Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Ellis during CMS and state inspections, most recent first.
A resident with paraplegia, impaired upper and lower extremities, and a care plan identifying impaired ability to manage hot beverages was served hot chicken broth from a hot water/coffee machine whose temperature was not being routinely checked. An LN placed the lidded cup on the bedside table while the resident was in bed. When the resident reached across the table for another item, the cup was knocked over, and hot liquid escaped through the straw opening, spilling onto the resident’s left elbow and abdomen. Assessments documented reddened areas and later blistering requiring topical treatment and dressings. After the incident, staff measured the machine’s output at 159°F, above the 150°F level referenced in the facility’s hot liquids policy, and nursing leadership acknowledged they had relied on a malfunctioning temperature regulator instead of actively monitoring hot liquid temperatures.
Failure to assess a resident’s safe use of an electric lift recliner led to an unwitnessed fall. The resident had dementia, anxiety, muscle weakness, and a prior fall history, and the EMR lacked evidence of an electric lift chair safety assessment since admission. The resident was later found on the floor after sliding out of the recliner, and an RN verified the assessment had not been completed.
A pharmacist failed to identify that staff were not obtaining a resident’s BP before giving losartan as ordered, and also missed that the order had been transcribed incorrectly. The resident had HTN, CHF, and atrial fibrillation, and the EMR lacked documentation of the required weekly BP checks and pre-dose BP monitoring. Staff confirmed losartan was being administered without knowing whether the resident’s BP was within ordered parameters, and the CP’s MRRs did not note the irregularities.
A resident with HTN, CHF, and atrial fibrillation had a physician order for weekly BP checks and for losartan 50 mg at bedtime only if BP was above 130/80 mmHg. The EMR lacked documentation of the ordered weekly BP monitoring and lacked evidence that BP was checked before losartan doses were given, and an LPN confirmed the medication was administered without knowing whether the resident’s BP was within parameters.
Burn Injury from Overheated Hot Liquid and Inadequate Temperature Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to prevent a hot liquid burn to a resident by not evaluating and monitoring the temperature of liquids dispensed from a hot water/coffee machine and instead relying on a temperature regulator that was not functioning. The resident involved had paraplegia with motor and sensory impairment of both upper and lower extremities, gastroparesis, epilepsy, and convulsions, and required total assistance with ADL self-care. The resident’s MDS documented intact cognition but impairment of bilateral upper and lower extremities, with a need for set-up or clean-up assistance with eating and dependence on staff for all other ADLs. The care plan identified an impaired ability to manage hot beverages and soups related to paraplegia, directed staff to offer foods at a liquid state at room temperature, and specified that hot beverages should be served in a mug with a lid, with reminders to be cautious with hot beverages and soups. On the day of the incident, a licensed nurse poured hot chicken broth for the resident in the dining room, placed it in a cup with a lid, and then placed the cup on the resident’s bedside table while the resident was in bed with the head of the bed elevated. A few minutes later, housekeeping staff heard the resident calling for help and found that the resident had spilled the hot chicken broth on himself. The liquid had escaped through the straw opening in the lid. The resident later explained that the nurse had set the broth on the middle edge of the bedside table closest to his body, and when he reached over the broth to get something in the middle of the table, he knocked the cup off to the left side. He stated he could not grab the cup and that it was leaking hot broth, and he attempted unsuccessfully to sop up the liquid with a napkin. Following the incident, assessments documented reddened areas and later blistering on the resident’s left elbow and left lateral abdomen consistent with a hot liquid burn. Initial measurements showed large reddened areas on the left elbow and abdomen, and subsequent documentation noted open blisters and pain with dressing changes, leading to the use of Silvadene cream and sterile dressings until the wound healed. After the burn occurred, administrative nursing staff manually checked the temperature of the hot water from the dispenser and found it measured 159°F immediately after dispensing and 154°F within a couple of minutes. Administrative nursing staff acknowledged that the facility did not regularly check the temperatures from the water/coffee machine because they relied on a built-in temperature regulator that was supposed to keep the temperature below 150°F, and they did not realize the regulator was not working until after this incident. The facility’s own hot liquids policy called for consideration of serving self-service hot liquids at or below 150°F and for evaluating residents with medical conditions that put them at risk for spills, allowing liquids to cool, and adding care plan interventions from the Hot Liquid Safety focus, underscoring that the failure to monitor and control the machine’s output temperature and to ensure safe serving conditions led to the resident’s burn. The resident consistently reported that the burn occurred when he accidentally knocked the hot beverage while reaching across his bedside table, and he initially stated he did not feel the event was traumatic, though he did report pain associated with the burn and dressing changes. Observations after the incident showed a dark pink area on the left outer elbow where the burn had been, in contrast to the resident’s pale surrounding skin. The documentation and interviews collectively show that the resident’s known physical impairments, dependence on staff, and identified risk related to hot liquids were present at the time of the event, and that the hot liquid was dispensed at a temperature above the facility’s policy threshold due to the unmonitored failure of the machine’s temperature regulator. These actions and inactions resulted in an actual burn injury to the resident.
Failure to Assess Safe Use of Electric Lift Recliner
Penalty
Summary
The facility failed to assess Resident 26 for the safe use of an electric lift recliner. Resident 26’s EMR documented dementia, anxiety, a wedge compression fracture at thoracic spine levels 11-12, and muscle weakness. The Quarterly MDS recorded a BIMS score of 14, indicating intact cognition, and noted the resident was independent with ADLs and had one fall with no injury. The Fall CAA identified fall risk related to antidepressant and antianxiety medications and chronic low back pain, and the Fall Care Plan documented a prior fall when the resident missed the chair in activities and later slid out of the recliner. The EMR lacked evidence that the facility assessed Resident 26 for safe use of the electric lift recliner since admission. The resident had an unwitnessed fall from the electric lift recliner and was found on the floor on her right side in the middle of the room. The resident stated she slid out of the chair and shimmied across the floor to get closer to the door to yell for help. The note documented low oxygen saturation, oxygen applied at two liters, and staff instructed the resident to call for help when getting up. Administrative Nurse D verified the resident had the electric lift recliner since admission and that an electric lift chair safety assessment had not been completed; the nurse also stated such assessments should be completed on admission, with a change in condition, and quarterly.
Pharmacist Failed to Identify Missing BP Monitoring for Losartan
Penalty
Summary
The facility’s Consultant Pharmacist failed to identify that staff were not obtaining Resident 7’s blood pressure before administering losartan as ordered, and failed to identify that the losartan order had been transcribed incorrectly. Resident 7 had diagnoses of hypertension, CHF, and atrial fibrillation, and the MDS documented intact cognition and use of a diuretic medication. The care plan directed staff to administer medications as ordered and to monitor, document, and report edema and weight changes. A physician’s order dated 11/15/21 directed staff to obtain weekly blood pressures on Mondays and notify the physician for specified blood pressure or pulse parameters, but the EMR lacked documentation that weekly blood pressures were obtained. A physician’s order dated 07/16/24 directed staff to administer losartan 50 mg by mouth at bedtime for CHF only if blood pressure was more than 130/80 mmHg, but the EMR lacked documentation that blood pressure was obtained prior to administration. Review of the Consultant Pharmacist’s medication regimen reviews from December 2024 through December 2025 lacked evidence that the pharmacist identified or reported the incorrect transcription of the losartan order or the absence of required blood pressure monitoring. Staff interviews confirmed that weekly blood pressures were not being obtained as ordered and that losartan was being administered without knowing whether the resident’s blood pressure was within parameters. Administrative staff stated the order had not been corrected in the EMR and that the Consultant Pharmacist had not made them aware of the irregularities.
Failure to Follow BP Parameters for Losartan
Penalty
Summary
The facility failed to administer medications as ordered for one resident with diagnoses of hypertension, CHF, and atrial fibrillation. The resident’s EMR documented intact cognition and dependence on staff for several activities of daily living, and the care plan included directions to administer medications as ordered and to monitor edema and weight changes. A physician’s order dated 11/15/21 directed staff to obtain weekly blood pressures on Mondays and to notify the physician for specified blood pressure or pulse parameters, but the EMR lacked documentation that weekly blood pressures were obtained. The physician also ordered losartan 50 mg by mouth at bedtime for CHF, to be given only if blood pressure was more than 130/80 mmHg. The EMR lacked documentation that blood pressure was taken before administering the bedtime dose of losartan in October, November, and December 2025. During interview, a licensed nurse verified that staff did not obtain the resident’s blood pressure every Monday as ordered and that losartan was administered without knowing whether the blood pressure was within parameters. An administrative nurse stated the order had not been corrected in the EMR and confirmed staff should have followed the physician’s orders as written.
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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 Ellis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Hays | 12.3 mi | ★★★★★ | 0 | 0 |
| Via Christi Village Hays Ks Llc | 14.2 mi | ★★★★★ | 6 | 0 |
| Trego Co-lemke Memorial Hospital Ltcu | 18.2 mi | ★★★★★ | 1 | 1 |
| Redbud Village | 24.2 mi | — | 2 | 0 |
| Locust Grove Village | 31.2 mi | ★★★★★ | 1 | 1 |
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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.