Average — CMS composite of the measures below.
The next survey window likely opens around January 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 - Auburn during CMS and state inspections, most recent first.
Menu Portion Sizes Not Followed: Staff were observed serving rice, pureed pork cutlet, and minced and moist pork using smaller portions than listed on the menu. The Dietary Dept Director confirmed the serving sizes in use, and the Consultant RD later confirmed the correct serving sizes had not been followed. The Consultant RD also stated the facility had no policy related to serving sizes, although menu serving sizes are to be followed.
Food Safety Deficiencies in Egg Preparation and Sanitizer Monitoring: The facility failed to use pasteurized eggs for soft-cooked eggs and failed to have test strips available to verify quat sanitizer concentration at the 3-compartment sink. During observation, whole eggs in the walk-in refrigerator were not documented as pasteurized, and the DDD and RD confirmed the wrong eggs had been ordered even though facility policy requires pasteurized eggs for soft eggs. The DDD also could not locate sanitizer test strips, and the sink sanitizer log was incomplete and not current.
A nursing assistant failed to perform hand hygiene while alternating dining assistance between three residents, including wiping a resident’s mouth and handling another resident’s silverware without cleaning hands between contacts. The facility also stored oxygen tubing improperly for two residents with O2 orders, leaving tubing wrapped or draped over equipment and wheelchairs instead of secured in a bag, which the RN confirmed was not done as required.
Failure to follow bowel management orders for two residents. One resident with severe cognitive impairment and multiple chronic conditions had standing PRN orders for Dulcolax suppository and Milk of Magnesia with instructions to notify the provider after three days without a significant BM, but bowel records showed multiple stretches of no BM and staff did not notify the provider. Another resident with constipation, reduced mobility, and total bowel incontinence also went several days without a BM; no PRN bowel meds were given and there was no evidence the provider was notified as ordered.
Restorative Services Not Provided as Planned: A resident with hemiplegia and hemiparesis after a CVA had restorative interventions on the care plan for transfers and ambulation with a hemi-walker, CGA, and gait belt. Documentation showed the resident received transfer restorative care only once and no ambulation restorative care during the review period. An LPN confirmed the program was not being done, the restorative aide said staffing duties kept the aide from providing the services, and the Administrator confirmed there was not adequate staffing to provide restorative services as scheduled.
A resident had a medication cup with pills left on the bedside table during an observation. The resident could not recall when the pills were placed there. An MA said they had not given the meds and did not know what they were, and an LPN confirmed they had administered the meds but did not stay to witness the resident take all of them.
The facility failed to maintain cleanliness in the kitchen, with a condenser fan and air conditioner covers coated in dark substances, and a scoop improperly stored in flour. These issues were confirmed by the DM, who acknowledged the lack of a cleaning schedule for these items. All 62 residents consumed food prepared in this environment, highlighting the potential impact of these deficiencies.
The facility failed to maintain cleanliness in 15 resident bathrooms, with ventilation covers coated in dust and corrosion around toilet bases. Observations confirmed these issues, and no active work orders were in place to address them.
A facility failed to properly secure a urinary catheter bag for a resident, leading to potential cross-contamination. The resident, with multiple diagnoses, was observed twice with the catheter bag touching the floor. Staff interviews confirmed that catheter bags should not touch the floor or be hung on a trash can, as per the facility's catheter care policy.
Menu Portion Sizes Not Followed
Penalty
Summary
The facility failed to ensure that portion sizes identified on the menu were followed when serving foods to residents. During observation of the steam table, staff were using a #10 scoop for rice and pureed pork cutlet and serving minced and moist pork in 3-ounce portions. In interview, the Dietary Department Director confirmed those were the serving sizes being used. However, review of the facility lunch menu showed the identified serving sizes were #8 scoops, or 1/2 cup, for rice, pureed pork cutlet, and minced and moist pork. The Dietary Department Director and Consultant Registered Dietitian later confirmed the correct serving sizes had not been used, and the Consultant Registered Dietitian stated the facility did not have a policy related to serving sizes but that the menu serving sizes are to be followed.
Food Safety Deficiencies in Egg Preparation and Sanitizer Monitoring
Penalty
Summary
The facility failed to ensure pasteurized eggs were used for preparation of soft, cooked eggs. During observation, the label on the box of whole eggs in the walk-in refrigerator did not show documentation that the eggs were pasteurized. In interview, the Dietary Department Director and Consultant Registered Dietitian confirmed the eggs were not pasteurized and that the wrong eggs had been ordered. They also confirmed that resident eggs are cooked to order and may be ordered over easy, and that facility policy requires pasteurized eggs when residents are served soft eggs. The facility also failed to ensure test strips were available to check the sanitizer concentration in the 3-compartment sink. During observation, quaternary sanitizer was being used for sanitizing pots and pans, but the Dietary Department Director could not locate test strips to evaluate the sanitizer concentration. A sanitizer log posted on the wall by the sink was not for the current month and was incomplete. In interview, the Dietary Department Director confirmed that test strips could not be found and that the sanitizer log for the 3-compartment sink was not being completed.
Infection Control Lapses During Dining Assistance and Oxygen Storage
Penalty
Summary
Failure to provide and implement an infection prevention and control program was identified when a nursing assistant did not perform hand hygiene while moving between residents during dining assistance. During an observation, the nursing assistant was feeding one resident, then moved to another resident’s wheelchair and began feeding that resident without completing hand hygiene, wiped one resident’s mouth, handled another resident’s silverware, and continued alternating between three residents without hand hygiene between contacts. The nursing assistant confirmed that hand hygiene was not completed while switching between residents and stated it should have been. The facility also failed to store oxygen tubing in a manner to prevent cross contamination for two residents who had oxygen orders. One resident had diagnoses including COVID-19, morbid obesity, and wheezing, and had an order for oxygen 1-4 L via nasal cannula as needed to maintain O2 above 90%. Observations showed the oxygen concentrator against the wall with tubing wrapped around it and not protected or secured in a bag. Another resident had diagnoses including personal history of COVID-19, pneumonia, and personal history of pulmonary embolism, with an order for oxygen 1-4 L via nasal cannula as needed for dyspnea, hypoxia, or acute angina. Observations showed the oxygen cylinder on the back of the wheelchair with the tubing and nasal cannula draped over the wheelchair and not stored in a bag; the RN confirmed the tubing was not stored as required and acknowledged the potential for cross-contamination.
Failure to Follow Bowel Management Orders
Penalty
Summary
The facility failed to implement physician orders for bowel management for two residents. One resident had severe cognitive impairment, multiple chronic diagnoses including diabetes, seizure disorder, atrial fibrillation, coronary artery disease, chronic kidney disease, and osteoarthritis, and had active orders for Dulcolax suppository and Milk of Magnesia with instructions to contact the provider if there were three days without a significant bowel movement. The facility’s bowel management protocol also called for intervention and provider notification when a resident had no bowel movement for three days. For one resident, the bowel record showed no bowel movements on January 19, 20, 21, 22, and 23, and again on February 4, 5, 6, and 7. An LPN confirmed the resident had no bowel movements on those dates and confirmed the order required provider notification after three days without a bowel movement, but did not know why the provider had not been notified. The LPN also described the facility process in which the night shift nurse prepared a report of residents at day three without a bowel movement, the day shift nurse notified the MA of residents needing bowel medication, and the DON was responsible for notifying the family or representative of changes in condition. For the second resident, the record showed diagnoses including constipation, muscle weakness, need for assistance with personal care, and reduced mobility. The resident was dependent on staff for toileting hygiene, lower body dressing, and transfers, was always incontinent of bowel, was not on a toileting program, and had constipation present. The bowel record showed no bowel movements on February 4, 5, 6, 7, and 8, yet the MAR showed no PRN bowel medications were given and progress notes showed no evidence the provider/practitioner was notified of no significant bowel movement in three days. An LPN confirmed the missed bowel movements, the lack of PRN bowel medication use, and the lack of provider notification.
Restorative Services Not Provided as Planned
Penalty
Summary
The facility failed to ensure restorative services were provided for one resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident’s quarterly MDS showed a Brief Interview for Mental Status score of 5, indicating severe cognitive impairment, and no information on mobility impairment of range of motion on one side for the upper and lower extremities. The care plan, dated 10/22/24, identified restorative interventions for limited physical mobility related to the cerebrovascular accident, including transfers with a hemi-walker and gait belt twice weekly and ambulation up to 90 feet with a hemi-walker, CGA, gait belt, and wheelchair follow twice weekly. Restorative documentation from 1/11/26 to 2/9/26 showed the resident received transfer restorative services only one time on 1/18/26 and did not receive any ambulation restorative services during that period. In interviews, an LPN confirmed the restorative program was not being done, and the restorative aide stated the resident had only received restorative services one time because the aide had been working on the floor as an aide or medication aide instead of as the restorative aide. The Administrator confirmed the facility did not have adequate staffing to provide restorative services for the number of days indicated. The facility policy stated each resident would receive restorative nursing care to the extent possible based on individual strengths, needs, and problems as defined in nursing assessments.
Medications Left at Resident Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for Resident 53. During an observation on 2/8/2026 at 10:25 AM, a medication cup containing pills was seen on the resident’s bedside table. Resident 53 stated they could not remember when the pills were placed there. A Medication Aide confirmed that they had not given Resident 53 the medications in the cup and did not know what the medications were, and stated the medications should not have been left at the resident’s bedside. A Licensed Practical Nurse later confirmed that they had administered medications to Resident 53 but had not witnessed the resident take all of the medications, and stated they should have remained in the room until the resident had taken all of the medications.
Deficiencies in Kitchen Cleanliness and Food Safety Practices
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, specifically in the walk-in cooler and food preparation areas, as observed by surveyors. A condenser fan in the walk-in cooler was found to be coated with a dark gray/black substance, and the interior walls and ceiling of the cooler had a dark gray fuzzy coating. Additionally, two large air conditioner covers above a food preparation table were also coated with a similar dark gray/black substance. These conditions were confirmed by the Dietary Manager (DM) during an observation. Furthermore, a plastic scoop was found in a flour bin with its handle in contact with the flour, which was also confirmed by the DM. The DM acknowledged that the scoop should not have been in contact with the flour and that the air conditioner covers, located directly above a food preparation area, could potentially cause foodborne illness if dust fell into the food. The DM admitted that the fan in the cooler and the air conditioner covers were not included in the dietary cleaning schedule, and was unsure of the last time they had been cleaned. A review of the dietary cleaning schedules confirmed that these items were not listed. The facility's Registered Dietician confirmed that all 62 residents consumed food prepared in the facility kitchen, indicating the potential impact of these deficiencies on the entire resident population.
Facility Fails to Maintain Cleanliness in Resident Bathrooms
Penalty
Summary
The facility failed to maintain the cleanliness and condition of bathroom ventilation covers and toilet bases in 15 out of 62 occupied resident rooms. Observations conducted on two separate occasions revealed that the ventilation covers in several resident bathrooms were coated with a dark, fuzzy substance resembling dust. Additionally, there was corrosion and a dark brown substance present around the base of the toilets, along with cracked caulking in multiple rooms. During an environmental tour with the facility Maintenance Director and Administrator, these issues were confirmed. The Maintenance Director acknowledged the presence of dust on the ventilation covers and the corrosion and cracked caulking around the toilet bases. It was also confirmed that there were no active work orders addressing these concerns at the time of the observations.
Improper Securing of Urinary Catheter Bag
Penalty
Summary
The facility failed to secure a urinary catheter bag properly, leading to a potential risk of cross-contamination for Resident 14. The resident, who has diagnoses of Diabetes Mellitus Type 2, heart failure, and obstructive uropathy, requires partial assistance with personal hygiene and total assistance with lower body dressing, transfers, and toileting. Observations on two separate occasions revealed the resident's urinary catheter bag hanging from a trash can with the bottom of the bag touching the floor. Interviews with a Nursing Assistant, an LPN, and the Director of Nursing confirmed that catheter drainage bags should not touch the floor or be hung on a trash can. The facility's policy on catheter care, dated 7-30-2024, states that catheters should always be properly secured, connected, and maintained using a sterile closed drainage system.
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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 Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Acres Of Humboldt | 15.7 mi | ★★★★★ | 31 | 0 |
| Pleasant View Nursing Home | 17.8 mi | ★★★★★ | 0 | 0 |
| The Ambassador Nebraska City, Inc | 20.8 mi | ★★★★★ | 1 | 0 |
| Prestige Care Center Of Nebraska City | 20.8 mi | ★★★★★ | 13 | 0 |
| Premier Estates Of Pawnee, Llc | 24.8 mi | — | 0 | 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.