Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 - Comforcare during CMS and state inspections, most recent first.
A resident with dysphagia was served a regular textured meal instead of the prescribed soft and bite-sized diet, with key restrictions missing from the diet slip, leading to an aspiration event and hospitalization. Staff interviews revealed breakdowns in communication and documentation of diet orders. Additionally, another resident's severe peanut allergy was not listed on the diet slip, despite being known to staff.
A resident with multiple medical conditions experienced a fall after being left unattended during a transfer. Staff failed to perform or document a comprehensive assessment, did not notify the provider promptly, and did not document the resident's refusal of assessment or provide education about the risks of refusal. Facility policy requiring assessment, documentation, and care plan updates after a fall was not followed.
Two residents with significant fall histories experienced repeated falls due to the facility's failure to comprehensively assess each incident, identify causal factors, and implement individualized interventions. One resident, physically dependent and cognitively intact, suffered multiple falls related to toileting needs and self-transfers, including a clavicle fracture, while another resident with severe cognitive impairment repeatedly fell due to self-transfer attempts. Incident reports and care plans lacked thorough analysis and timely updates, and interventions did not address root causes, as confirmed by staff and the interim DON.
Staff did not use required gowns and gloves during high-contact care for a resident with an indwelling medical device, and proper hand hygiene was not performed before or after care activities for two residents. These actions were not in accordance with the facility's infection prevention and control policies.
The facility failed to provide the SNFABN-CMS-10055 to two residents who remained in the facility after their Medicare services ended. Both residents had remaining Medicare days, but the necessary notice to inform them of their financial responsibility for non-covered services was not given. Staff interviews revealed a lack of awareness about the requirement to provide this notice, and the administrator confirmed the oversight.
A resident in hospice care reported a broken window shade that compromised privacy, especially during catheter changes. Despite informing staff, the issue remained unresolved for months. The facility lacked a maintenance tracking system, and the administrator was unaware of the problem until it was observed during a survey. Maintenance staff confirmed they were not informed of the issue until the survey day.
Failure to Provide Correct Diet Texture and Document Allergies on Diet Slips
Penalty
Summary
The facility failed to ensure that a resident with a history of dysphagia and at risk for choking received the correct physician-ordered diet texture. The resident was supposed to receive an IDDSI Level 6 Soft and Bite-Sized diet with specific restrictions, including no bread, no coleslaw, no straws, and line of sight supervision. However, the diet slip did not include these restrictions, and the resident was served an IDDSI Level 7 regular textured breakfast, including sausage patty and toast, without dentures in place. The speech therapist observed the resident eating the incorrect diet unsupervised, which led to coughing, regurgitation, and a subsequent aspiration event requiring emergency intervention and hospitalization. Interviews with staff revealed that the process for updating and communicating diet changes was inadequate. The Food and Nutrition Services supervisor was responsible for updating diet slips, but if not present, changes were only written in a communication book, and the diet slips were not updated in a timely manner. Dietary staff relied solely on the diet slips for meal preparation and were unaware of the resident's specific dietary restrictions. Nursing staff also assumed dietary staff would provide the correct meals based on the slips, and there was no consistent supervision in the dining room during meals. Additionally, the facility failed to include a severe peanut allergy on the diet slip for another resident with a history of anaphylaxis. Although the allergy was posted in the kitchen and known to staff, it was not documented on the diet slip, which was the primary reference for dietary staff when preparing and serving meals. This omission was confirmed during interviews with dietary staff and the Food and Nutrition Services supervisor.
Removal Plan
- Complete a dining assessment on all residents who have not had one recently and review recent assessments for accuracy.
- Educate nursing staff that someone from nursing must always be in the dining room during meal service.
- Educate dietary staff on diet slips and re-educate on the process of how diets are communicated.
- Place a binder with all of the IDDSI diets in all kitchenettes for staff reference to ensure appropriate foods are served to residents.
- DON and nurse managers will work with the interdisciplinary team to review new diet changes and update the diet slips.
- Audit all processes.
Failure to Assess and Document After Resident Fall
Penalty
Summary
The facility failed to comprehensively assess, monitor, and implement appropriate interventions for a resident following a fall. The resident, who had diagnoses including obesity, diabetes mellitus, and heart failure, was cognitively intact and dependent for transfers. The care plan specified the use of mechanical lifts for transfers but did not clearly delineate when to use a sit-to-stand versus a full-body mechanical lift. On the night of the incident, the resident was found on the floor by a nursing assistant after being left briefly to retrieve a lift device. The nursing assistant noted the resident appeared weak prior to the fall but did not communicate this to the nurse before the incident. After the fall, the resident refused vital signs, skin assessment, range of motion, and neurological examination. The incident report indicated that the provider was not notified of the fall until over an hour later. Progress notes did not document the occurrence of the fall, the resident's refusals, or any education provided regarding the risks of refusing assessment. There was also no documentation of a mobility assessment to determine safe transfer methods following the fall. Interviews with staff revealed that the nurse did not perform or document a comprehensive assessment after the fall, nor did she document the resident's refusals or provide education about the risks of refusing assessment. Facility policy required that a nurse observe and perform a full-body exam before moving a resident after a fall, obtain vital signs, and conduct neurological checks if the fall was unwitnessed. The policy also required documentation of any teaching provided and updates to the care plan with new interventions. These procedures were not followed in this incident, as the nurse did not assess the resident before moving her, did not document refusals or education, and did not update the care plan following the fall.
Failure to Assess and Address Fall Risks for Two Residents
Penalty
Summary
The facility failed to comprehensively assess and address falls for two residents, resulting in repeated incidents without adequate identification of causal factors or implementation of individualized interventions. One resident, with diagnoses including obesity, diabetes, and heart failure, experienced multiple falls over a short period. Despite being cognitively intact but physically dependent for transfers and toileting, the resident's care plan did not include a specific toileting schedule or address the risk factors associated with her falls, such as attempts to self-transfer to the bathroom. Incident reports and care plan updates primarily focused on reminders to use the call light and environmental modifications, but did not address underlying causes like toileting needs or the use of a slippery nightgown. Several falls occurred while the resident attempted to transfer independently, often related to toileting, and one incident resulted in a clavicle fracture. Interviews with staff and the interim director of nursing confirmed that investigations into these falls did not thoroughly assess whether the resident's basic needs were being met or if the care plan was appropriate. Another resident, with severe cognitive impairment, a history of falls, and a recent leg fracture, also experienced multiple falls. The care plan identified a risk for falls but did not include specific interventions. Incident reports documented repeated falls, often involving the resident being found on the floor after attempting to self-transfer or scoot out of the room. Immediate actions taken included placing fall mats, frequent checks, and reminders to use the call light, but these interventions did not consider the resident's cognitive limitations or address root causes such as unmet toileting needs. The facility's fall investigation forms often lacked comprehensive analysis and did not consistently result in care plan revisions tailored to the resident's needs. Interviews with the interim director of nursing revealed that fall investigations for both residents were not thorough, and interventions implemented were not always related to the root causes of the falls. The interdisciplinary team did not consistently document fall discussions or update care plans in a timely manner. The facility's own policies required comprehensive assessment and care plan updates following falls, but these procedures were not followed, leading to repeated incidents and a failure to prevent further accidents.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene protocols as required for certain residents. For one resident with heart failure and a biliary drainage tube, staff did not use gowns or gloves while performing high-contact care activities such as dressing, transferring, and repositioning, despite the care plan indicating EBP was necessary due to the presence of an indwelling medical device. Staff involved acknowledged that gowns and gloves should have been used for residents on EBP. Additionally, hand hygiene was not performed as required for two other residents. In one instance, a staff member applied gloves without performing hand hygiene before or after providing perineal care and adjusting the resident's clothing and oxygen tubing. In another case, a staff member failed to perform hand hygiene before donning gloves, between glove changes, and after providing care, including when handling the resident's drinkware. The facility's policies required hand hygiene at specific moments, including before and after care, glove removal, and entering or exiting a resident's room, but these protocols were not followed during the observed care activities.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN-CMS-10055) to two residents, R99 and R100, as required when their Medicare services ended, and they remained in the facility. R99 was admitted and discharged on specific dates, with a Notice of Medicare Non-Coverage (NOMNC-CMS-10123) indicating services would end on 7/29/24, but R99 stayed until 8/15/24. Similarly, R100's NOMNC-CMS-10123 indicated services would end on 8/12/24, but R100 remained until 8/14/24. The medical records for both residents lacked evidence that the SNFABN-CMS-10055 was provided, which is necessary to inform residents of their financial responsibility for services not covered by Medicare. Interviews with facility staff revealed that the social worker used a flow sheet to determine which forms to provide but was unaware that the SNFABN-CMS-10055 was needed for residents staying beyond their Medicare coverage. The administrator confirmed the oversight, acknowledging that the SNFABN-CMS-10055 should have been completed for both residents, as they had remaining Medicare days when discharged from services. An email from the office manager corroborated that both residents had remaining Medicare days, emphasizing the importance of providing the SNFABN-CMS-10055 to inform residents of potential private pay charges.
Failure to Address Maintenance Issue in Resident's Room
Penalty
Summary
The facility failed to ensure necessary maintenance services were performed for a resident, identified as R4, who was reviewed for a home-like environment. R4, who had intact cognition, required assistance with catheter care, and was on hospice, reported that her window shade had not worked for several months. She expressed concern that the broken shade did not provide adequate privacy, especially at night. Despite informing staff about the issue, the shade remained unfixed, and during a recent catheter replacement, a nurse had to use a blanket to cover the window for privacy. The facility's administrator was unaware of the broken window shade until it was brought to her attention during an interview and observation. The facility lacked a maintenance tracking system, relying instead on verbal communication during meetings to address maintenance issues. The maintenance staff confirmed they were not informed about the broken shade until the day of the observation. The hospice nurse also confirmed the shade was not working properly during a catheter replacement in October and reported it to a nursing assistant, but the issue was not resolved. The facility's policy on maintenance requests did not specify a timeline for completing such requests.
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Illustrative
What surveyors actually found near you
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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 Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Marks Living | 2 mi | ★★★★★ | 6 | 1 |
| Sacred Heart Care Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Prairie Manor Care Center | 14.5 mi | ★★★★★ | 0 | 0 |
| Field Crest Care Center | 15.9 mi | ★★★★★ | 11 | 0 |
| Stacyville Community Nursing Home | 18.8 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.