Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Society - Ellsworth Village during CMS and state inspections, most recent first.
A facility failed to identify causes and implement effective fall interventions for residents with severe cognitive and mobility impairments. One resident with Parkinson’s disease, Lewy body neurocognitive disorder, hallucinations, and dependence for transfers had repeated unwitnessed falls involving wheelchair pedals, unlocked brakes, attempts to reach a walker, and sliding from bed, while event reports repeatedly lacked root cause analysis and the care plan often had no new interventions. Another resident with Parkinson’s disease and dementia had multiple toileting-related falls, but the EMR lacked a toileting plan or toileting assessments after the falls. A third resident with Parkinson’s disease and dementia had repeated falls in the room and lobby, with care plans that did not document new interventions after several events.
The facility failed to maintain sanitary conditions in the kitchen, affecting food storage, preparation, and serving for 38 residents. Observations included improper storage of food items, expired sanitation test strips, and inadequate hygiene practices by dietary staff. These deficiencies placed residents at risk for foodborne illness.
The facility did not ensure that the required members, including the medical director, attended QAPI meetings at least quarterly. A review of attendance sheets from July 2023 through June 2024 showed low attendance at the November 2023 meeting, with the medical director absent during the last quarter of 2023. This was confirmed by administrative staff, indicating a failure to adhere to the facility's QAPI Plan, which aimed to improve resident outcomes and experiences.
The facility failed to ensure that residents had approved indications for antipsychotic medications and did not attempt gradual dose reductions (GDR) or document clinical contraindications. A resident received Zyprexa for anxiety without an approved indication or a 14-day stop date for the PRN dose. Another resident received Seroquel for anxiety without GDR attempts, and a third resident received Zyprexa and Celexa without appropriate documentation. Additionally, a resident was given paroxetine and clonazepam without a risk versus benefit statement or GDR attempts, placing them at risk of unnecessary psychotropic medications.
A facility failed to revise the care plan for a resident with PTSD, lacking specific triggers and interventions to prevent re-traumatization. Despite the resident's intact cognition and PTSD diagnosis, the care plan was incomplete, and staff were unaware of specific triggers. Administrative Nurses confirmed the deficiencies, and the facility did not provide a care plan policy.
A resident with multiple medical conditions, including dementia and malnutrition, did not receive adequate nursing care as the facility failed to monitor and document oral meal intake and administer tube feedings per physician orders. Additionally, the resident's low urinary output was not reported to the physician, placing the resident at risk for complications.
Two residents received inadequate catheter care, with catheter tubing dragging on the floor and improper use of personal protective equipment, increasing the risk of UTIs. Staff failed to follow enhanced barrier precautions and catheter care protocols, compromising resident safety and dignity.
A facility failed to provide trauma-informed care for a resident with PTSD, as the care plan lacked specific triggers and coping strategies. Staff were aware of the PTSD diagnosis but not the specific triggers, and the trauma assessment was incomplete. This oversight placed the resident at risk for unmet behavioral health care needs.
The facility failed to act on the Consultant Pharmacist's recommendations for three residents regarding the use of antipsychotic and psychotropic medications. A resident continued to receive Zyprexa and Celexa without a documented rationale, another resident was given paroxetine and clonazepam without a risk versus benefit statement, and a third resident lacked a 14-day stop date for PRN Zyprexa. These oversights placed the residents at risk for unnecessary medication use.
The facility failed to implement enhanced barrier precautions (EBP) during catheter care for two residents, leading to potential infection risks. Staff did not use gowns or follow proper hand hygiene protocols, and contaminated equipment was used. Administrative staff confirmed EBP was not initiated as required, and the facility's EBP protocol was not followed, including the setup of PPE stations and proper signage.
A facility failed to implement antibiotic stewardship protocols, resulting in the unnecessary extended use of Augmentin for a resident with multiple diagnoses, including dementia and UTI. The facility did not monitor the antibiotic's effectiveness or provide a rationale for its prolonged use, lacking a stop date in the physician's order. Despite attempts by the administrative nurse to address the issue, the physician declined to discontinue the antibiotic, placing the resident at risk for complications.
Repeated Falls Without Effective Root Cause Analysis or Updated Care Plans
Penalty
Summary
The facility failed to identify causative factors and implement effective interventions to prevent falls for three residents with significant cognitive and mobility impairments. One resident had chronic kidney disease, anxiety disorder, Parkinson’s disease, neurocognitive disorder with Lewy bodies, visual hallucinations, generalized weakness, and unsteadiness on feet, and the MDS documented severe cognitive impairment, hallucinations, delusions, and dependence for transfers and walking. The resident had repeated noninjury falls, and the fall care area assessment noted decreased cognition and safety awareness, tremors that made ambulation unsafe without assistance, and staff instruction to assist with ambulation when restless. For this resident, multiple fall investigations documented repeated episodes of being found on the floor in the room, lobby, doorway, or near the bed or wheelchair. The reports described situations such as the resident tripping on wheelchair pedals, trying to reach a walker, attempting to stand or walk on his own, sliding or rolling out of bed, and being found with wheelchair brakes unlocked. Several events noted that the resident was confused, agitated, or unclear about where he was going. The care plan was repeatedly noted to lack new interventions after falls, and the event reports repeatedly lacked a root cause analysis. A second resident had Parkinson’s disease and dementia with mood disturbance, severely impaired cognition, frequent incontinence, and dependence for toileting. The resident had multiple falls associated with attempts to toilet, self-transfer, or use the recliner, including being found on the floor with pants down, in the bathroom after slipping while trying to sit on the toilet, and sliding out of a recliner after raising it with the remote. The EMR lacked documentation of a toileting plan, toileting diary, or toileting assessments after the falls, and staff stated the resident did not have a toileting routine and was only observed hourly. A third resident had Parkinson’s disease, dementia without behavioral disturbance, severe cognitive impairment, wandering, dependence for toileting and transfers, and repeated falls in the room and lobby. The fall investigations described attempts to self-transfer, leaning forward in the wheelchair, sliding to the floor, and being found wrapped in blankets on the floor. For this resident, the care plan lacked documentation that new interventions were put into place after several falls, and the facility stated it was still working toward a better fall investigation process and root cause analysis.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the storage, preparation, and serving of food for 38 residents. During an inspection, it was observed that numerous boxes were stored directly on the floor of the walk-in refrigerator and freezer. An opened bag of carrots with an expired use-by date and an unsealed bag of chicken patties without a label or use-by date were found in the refrigerators. Additionally, cups were improperly stored in a bulk bin of thickener, and the ice machine drainage spout was improperly positioned. The kitchen also had two fans with visible dust blowing directly onto clean areas and food service windows, and sanitation test strips were found to be expired. Dietary staff were observed not following proper hygiene protocols. One staff member, while preparing meals, did not change gloves after touching various surfaces and wiping hands on clothing. Another staff member continued to wear the same gloves after leaving and returning to the kitchen. The facility's policies on food storage, hand washing, and glove use were not adhered to, and there was a lack of information regarding the ice machine's drainage air gap in the facility's policy. These deficiencies placed the residents at risk for foodborne illness.
QAPI Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the required members, including the medical director, attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. The facility had a census of 38 residents, and the sample included 12 residents. A review of the QAPI meeting attendance sheets from July 2023 through June 2024 revealed that only four members attended the November 2023 meeting, and the medical director did not attend any QAPI meeting during the last quarter of 2023. This lack of attendance was verified by Administrative Staff B on 07/02/24. The facility's 2024 QAPI Plan, dated 01/30/24, outlined a comprehensive and data-driven program aimed at improving resident outcomes and experiences, but the failure to ensure the medical director's attendance placed residents at risk of unidentified quality care services.
Failure to Ensure Approved Indications and GDR for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that several residents had an approved indication for the use of antipsychotic medications and did not attempt gradual dose reductions (GDR) or document clinical contraindications for these medications. Resident 25, who had severe cognitive impairment and multiple health issues, was receiving Zyprexa for anxiety without an approved indication and without a 14-day stop date for the PRN dose. The facility's consultant pharmacist did not identify or report the lack of an approved indication or the absence of a required stop date for the PRN medication. Additionally, non-pharmacological interventions were not documented as attempted or failed before the use of the antipsychotic. Resident 31, diagnosed with dementia and anxiety, was receiving Seroquel for anxiety without an approved indication and without attempts at GDR. The facility's care plan included non-medication approaches for anxiety, but there was no evidence of a physician-documented rationale for the continued use of Seroquel without GDR attempts. The consultant pharmacist had recommended a GDR, but the prescriber chose to continue the medication without providing the required documentation or rationale. Resident 22 was receiving Zyprexa and Celexa for anxiety and depression, respectively, without appropriate documentation or rationale for the continued use of these medications. The facility failed to follow up on the consultant pharmacist's recommendations for GDR and did not obtain an appropriate indication for the use of Zyprexa. Similarly, Resident 32 was receiving paroxetine and clonazepam without a documented risk versus benefit statement or rationale for their continued use, and no GDR attempts were made. These failures placed the residents at risk of receiving unnecessary psychotropic medications.
Failure to Revise Care Plan for PTSD Resident
Penalty
Summary
The facility failed to revise the care plan for a resident diagnosed with PTSD, which placed the resident at risk for impaired care due to uncommunicated care needs. The resident's care plan, initiated in 2021, included the use of antianxiety medications related to adjustment issues, his mother's death, and PTSD. However, it lacked specific information regarding triggers and interventions to prevent re-traumatization. Despite the resident's intact cognition and the presence of a PTSD diagnosis, the Trauma Assessment recorded an answer of no to experiencing trauma, and the assessment was incomplete in describing trauma symptoms, triggers, and coping strategies. Observations and interviews with staff revealed a lack of awareness and understanding of the resident's PTSD triggers. Certified Nurse Aides and Licensed Nurses were aware of the PTSD diagnosis but were unsure of the specific causes or triggers. Administrative Nurses confirmed the care plan's deficiencies, acknowledging the absence of triggers and coping strategies that would benefit the resident. The facility did not provide a care plan policy, further contributing to the deficiency in addressing the resident's PTSD needs.
Failure to Monitor Nutritional Intake and Urine Output
Penalty
Summary
The facility failed to provide adequate nursing care for a resident, identified as R25, by not adhering to physician orders for tube feedings and monitoring urine output. R25 had multiple medical conditions, including dementia, dysphagia, and malnutrition, and was dependent on staff for various activities of daily living. The resident's care plan required monitoring of nutritional intake and urine output, but the facility did not consistently document or administer the prescribed tube feedings when the resident's oral intake was insufficient. The resident's electronic medical record (EMR) showed a lack of documentation for oral meal intake for 15 out of 45 meal opportunities, and there was no evidence that the staff assessed or administered the physician-ordered tube feedings during these times. Additionally, the EMR recorded a urinary output of less than 30 ml per hour for 15 days, indicating minimal kidney function, but there was no evidence that this was reported to the physician. These lapses in care placed the resident at risk for medical complications. Interviews with staff revealed that the dietary department was responsible for recording meal intake and reporting it to the charge nurse, but the nursing staff failed to ensure supplemental feedings were given when necessary. The facility's policy on intake and output with hydration guidelines emphasized the importance of maintaining proper hydration and nutritional status, but the staff did not follow these guidelines, leading to the deficiency in care for R25.
Inadequate Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for two residents, R22 and R91, which placed them at risk for urinary tract infections and other catheter-related complications. R22, who had a history of multiple medical conditions including cerebral infarction, kidney failure, diabetes, and a history of UTIs, was observed with improper catheter care. The catheter tubing was allowed to drag on the floor, and catheter care was performed without using enhanced barrier precautions (EBP) as required. Additionally, catheter care was conducted in a common bathroom, which was against the facility's protocol. R91, who had a cervical spine fracture and urinary hesitancy, was also subjected to inadequate catheter care. Observations revealed that R91's urinary catheter bag was not covered, exposing the urine to other residents, and catheter care was performed without the use of an isolation gown. The catheter drainage bag was placed directly on the floor without a barrier, and contaminated wipes were used improperly, further increasing the risk of infection. The facility's failure to implement EBP for R91 upon admission further contributed to the deficiency. The facility's policies on catheter care and EBP were not adhered to, as evidenced by the observations and staff interviews. Staff failed to use personal protective equipment appropriately and did not follow procedures to prevent catheter tubing from touching the floor. These lapses in protocol and care placed both residents at risk for further UTIs and compromised their dignity and safety.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, epilepsy, heart failure, weakness, morbid obesity, and localized edema. The resident's care plan did not include specific triggers or coping strategies to prevent re-traumatization, despite the resident's history of trauma related to COVID-19 and the death of a close family member. The trauma assessment was incomplete, lacking descriptions of how trauma affected the resident and what might trigger re-traumatization. Staff members, including CNAs and licensed nurses, were aware of the resident's PTSD diagnosis but were not informed about specific triggers or the cause of the PTSD. The facility's trauma-informed care policy aimed to avoid re-traumatization by anticipating and avoiding practices that could trigger trauma, but this was not effectively implemented for the resident. The lack of a comprehensive care plan addressing the resident's PTSD placed the resident at risk for unmet behavioral health care needs.
Failure to Act on Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to follow up on the Consultant Pharmacist's (CP) recommendations regarding the use of antipsychotic and psychotropic medications for three residents, placing them at risk of receiving unnecessary medications. For Resident 22, the CP questioned the use of Zyprexa for anxiety without a documented rationale. Despite recommendations for a gradual dose reduction (GDR) of Zyprexa and Celexa, the physician did not provide a risk versus benefit rationale for the continued use of these medications. The facility's Drug Regimen Review policy required such follow-ups, but they were not conducted, leading to the deficiency. Resident 32's case involved the use of paroxetine and clonazepam for anxiety and dementia. The CP recommended a GDR for these medications, but the physician declined without providing a rationale or risk versus benefit statement. The facility did not ensure that the CP's recommendations were acted upon, as required by their policy, resulting in the resident continuing to receive these medications without proper justification. For Resident 25, the facility failed to ensure the CP identified and reported the lack of a 14-day stop date for PRN Zyprexa and the absence of an appropriate indication for its use. The CP's progress notes did not address these issues, and the facility did not follow up on the CP's recommendations. This oversight placed the resident at risk for inappropriate medication use, as the facility's policy required action on the CP's findings.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were used during catheter care for two residents, R22 and R91, which placed them at risk for potential infections and cross-contamination. Observations revealed that staff members did not follow proper infection control protocols. For instance, CNA N assisted R22 with catheter care without wearing a gown and failed to wash hands between glove changes. Similarly, CNA M provided catheter care for R91 without using an isolation gown and placed the measuring container directly on the floor without a barrier. Additionally, CNA M used a contaminated alcohol wipe on the port holder of the catheter bag. Administrative staff confirmed that EBP should have been initiated for R91 upon admission and verified that it was not implemented. The facility's EBP protocol required staff to determine the need for EBP for residents with indwelling medical devices and to set up a PPE station, notify staff, post signs, update care plans, and educate staff, residents, and families. However, these procedures were not followed, as evidenced by the lack of proper signage and PPE use during high-contact care for residents with urinary catheters.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic stewardship protocols, leading to the unnecessary and inappropriate extended use of the antibiotic Augmentin for a resident identified as R25. The resident's electronic medical record documented multiple diagnoses, including dementia, dysphagia, and urinary tract infection, among others. Despite these conditions, the facility did not monitor the effectiveness of the antibiotic treatment or provide a physician-documented rationale for the extended use of Augmentin. The physician order for the antibiotic lacked a stop date, and there was no evidence that the benefits of prolonged antibiotic use outweighed the risks of increased antibiotic resistance. Observations and interviews revealed that the resident had been on Augmentin since admission, and the facility's administrative nurse had attempted to address the issue with the physician, who declined to discontinue the antibiotic. The facility's antibiotic stewardship policy aimed to decrease the incidence of multi-drug resistant organisms and promote appropriate antibiotic use, but it was not effectively implemented in this case. This oversight placed the resident at risk for complications related to antibiotic use, as the facility did not adhere to its own protocols for monitoring and evaluating antibiotic therapy.
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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 Ellsworth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilson Care And Rehab | 14.8 mi | ★★★★★ | 19 | 0 |
| Lincoln Park Manor Inc | 23.3 mi | ★★★★★ | 28 | 0 |
| Riverview Estates | 24.5 mi | ★★★★★ | 0 | 0 |
| Sandstone Heights | 25 mi | ★★★★★ | 0 | 0 |
| Bethany Home Association | 31.5 mi | ★★★★★ | 2 | 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.