet in place when non-compliance was identified. The DON stated the MDS Coordinator was responsible for the update, and the facility policy did not address time-limited Level II requirements.
A resident with intact cognition on MDS, hearing impairment, and multiple chronic conditions was started on mirtazapine for depression without documented education or informed consent from the resident or a legal representative. After the antidepressant was initiated, staff documented marked drowsiness, confusion, and sleep talking, and the provider later reduced the dose. Interviews with the DON and MDS Coordinator confirmed the facility could not find consent documentation for the psychotropic medication.
Failure to provide required Medicare non-coverage notices for two residents. The facility did not serve a SNF ABN when skilled services were ending for one resident, and for another resident the ABN did not clearly identify that PT and OT were ending or include the estimated cost to continue services. Staff interviews confirmed the notices were incomplete or not provided as required.
Incorrect MDS Coding for Insulin. The facility failed to accurately code insulin on the MDS for a resident reviewed for insulin use. The MDS showed insulin was received once during the assessment period, but the order summary lacked an insulin order and the MAR/TAR had no documentation that insulin was administered. The MDS coordinator stated the insulin should not have been coded because the resident was not taking insulin, and the DON stated she expected the MDS to be accurate and completed according to RAI guidelines.
Failure to implement a revised RNP and provide AAROM: A resident with stroke, hip fracture, MS, impaired mobility, and intact cognition was ordered multiple restorative exercises including AAROM, standing, dowel work, and arm bike. During observation, a restorative aide/CNA had the resident attempt several lower-extremity exercises but did not provide hands-on AAROM when the resident could not complete them, and the updated RNP was not visible in the EHR restorative section because it had been entered in the wrong area. Records lacked documentation of several revised restorative activities, and the policy lacked specific direction for communicating and implementing revised RNPs.
A facility failed to submit a new PASRR assessment for a resident with severe cognitive impairment and multiple diagnoses, including a new diagnosis of paranoid schizophrenia. Despite the facility's policy requiring a Level II screening for new mental disorder diagnoses, the Director of Nursing did not submit the necessary PASRR update, resulting in a deficiency.
The facility failed to provide adequate staffing, resulting in delayed call light responses for several residents. A resident with diabetes and dementia reported falls due to waiting for assistance, while another with paraplegia experienced waits of 15-30 minutes. Staff interviews revealed frequent understaffing, with only three aides working instead of the required four, affecting resident care and meal service.
The facility did not conduct the required tuberculosis (TB) screening for two new Certified Nurses Aides, as per its policy. Staff H did not complete the second step of the TB test, and there was no record of any TB screening for Staff I. The Interim DON confirmed the absence of TB testing records for both staff members.
The facility failed to ensure that four residents were educated about and offered annual Influenza and Pneumococcal vaccinations. The residents' records lacked documentation of education or offers for these vaccines, and the Infection Preventionist confirmed that such documentation should exist.
The facility failed to send appropriate records for a resident's transfer to the ER. The resident's EHR lacked a discharge assessment and documentation of sent paperwork. The Administrator confirmed that the hospital was not updated, and necessary documents were not sent. The facility's policy for completing and sending a Transfer Form was not followed.
The facility inaccurately coded the MDS for two residents by documenting insulin administration when none occurred. The Nurse Consultant mistakenly identified Trulicity as insulin based on incorrect information from a corporate form.
The facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medications to a resident. The resident received the medication on multiple dates without any documented attempts of non-pharmacological interventions, and the Pharmacy Consultant's notes lacked direction for such documentation. The Director of Nursing confirmed the expectation for this documentation, which is also outlined in the facility's policy.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse for one resident. Resident #2 had a BIMS score of 8 out of 15, indicating moderate cognitive impairment, and diagnoses that included renal insufficiency, over-active bladder, non-Alzheimer’s dementia, and PTSD. The care plan identified a psychosocial well-being deficit related to PTSD and directed staff to explain care procedures before completing them and to allow time for the resident to answer questions and express feelings and fears. A facility concern form documented that Resident #2 reported a CNA came in to do a brief check for incontinence and that she felt the CNA squeezed her vaginal lips. The DON investigated and determined the incident occurred on 3/23/26, with the investigation noting an LPN witnessed an agency staff member check the resident’s brief with no inappropriate contact occurring. Progress notes did not document the resident reporting the incident, but an outpatient behavioral health note recorded the resident’s account that a CNA put hands down her pants and squeezed her vagina lips, that she yelled at the CNA, and that she had told the DON and Administrator. The facility’s self-report was filed on 4/24/26 for an allegation of abuse, and the DON acknowledged the allegation was reported nearly a month after the incident and was not reported timely.
Failure to Update Time-Limited PASRR
Penalty
Summary
The facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) before the short-term Level II approval end date for one resident. Resident #2’s MDS documented an admission date of 2/25/26, a BIMS score of 8 out of 15 indicating moderate cognitive impairment, and diagnoses of depression, bipolar disorder, and post-traumatic stress disorder. The MDS also identified the resident as being considered by the state level II PASRR process to have a serious mental illness and noted no hallucinations or delusions. The Notice of PASRR Level II Outcome dated 2/16/26 showed a short-term approval end date of 4/17/26 and stated that if the resident needed to remain in the nursing facility longer, the facility had to contact the state for additional authorization. Staff C, the MDS Coordinator/RN, acknowledged that the current PASRR was completed on 2/16/26 with the time-limited Level II ending on 4/17/26 and stated she had been trying to submit an update and ensure services were in place and on the care plan. She also acknowledged receiving a notification of non-compliance on 4/24/26, at which time psychiatric appointment dates or medication management had not been in place. The resident later discharged against medical advice on 5/2/26. The DON stated the MDS Coordinator was responsible for submitting updated PASRR information and expected an update for a time-limited Level II to be submitted before the end date. The facility policy described the PASRR process but did not include direction for time-limited Level II requirements.
Failure to Obtain Informed Consent for Antidepressant Use
Penalty
Summary
The facility failed to provide education and obtain informed consent before starting mirtazapine, an antidepressant with black box warnings, for one resident. The resident had a BIMS score of 13 out of 15, used a hearing aid, had unclear speech but was usually able to understand others, and had diagnoses including cancer, heart failure, end stage renal disease, diabetes mellitus, Parkinson’s disease, and depression. The MDS documented depressive symptoms and that the resident was receiving an antidepressant medication. A physician order was entered to start mirtazapine 15 mg at bedtime, and the resident then became extremely drowsy, confused, and was noted to be talking in sleep after the medication was started. Staff documented the resident was not making sense, required a sternal rub to get attention, appeared drowsy and confused, and was confused about the time of day. The provider was notified by fax that the resident seemed sensitive to the antidepressant dose, and the dose was reduced to 7.5 mg. The facility was unable to find documentation that the resident or a legal representative received education or signed informed consent for the antidepressant, and staff interviews showed the DON, MDS Coordinator, and nursing staff described psychotropic education and consent as part of the process, but no documentation was found for this resident.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to serve the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) when Medicare-covered skilled services were ending and failed to document the specific Medicare services that would stop and the estimated charges to continue skilled services for 2 of 3 sampled residents. The report states that the facility had a census of 38 residents and that the SNF ABN is used to notify a resident and/or legal representative when Medicare services will no longer be covered and the resident may be liable for payment. For one resident, the EHR showed admission to Medicare skilled services with PT and OT documented as part of the stay, and the CMS SNF Beneficiary Protection Notification Review Form showed the last covered day of service was 2/11/26. The form also documented that a SNF ABN was not provided, without explanation. During interview, the Interim Administrator stated the resident had not been served a SNF ABN when skilled services were ending and that it should have been done. For another resident, the EHR showed admission for Medicare A skilled services with PT and OT needs. A communication note documented staff contacted a family member about the Medicare Part A stay ending and said they would get back regarding pricing to remain at the facility after the skilled stay. The SNF ABN signed by the resident did not document that PT and OT services were ending and did not include the estimated cost for services to continue. The Interim Administrator verified the notice did not specifically address the ending therapy services or the estimated cost, and the Social Service Director stated she was responsible for serving the NOMNC when therapy services ended and was not aware of the SNF ABN requirements for the notice content.
Incorrect MDS Coding for Insulin
Penalty
Summary
Ensure each resident receives an accurate assessment. Based on clinical record review, policy review, the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, and staff interviews, the facility failed to correctly code insulin on the MDS for 1 of 3 residents reviewed for insulin use, Resident #12. The resident’s admission record documented an admission date of 10/10/22. The MDS dated [DATE] documented that the resident received insulin 1 time during the assessment period of 12/19/25-12/25/25, but the Order Summary Report dated 12/25/25 lacked an insulin order, and both the MAR and TAR lacked documentation that insulin was given. Facility policy directed staff to determine whether documentation supported MDS coding and stated nursing staff were responsible for entering medications on the MDS. The RAI instructed staff to code the number of days insulin was received. During interview, the MDS coordinator stated the insulin should not have been coded because the resident was not taking insulin, and the DON stated she expected the MDS to be accurate and staff to follow the RAI guidelines when completing it.
Failure to Implement Revised Restorative Nursing Program and Provide AAROM
Penalty
Summary
The facility failed to implement a revised Restorative Nursing Program (RNP) and failed to provide active assist range of motion (AAROM) as directed for one resident. The resident had a BIMS score of 15/15, impaired functional mobility on one side of the upper and lower body, and used a walker and wheelchair. Her MDS listed diagnoses of stroke, hip fracture, and multiple sclerosis, and documented participation in restorative nursing active range of motion in only 1 day during the prior 7 days. A Therapy and Nursing Communication Form signed by the PT specified a restorative program that included upper extremity exercises, static standing, arm bike, and lower extremity exercises with AAROM. The revised Restorative Care Plan also directed multiple nursing rehabilitation activities, including AROM laying down or seated Therex with AAROM, standing at the wheeled walker, 3-pound dowel exercises, static standing, and arm bike exercises. During observation, the resident was seen slumped in her wheelchair and performing lower body exercises with Staff C, a restorative aide/CNA, but Staff C did not provide AAROM when the resident could not complete the movements. The resident struggled with marches, leg kicks, leg pulls, leg abductions, ball squeezes, and toe raises, and Staff C either continued counting repetitions without hands-on assistance, moved on to other residents, or performed passive range of motion only at the end of one exercise. Staff C stated she completed the program only as it appeared in the EHR and had not seen the updated exercises because the revised RNP had been entered in the wrong area of the system. Review of the February and March restorative records showed the updated Nursing Rehabilitation #1 was documented, but the records lacked documentation of the other revised programs. Staff A and the DON stated the updates had been entered incorrectly into CNA documentation rather than restorative documentation, and the DON reported the restorative nurse had been moved to the floor and that more training was planned. The facility policy on restorative nursing care lacked staff direction on specific communication and implementation of revised RNP programs.
Failure to Update PASRR for Resident with New Diagnosis
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, schizophrenia, and depression. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment. The resident's PASRR Level 1 Screening Outcome had previously referred them for a Level II onsite visit, but the PASRR determination excluded them from further PASRR requirements due to no PASRR diagnosis. However, a new diagnosis of paranoid schizophrenia was documented in the resident's medical records, which should have prompted a PASRR update. The Director of Nursing (DON) acknowledged awareness of the new diagnosis but failed to submit the required PASRR update. The facility's policy mandates that if a resident is diagnosed with a mental disorder while in the facility, the designated individual must contact the state agency for a Level II screening. The policy also requires that PASRR recommendations be incorporated into the care plan and that the state-designated mental health authority be notified promptly when a resident experiences a significant change in mental or physical status. Despite these requirements, the necessary PASRR update was not completed for the resident, leading to the deficiency.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide a sufficient number of staff to ensure timely response to residents' call lights, affecting five out of six residents reviewed. Resident #2, who has diabetes and dementia, reported having to wait for assistance to the restroom, leading to several falls. Resident #3, with thoracic spinal bifida and paraplegia, noted that call light response times varied, with waits of 15-30 minutes when staffing was low. Resident #4, who is dependent on staff for all activities of daily living, reported extended waits to be assisted off the commode. Resident #5, with morbid obesity, experienced waits of up to an hour for call light responses, with staff sometimes turning off the light without returning. Resident #6, who has chronic kidney disease and a history of falls, reported call light waits of over 15 minutes, sometimes up to 40 minutes. Interviews with staff revealed that staffing levels were frequently below the required number, with only three aides working instead of the needed four, leading to delays in resident care and meal service. Staff interviews highlighted the challenges faced due to inadequate staffing, with aides responsible for multiple halls and unable to meet residents' needs promptly. The facility's interim Director of Nurses was unaware of the staffing issues and related complaints. The dining room's meal service was also affected, with residents receiving room trays instead of dining room service due to insufficient staff to assist them in getting to meals on time.
Failure to Conduct Required TB Screening for New Employees
Penalty
Summary
The facility failed to provide tuberculosis (TB) screening for two of three new employees reviewed, specifically Staff H and Staff I, which is a requirement according to the facility's policy. Staff H, a Certified Nurses Aide, was hired on June 25, 2024, and worked full-time without completing the second step of the TB screening test. This was confirmed during an interview with Staff H, who stated that the former Director of Nurses only administered one TB screening test. Staff I, also a Certified Nurses Aide, was hired on December 19, 2023, and there was no record of any TB screening in her archived employee file received from the corporate office. The facility's Tuberculosis Control Plan and Screening for Employees policy, dated December 7, 2023, mandates that new employees undergo baseline TB screening and post-exposure screening according to CDC guidelines prior to employment. The Interim Director of Nurses, Staff F, confirmed the absence of TB testing records for both Staff H and Staff I, acknowledging that the screenings were not conducted as required.
Failure to Educate and Offer Annual Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five residents were educated about immunizations and offered the Influenza and Pneumococcal vaccinations annually. Specifically, Resident #20's Electronic Health Record (EHR) revealed she had not received the Pneumococcal Polysaccharide (PPSV23) and Pneumococcal Conjugated (PCV20) vaccines, and there was no documentation in her progress notes from 2/28/2020 to 5/9/2024 indicating that she was educated about or offered these vaccinations. Similarly, Resident #39's EHR showed he was not up to date with Pneumococcal vaccinations, and his progress notes from 11/30/2023 to 5/9/2024 lacked documentation of education or offers for these vaccines. Resident #15's EHR indicated he was not up to date with Influenza and Pneumococcal vaccinations, and his progress notes from 10/26/2021 to 5/9/2024 also lacked documentation of education or offers for these vaccines. Resident #34's EHR showed he was not up to date with Influenza and Pneumococcal vaccinations, with progress notes from 10/26/2021 to 5/9/2024 similarly lacking documentation of education or offers. During an interview, the facility's Infection Preventionist, who had been working at the facility for one month, confirmed that there should be documentation showing that residents were asked and educated annually about these vaccinations. The facility's policy stated that residents would be reviewed for vaccine eligibility on an ongoing basis as immunization recommendations change.
Failure to Send Appropriate Records During Resident Transfer
Penalty
Summary
The facility failed to send appropriate records for a transfer to the local emergency room (ER) for one resident. Record review of the resident's Minimum Data Set (MDS) indicated that the resident was discharged to the local hospital and had severely impaired cognitive skills for daily decision-making. The resident's Electronic Health Record (EHR) lacked documentation of a discharge assessment and did not specify what paperwork was sent with the resident to the hospital. During an interview, the facility's Administrator revealed that the hospital was not updated, and documents regarding Activities of Daily Living (ADLs), the Care Plan, or personal belongings were not sent with the resident. The facility's policy required completing a Transfer Form in the EHR, printing it, and placing it in an Acute Care Transfer envelope to be sent with the resident, which was not followed in this case.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility inaccurately coded the Minimum Data Set (MDS) for two residents by documenting that they received insulin during the look-back period when they did not. Specifically, the MDS for Resident #4 indicated she received one insulin injection between 2/9/24 and 2/15/24, but her Treatment Administration Record (TAR) for February 2024 showed no insulin medications were administered. Similarly, the MDS for Resident #10 indicated she received one insulin injection between 2/16/24 and 2/22/24, but her TAR also showed no insulin medications were administered. During interviews, it was revealed that the Nurse Consultant mistakenly identified Trulicity, an incretin mimetic, as insulin based on incorrect information from a form provided by the corporation, rather than using the Resident Assessment Instrument (RAI) medication websites.
Failure to Document Non-Pharmacological Interventions Before Administering PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to provide documentation of non-pharmacological interventions attempted prior to administering PRN anti-anxiety medications for a resident. Specifically, Resident #22 received his once-a-day PRN anti-anxiety medication on multiple dates in March 2024 without any documented attempts of non-pharmacological interventions in his Progress Notes. The review of the resident's Progress Notes from 3/4/24 to 3/18/24 showed a lack of documentation regarding these interventions. Additionally, the Pharmacy Consultant's Progress Notes from 2/4/24 to 5/3/24 did not include any direction to staff to document interventions attempted before administering PRN anti-anxiety medications. During an interview, the Director of Nursing confirmed that she would expect such documentation and noted that their Electronic Health Record system has a feature for adding Progress Notes. The facility's policy on Psychotropic Medications, last revised on 12/06/2023, also instructed that non-pharmacological interventions should be attempted and documented before medication interventions.
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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 West Union
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Crest Manor | 9 mi | ★★★★★ | 0 | 0 |
| Ossian Care Center | 12.3 mi | ★★★★★ | 15 | 0 |
| Hillcrest Home | 17.4 mi | ★★★★★ | 0 | 0 |
| Grandview Healthcare Center | 21.2 mi | ★★★★★ | 5 | 0 |
| Oelwein Health Care Center | 21.4 mi | ★★★★★ | 9 | 0 |
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