Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Society - Atwood during CMS and state inspections, most recent first.
Mail was not delivered to residents on Saturdays because there was no designated staff member assigned to this task on weekends. A resident reported the issue during a council meeting, and an administrative nurse confirmed the lack of weekend mail delivery, which was inconsistent with the facility's policy requiring prompt mail distribution.
The facility did not have a full-time Certified Dietary Manager overseeing food and nutrition services, as the current staff member in the role had only recently started the certification process and had not completed required training. This resulted in residents receiving meals from a kitchen without oversight from a fully qualified dietary professional.
The facility did not serve the midday meal within 45 minutes of the scheduled time on multiple occasions, resulting in two residents waiting nearly 90 minutes and not receiving the main menu item due to it running out. Staff were observed taking food intended for residents to the breakroom, and unannounced menu substitutions were made without informing residents. These actions did not align with the facility's policy to maintain dignity and respect in dining services.
Surveyors found food items, including canned pears, oatmeal cream pies, sliced zucchini, and frozen buns, stored directly on the floor in both the dry storage room and walk-in freezer. Dietary staff confirmed these items should have been on shelves, in accordance with facility policy requiring food to be stored at least six inches off the floor.
Staff did not consistently use required PPE, such as gowns and gloves, during high-contact care activities for a resident with a gastrostomy tube, despite facility policy and available signage indicating the need for Enhanced Barrier Precautions. This included a nurse cleaning a nebulizer mouthpiece and a CNA assisting with changing the resident's shirt without appropriate PPE.
Two residents and their representatives were not given the correct CMS notification forms regarding the end of skilled services and potential financial liability for non-covered services. Instead of receiving the required ABN and NOMOC forms, they were provided with incorrect or incomplete documentation, resulting in a lack of proper notification about Medicare non-coverage and their options.
A resident reported a sexual abuse incident, but the facility failed to investigate or initiate protective measures. The resident, with intact cognition, informed her representative, who reported it to an LPN. The LPN did not notify administration for nearly 24 hours and concluded it was a dream without a thorough investigation. The facility's inaction placed residents at risk, and no report was made to the state agency.
A resident reported an alleged sexual abuse incident to her representative, who informed a Licensed Nurse (LN) at the facility. The LN delayed reporting the allegation, and the facility failed to notify the required state agencies or conduct a proper investigation. The resident, with intact cognition, expressed fear of the incident, but staff dismissed it as a dream without thorough investigation, placing the resident in immediate jeopardy.
A resident with multiple diagnoses, including multiple sclerosis and malnutrition, developed an unstageable pressure ulcer on her left heel. The facility failed to notify the physician promptly, did not measure the wound for two weeks, and did not provide adequate treatment, leading to the wound becoming necrotic and advancing to a Stage 4 pressure ulcer. The resident was eventually hospitalized, diagnosed with osteomyelitis, and placed on palliative care, where she passed away.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to deliver mail to residents on Saturdays, resulting in residents not having reasonable access to send or receive written communications. Observations revealed a basket labeled United States Postal Service (USPS) containing numerous envelopes at the front entry, and interviews with a resident and the Administrative Nurse confirmed that mail was not delivered on weekends due to the absence of a designated staff member for this task. The facility's policy required mail to be delivered to residents within 24 hours of receipt by the post office, except when there is no regularly scheduled postal pick-up service, but this was not followed on Saturdays.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time Certified Dietary Manager for its 25 residents who receive meals from the kitchen. Observation showed that the kitchen staff member identified as the Dietary Manager was not yet certified, having only recently enrolled in a Certified Dietary Manager course. The facility's policy requires new Directors of Food and Nutrition Services to complete a job orientation and training program within three months of hire, with the initial two weeks prioritized for orientation. At the time of the survey, the Dietary Manager had just begun the certification process and had not yet completed the required training or obtained certification.
Delayed Meal Service and Menu Substitutions Impact Dining Experience
Penalty
Summary
The facility failed to serve the midday meal within 45 minutes of the designated time of 11:30 AM, as observed on multiple occasions. On one day, dietary staff began preparing the dining room at 11:18 AM, but the first meal was not served until 12:16 PM. Two residents who had been present in the dining room since 11:30 AM were not served until 12:55 PM, after being informed that the kitchen had run out of the main menu item, roast beef. These residents reported that they were always served last and that menu items often ran out before they were served. Additionally, a staff member was observed taking a plate of roast beef and cabbage to the breakroom, and it was reported that the remaining roast beef consisted only of end pieces not intended for residents. On another day, the last meal was served at 12:50 PM, with residents present in the dining room since 11:30 AM. There were unannounced substitutions to the menu, such as broccoli replacing cauliflower and tomato soup being offered instead of tomato salad, without prior notification to the residents. Dietary staff reported that meals were not plated and ready for delivery until after drinks and silverware had been placed on the tables. The facility's policy requires dining services to be provided in a manner that maintains or enhances each resident's dignity and respect.
Improper Food Storage in Kitchen and Freezer
Penalty
Summary
During an inspection of the facility's kitchen, surveyors observed multiple food items improperly stored directly on the floor in both the dry storage room and the walk-in freezer. Specifically, a case of canned pears and a box of oatmeal cream pies were found sitting on the floor in the dry storage area, while a bag of sliced zucchini and a box of frozen buns were found on the floor of the walk-in freezer. Dietary staff confirmed that these items should have been placed on shelves and acknowledged that the items in the freezer had fallen from the shelf and were not properly stored. The facility's own policy requires all food and supply items to be stored at least six inches off the floor and not in contact with walls, ceilings, or waste pipes. These observations were made while the facility had a census of 26 residents, with a sample of 12 residents included in the review.
Failure to Adhere to Enhanced Barrier Precautions for Resident with G-Tube
Penalty
Summary
The facility failed to adhere to infection control protocols for Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube. Observations revealed that a licensed nurse did not wear a gown while cleaning the resident's nebulizer mouthpiece after administering a nebulizer treatment. Additionally, a certified nurse aide assisted the same resident with changing his shirt without wearing gloves or a gown, despite the presence of personal protective equipment (PPE) and signage indicating the need for EBP for residents with indwelling medical devices such as feeding tubes. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, including feeding tubes, to prevent the spread of infection. PPE was available near the resident's room, and signage was posted with instructions for its use. However, staff did not consistently follow these protocols during observed care activities, resulting in a failure to implement the infection prevention and control program as outlined in facility policy.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the correct Centers for Medicare and Medicaid Services (CMS) notification forms to two residents or their representatives regarding the end of their skilled services and potential financial liability for non-covered services. Specifically, one resident received the CMS-R-131 and CMS 10055 forms but did not receive the required CMS Form 10123, while another resident received only the CMS-R-131 and did not receive either the CMS 10055 or the CMS 10123 forms. These forms are necessary to inform beneficiaries about the potential for Medicare non-coverage and to allow them to make informed decisions about continuing services and accepting financial responsibility. Administrative staff confirmed that the incorrect forms were provided and that the required notifications were not issued as per facility policy and CMS requirements. The facility's policy states that advance written notice must be given to beneficiaries before the termination of services or when services are likely to be denied by Medicare, in order to transfer financial liability. The failure to provide the correct forms meant that the residents or their representatives were not properly informed about their options or potential financial obligations related to the discontinuation of skilled services.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse and initiate protective measures for a resident, identified as R1, who reported an incident involving a male entering her room and attempting to molest her. R1, who had a BIMS score indicating intact cognition, reported the incident to her representative, who then informed a Licensed Nurse (LN G) at the facility. Despite the report, LN G did not notify the administration for almost 24 hours and concluded that R1 might have been dreaming, without conducting a thorough investigation. R1's medical records indicated she had diagnoses of congestive heart failure, hypertension, weakness, and macular degeneration, but no history of hallucinations or delusions. The facility's records showed that R1 was alert and oriented, and her care plan was updated to address a new behavior symptom related to dreaming. However, the facility did not provide any investigation, incident report, or witness statements related to the incident, and the administration agreed with LN G's conclusion without further inquiry. The facility's inaction placed R1 and other cognitively impaired residents in immediate jeopardy, as no protective measures were initiated to prevent further potential abuse. The facility did not report the incident to the state agency, and the administration was satisfied with the incomplete investigation conducted by LN G. This lack of action and failure to follow proper procedures for abuse allegations resulted in a deficiency being identified by the surveyors.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that staff immediately reported a resident's allegation of sexual abuse to the Licensed Nursing Home Administrator (LNHA) and further failed to report the allegation to the required state agencies, including law enforcement. The incident involved a resident who reported to her representative that a man had entered her room and attempted to molest her. The representative promptly informed a Licensed Nurse (LN) at the facility, who did not report the allegation until the following day, and the facility did not conduct a proper investigation or report the incident to the appropriate authorities. The resident involved had a history of congestive heart failure, hypertension, weakness, and macular degeneration, but was documented to have intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. Despite the resident's clear report of the incident to her representative and later to the ombudsman, the facility staff, including the LN and administrative staff, dismissed the allegation as a possible dream without conducting a thorough investigation or taking immediate protective actions. The facility's failure to act on the resident's report placed her in immediate jeopardy. The staff did not document an investigation, incident report, or witness statements related to the incident, and the administrative staff expressed uncertainty about the need to investigate allegations perceived as dreams. This lack of action and failure to follow proper reporting protocols resulted in a deficiency being identified by surveyors.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure adequate treatment to prevent the worsening of a facility-acquired pressure ulcer and failed to promote healing for a resident. The resident, who required assistance from two staff for bed mobility, developed an unstageable pressure ulcer on her left heel. Despite the application of heel protectors, the facility did not involve the provider until seven days later. The provider ordered a dressing to be changed every seven days, but the wound became stagnant and showed no signs of healing for several months. The facility also failed to measure the wound for two weeks and did not notify the physician despite increased wound dimensions and signs of possible infection, including increased drainage and pain. The resident was eventually sent to the hospital, where the wound was found to be necrotic with purulent, foul-smelling drainage and had advanced to a Stage 4 pressure ulcer with exposed bone. The resident was diagnosed with osteomyelitis and was recommended for amputation, which she and her family declined. She was placed on palliative care and passed away at the hospital. The resident's electronic medical record documented multiple diagnoses, including multiple sclerosis, moderate protein-calorie malnutrition, weakness, depression, and anxiety. The resident was admitted to the facility with intact skin but was at risk for pressure ulcer development. The facility's care plan directed staff to provide a pressure-reducing mattress and cushion, float her heels, and notify the nurse immediately of any new areas of skin breakdown. However, the care plan lacked direction regarding how often the resident was to be repositioned. The facility's records showed multiple instances where the wound was not properly documented, and the primary care physician was not notified of the wound's status or changes. The facility's failure to notify and involve the physician and ensure physician assessment of the evolving and progressively worsening pressure ulcer placed the resident in immediate jeopardy. The facility's records lacked evidence of timely and appropriate wound care interventions, and the resident's condition deteriorated significantly, leading to severe complications and ultimately her death. The facility's inaction and lack of proper documentation and communication contributed to the resident's suffering and poor outcome.
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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 Atwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Decatur County | 27.1 mi | ★★★★★ | 19 | 0 |
| Colby Operator, Llc | 30 mi | ★★★★★ | 0 | 0 |
| Citizens Medical Center Ltcu | 30.2 mi | ★★★★★ | 0 | 0 |
| Sarah Ann Hester Memorial Home | 31 mi | ★★★★★ | 7 | 0 |
| Hillcrest Nursing Home | 34 mi | ★★★★★ | 14 | 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.