Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 - Decatur County during CMS and state inspections, most recent first.
The facility did not submit complete and accurate nurse staffing data through the PBJ system as required, despite having adequate licensed nurse coverage on the dates in question. The PBJ report indicated missing coverage due to inaccurate data submission, which was the responsibility of a former HR staff member.
The facility did not maintain a secure and accurate system for the emergency medication kit, leaving it unlocked and without an inventory list, and failed to properly label and date a resident's Insulin aspart pen. Staff were unable to account for missing medications from the E-Kit, and there was no system in place for reconciling medication usage, contrary to facility policy.
The facility did not ensure that the director of food and nutrition services was a certified dietary manager, as the staff member in this role was still in the process of obtaining certification and had not yet taken the required test. The facility also lacked a policy outlining the qualifications for this position, and a registered dietician only visited twice a month to review residents' diets.
The facility failed to notify the Ombudsman and provide written bed-hold policy information to a resident and their family during multiple hospital transfers, and did not complete a required recapitulation and medication reconciliation in the discharge summary for another resident. These actions did not follow facility policies for resident transfers and discharges.
A resident with dementia and impaired vision, dependent on staff for all ADLs, did not have access to a functional pair of glasses for an extended period. Despite care plan directives and physician orders requiring staff to ensure the resident wore her glasses, the glasses remained broken and the resident's representative was not notified. Staff interviews revealed a lack of communication and follow-through, resulting in the resident being without her necessary visual aid.
A resident with a history of hypertension and vascular conditions was administered metoprolol without physician-ordered blood pressure parameters. Staff confirmed that daily blood pressure readings were taken, but the medication order lacked specific parameters as required by facility policy, resulting in a deficiency related to medication management.
A resident's Insulin Aspart pen was discovered in the medication cart without a date indicating when it was opened. A licensed nurse confirmed the pen had been used and was not labeled as required, and the administrative nurse stated that staff are expected to document both the opened and expiration dates on insulin pens. The facility could not provide a policy on insulin pen storage and labeling when asked.
Multiple residents with severe cognitive impairments and high care needs were left in unkempt conditions, without adequate personal hygiene, and without access to scheduled activities or staff interaction due to insufficient nursing and activity staff. Staff reported that the number of CNAs was inadequate to meet residents' ADL needs, especially for those requiring two-person transfers, and that activities were outdated and not consistently provided. Administrative staff acknowledged the issues with activity programming but maintained that staffing was appropriate, despite evidence to the contrary.
Multiple residents with severe cognitive impairments and high ADL needs were observed unkempt, in soiled or wrinkled clothing, with food debris on their bodies and wheelchairs, and left unattended without engagement in activities. Staff interviews revealed that inadequate CNA staffing prevented completion of personal hygiene and grooming, and administrative staff had conflicting views on staffing sufficiency, despite facility policy requiring adequate staff to meet resident needs.
Multiple residents with cognitive and physical impairments did not receive proper assistance with ADLs, personal hygiene, or engagement in meaningful activities. Residents were observed in unkempt and soiled conditions, left unattended for long periods without staff interaction, and did not consistently receive drinks or snacks between meals. Staff interviews confirmed that inadequate staffing prevented completion of necessary care and activities, and the activity calendar was outdated and not individualized. Administrative staff and direct care staff disagreed on whether staffing was sufficient to meet residents' needs.
Multiple residents with severe cognitive and physical impairments were left without meaningful activities or staff engagement, often sitting unattended in the activity room with only recorded hymnals playing. Staff interviews revealed insufficient staffing to provide both personal care and activities, and the activity calendar was rarely updated to reflect current resident interests. Administrative staff confirmed that activities were outdated and did not meet all residents' needs, resulting in a lack of meaningful interaction and engagement.
Failure to Accurately Report Staffing Data in PBJ Submission
Penalty
Summary
The facility failed to submit complete and accurate staffing information through the Payroll Based Journaling (PBJ) system as required by CMS. Although the facility maintained licensed nurse coverage 24 hours a day and had adequate staffing on the dates in question, the PBJ report for Fiscal Year Quarter 4, 2024, indicated missing licensed nurse coverage on several specific dates. Review of the facility's daily nursing staff coverage confirmed that licensed nurse coverage was present on those dates, but the submitted PBJ data did not accurately reflect this. The human resource staff member responsible for submitting the PBJ during that period was no longer employed at the facility. The facility's policy required complete and accurate reporting of direct care staffing information to CMS in the specified format.
Failure to Secure and Reconcile Emergency Medication Kit and Label Insulin
Penalty
Summary
The facility failed to maintain a secure and accurate system for managing medications in the emergency medication kit (E-Kit). During an inspection, the E-Kit was found unsecured on the medication room counter, lacking the required inventory list. Staff were unable to locate the inventory sheet, and it was confirmed by multiple nurses that the E-Kit should be secured with a zip tie and that an inventory list should be present inside the kit. Additionally, the staff did not consistently check to ensure the E-Kit was locked after use. An audit revealed missing medications, including vials of Haldol, lidocaine, and ampules of Phenergan, and there was no system in place for reconciling the medications removed from the E-Kit. Furthermore, the facility failed to properly label and date a resident's Insulin aspart pen, which is necessary for accurate medication administration and billing. The pharmacist delivered the E-Kit unlocked and provided an inventory list, but did not supply a reconciliation sheet for tracking medication usage. The facility's policy required the E-Kit to be kept locked, with an inventory list posted, and for record keeping to be in accordance with state pharmacy regulations. These lapses in medication management and record keeping placed residents at risk for inaccurate billing and potential medication errors.
Unqualified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a certified dietary manager (CDM). During an initial tour of the kitchen, the staff member responsible for dietary services stated she was currently taking classes to become certified but had not yet taken the certification test. It was also noted that a registered dietician visited the facility twice a month to review residents' diets and address any weight loss. Additionally, administrative staff confirmed that the dietary manager had not yet achieved certification and would be taking the test soon. The facility was unable to provide a policy regarding the qualifications for a Certified Dietary Manager when requested.
Failure to Provide Required Notifications and Complete Discharge Documentation
Penalty
Summary
The facility failed to provide required notifications and documentation related to resident transfers and discharges. Specifically, when a resident with multiple complex diagnoses, including a femur fracture, diabetes, COPD, CHF, and chronic kidney disease, was transferred to the hospital on several occasions, there was no evidence in the clinical record that the resident's family received written information regarding the facility's bed-hold policy. Additionally, there was no documentation that the Office of the Long-Term Care Ombudsman was notified of the resident's hospital transfers, as required by facility policy. The same resident experienced multiple hospital admissions for events such as a transient ischemic attack and stroke-like symptoms, yet each transfer lacked the required notifications to both the family and the Ombudsman. The facility's own bed-hold policy stipulated that written information about bed-hold duration and payment policies must be provided at the time of transfer, and that a copy should be sent with the resident to the hospital for the representative. The discharge and transfer policy also required that the Ombudsman be notified of transfers, but these steps were not documented as completed. In a separate case, another resident was transferred to a different facility to be closer to family. The discharge summary for this resident was incomplete, lacking a recapitulation of the resident's stay and a reconciliation of medications, despite the facility's policy requiring these elements to be included in the discharge documentation. Administrative staff confirmed that the medication reconciliation section was not completed, and acknowledged that it should have been done according to policy.
Failure to Provide Functional Glasses for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with impaired vision had access to a functional pair of glasses as required by her care plan and physician orders. The resident, who had diagnoses including dementia, hypertension, and a history of falls, was dependent on staff for all activities of daily living and required full assistance, including the use of a wheelchair and mechanical lift. Her care plan and medical orders specified that staff were to assist with her glasses, ensuring they were worn during awake hours and stored in the medication room when not in use. Despite these directives, the resident's glasses remained broken for an extended period, and she was observed without them on multiple occasions. Staff interviews and record reviews revealed that the facility was aware of the broken glasses since early July, but the resident's representative was not notified, and no action was taken to repair or replace the glasses. Administrative staff stated they were unaware of the issue and would have acted had they known. The facility's policy required staff to report problems with glasses to a licensed nurse, but this did not occur, resulting in the resident not having access to her necessary visual aid for an extended period.
Failure to Obtain Physician-Ordered Blood Pressure Parameters for Antihypertensive Medication
Penalty
Summary
The facility failed to obtain physician-ordered blood pressure parameters for a resident receiving metoprolol to treat hypertension. The resident had a medical history including hypertension, occlusion and stenosis of the right carotid artery, and occlusion and stenosis of the right posterior cerebral artery. The resident was cognitively intact, independent with activities of daily living, and did not ambulate. The care plan directed staff to monitor and report signs and symptoms of malignant hypertension and to administer medication as ordered. However, the physician's order for metoprolol did not specify blood pressure parameters, and this omission was confirmed by both a licensed nurse and an administrative nurse during interviews. The facility's policy required staff to document vital signs and recognize significant changes in blood pressure, reporting symptoms such as lightheadedness, dizziness, blurred vision, or shallow breathing. Despite this, the lack of specific physician-ordered parameters for blood pressure monitoring in relation to the administration of metoprolol represented a failure to ensure the resident's drug regimen was free from unnecessary drugs and that medications were administered safely according to physician guidance.
Undated Insulin Pen Found in Medication Cart
Penalty
Summary
A deficiency was identified when a resident's Insulin Aspart pen was found in the medication cart without a date indicating when it was opened. Observation confirmed that the insulin pen had been used and was not labeled with the opened date, as required. A licensed nurse verified the pen was undated and acknowledged that staff are expected to date insulin pens upon opening. The administrative nurse also stated that staff should document both the opened date and expiration date on insulin pens. The facility was unable to provide a policy regarding the storage and labeling of insulin pens when requested.
Failure to Provide Sufficient Nursing Staff and Activities
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate skill sets and competencies to meet the needs of multiple residents, resulting in unmet activities of daily living (ADL), lack of personal hygiene, and insufficient engagement in activities. Several residents with severe cognitive impairments, including dementia and Alzheimer's disease, were observed to be dependent on staff for all ADLs. Observations revealed that residents were left in unkempt conditions, such as uncombed hair, wrinkled or soiled clothing, and food debris on their faces and wheelchairs. Residents were also left unattended in the activity room for extended periods without staff interaction or access to drinks and snacks, and scheduled activities were not provided as outlined in their care plans. Certified Nurse's Aides (CNAs) and other staff consistently reported that there were not enough CNAs on shift to complete all required resident care, especially given that over half of the residents required two-person assistance for transfers. Staff stated that the lack of adequate staffing led to delays in morning personal hygiene, cold meals, and incomplete care. Activity staff were also absent, and replacement coverage was not observed, resulting in residents missing scheduled activities and spiritual support. Staff interviews indicated that activities were outdated and not tailored to residents' current needs, and administrative staff were not seen assisting with resident care. Administrative staff acknowledged the high acuity of the resident population and the need for two-person transfers for many residents but maintained that staffing was appropriate. However, they also admitted that the activity calendar was rarely updated and did not meet all residents' needs. The facility's own policy required sufficient nursing staff to ensure resident safety and well-being, but observations and staff interviews demonstrated that this standard was not met, leading to deficiencies in resident dignity, care, and quality of life.
Failure to Ensure Resident Dignity and Personal Hygiene Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that the facility failed to honor residents' rights to a dignified existence by not ensuring that multiple residents were well-groomed, clean, and dressed appropriately for the day. Observations revealed that several residents, all with significant cognitive impairments and dependent on staff for activities of daily living (ADLs), were left with uncombed hair, wrinkled or stained clothing, and food debris on their bodies and wheelchairs. In several instances, residents were left unattended in the activity room or in their own rooms without engagement in activities, and without staff present to assist or interact with them. Some residents were observed with visible food residue around their mouths after meals, and one resident was left in an uncomfortable, slouched position in a recliner with water out of reach. Interviews with multiple Certified Nurse's Aides (CNAs) consistently indicated that there was insufficient staffing to complete all required resident care, particularly for those needing two-person assistance for transfers. CNAs reported that the lack of adequate staff made it difficult to provide timely morning hygiene and personal care, resulting in residents being brought to breakfast and activities without being properly groomed or cleaned. Staff also noted that administrative personnel did not assist with resident care, and that the current staffing levels did not allow for the completion of all necessary ADLs and personal hygiene tasks. Administrative staff expressed differing views on staffing adequacy, with some acknowledging ongoing struggles to maintain sufficient staffing and others stating that staffing was appropriate. Despite this, administrative staff confirmed that a majority of residents required extensive assistance for transfers and ADLs. Facility policy required sufficient nursing staff to meet the needs of residents based on their acuity and care plans, but observations and staff interviews demonstrated that these standards were not being met, resulting in compromised resident dignity and psychosocial well-being.
Failure to Provide Adequate ADL Care and Activities Due to Insufficient Staffing
Penalty
Summary
Surveyors identified that multiple residents with significant cognitive and physical impairments did not receive appropriate assistance with activities of daily living (ADLs), personal hygiene, and engagement in meaningful activities. Observations revealed that several residents were left in unkempt conditions, such as uncombed hair, wrinkled or soiled clothing, and food debris on their faces and wheelchairs. Residents were also left unattended in the activity room for extended periods without staff interaction or access to scheduled activities, and some went without drinks or snacks between meals. These findings were corroborated by staff interviews, which consistently reported insufficient staffing levels to meet residents' care needs, particularly for those requiring two-person assistance for transfers and lifts. The report details that residents with diagnoses including dementia, Alzheimer's disease, depression, anxiety, and other chronic conditions were dependent on staff for all or most ADLs. Care plans for these residents specified individualized needs, such as wearing a bra daily, having hair combed, participating in preferred activities, and receiving one-on-one visits. Despite these directives, residents were observed without proper grooming, in soiled or stained clothing, and not engaged in activities tailored to their preferences. Staff interviews confirmed that due to inadequate staffing, morning personal hygiene was often neglected, and activities were not consistently provided or updated to reflect residents' interests and needs. Activity staff were not always present, and when absent, there was no effective coverage or communication to ensure residents' activity needs were met. The activity calendar was described as outdated and rarely changed, and spiritual needs for certain residents were not addressed due to lack of outreach to appropriate clergy. Administrative staff acknowledged that not all activities met residents' needs and that staffing levels were a point of contention, with some administrators believing staffing was sufficient while direct care staff disagreed. Facility policy required sufficient nursing staff to maintain residents' highest practicable well-being, but observations and staff statements indicated this standard was not met.
Failure to Provide Resident-Centered Activities and Adequate Engagement
Penalty
Summary
Surveyors identified that the facility failed to provide a resident-centered activities program that incorporated the interests, hobbies, and cultural preferences of multiple residents, specifically those with severe cognitive impairments and high ADL dependency. Observations revealed that several residents, including those with dementia, Alzheimer's disease, depression, and anxiety, were left in the activity room without staff presence or engagement in meaningful activities. Residents were observed sitting idly or sleeping in their wheelchairs, with only hymnals playing on an iPad and no staff interaction. Additionally, residents were not offered drinks or snacks for extended periods, and personal hygiene needs were not consistently met, as evidenced by uncombed hair, wrinkled or soiled clothing, and food debris on their bodies and wheelchairs. Interviews with CNAs and activity staff confirmed that there was insufficient staffing to provide both personal care and activities, with staff reporting that the majority of residents required two-person assistance for transfers, leaving little time for hygiene or engagement. Activity staff admitted that the activity calendar was rarely updated and did not reflect the current interests or needs of the residents. When the designated activity staff was absent, there was no effective coverage, and other staff were often unaware of the activity schedule or unable to facilitate activities due to workload. Administrative staff acknowledged that the activities provided were outdated and redundant, and that the activity calendar did not meet all residents' needs. They also confirmed that over half of the residents required significant assistance for mobility and ADLs, further straining available staff resources. Facility policy required sufficient staffing to maintain residents' physical, mental, and psychosocial well-being, but observations and staff interviews indicated that this standard was not being met, resulting in a lack of meaningful interaction and activities for residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oberlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Nursing Home | 26.6 mi | ★★★★★ | 14 | 0 |
| Good Samaritan Society - Atwood | 27.1 mi | ★★★★★ | 0 | 0 |
| Andbe Home, Inc | 33.9 mi | ★★★★★ | 23 | 0 |
| Sheridan County Hospital Ltcu | 38 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Samaritan Society - Decatur County.
100% money-back within 48 hours.
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.