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 - Beatrice during CMS and state inspections, most recent first.
Failure to follow the meatloaf recipe during meal prep. A Lead Cook prepared meatloaf by using 20 lbs. of ground beef instead of the 17.5 lbs. listed, poured eggs directly over the beef rather than mixing eggs and milk separately, added extra amounts of ingredients by eyeballing, and mixed the batch by hand instead of using the mixer. The cook also said the meatloaf would sit overnight and more eggs or milk might be added if it looked too dry, while the FSD stated cooks are expected to follow the recipes provided.
Food was served below the required hot-holding temperature on a unit dining room. An insulated food cart brought hot lunch items from the kitchen showed several foods at acceptable or borderline temperatures at first, but lids were left off during plating, room trays were covered with a Styrofoam plate instead of insulated covers, and dessert was delivered uncovered. Later temperature checks showed the breaded chicken, potato casserole, and peas had dropped well below 135 degrees Fahrenheit, and the survey team found the food barely warm.
Bathroom ventilation was not operational in seven resident bathrooms, including rooms 120, 301, 303, 305, 308, 309, and 313. Surveyors observed the issue during two tours, and WM confirmed the vents should have been working. WM stated the HVAC vendor reported frozen coils due to cold temperatures, and the vents were not checked when temperatures dropped below freezing; the most recent vent log showed the last check was completed in October 2025.
Missing discharge summaries and transfer notifications: The facility failed to complete required discharge documentation for two residents who were transferred out of the facility. One resident was sent from an appointment to the hospital for kidney failure and had no documented transfer notice or discharge summary, including required medical and contact information, and the DON confirmed the resident’s representative was not notified in writing. Another resident was discharged without a facility Discharge Summary, which the DON confirmed.
A resident with obstructive sleep apnea had a CPAP machine in the room, and the MDS and care plan documented CPAP use and risk for altered respiratory status. However, the order summary contained no physician order for CPAP pressure settings, and the DON and an LPN confirmed the EMR lacked an order; the CCL stated the facility did not have a system to ensure residents admitted with a personal CPAP had an order.
Infection Control Lapses During Catheter and Wound Care: An LPN failed to follow HH and PPE practices during catheter care and wound care for multiple residents. Observations showed gloves and a gown that touched the floor were still used, HH was missed between glove changes or done for only a few seconds, and a catheter drainage bag was placed on the floor. The residents involved had urinary retention, an indwelling device, chronic wounds, MASD, and a heel DTI.
A lead cook in the facility failed to follow proper hand hygiene protocols after handling raw chicken, washing their hands for only 10 seconds instead of the required 20 seconds. This deficiency was confirmed by both the cook and the Dietary Manager, potentially affecting all 60 residents served by the kitchen.
The facility failed to follow proper infection control practices during wound and catheter care for two residents. An LPN did not change gloves or perform hand hygiene between tasks, compromising the care of residents with chronic ulcers and other conditions. The facility's policies were not adhered to, as confirmed by staff interviews.
A facility failed to maintain proper respiratory care for a resident by not keeping the oxygen tubing nasal cannula off the floor and failing to date the tubing. The resident, with chronic heart failure and COPD, uses oxygen as needed. Observations showed undated tubing and the nasal cannula touching the floor, contrary to facility policy requiring weekly dating and proper storage.
The facility failed to provide stop dates for PRN antianxiety medications and did not monitor specific target behaviors for antipsychotic medications for four residents. Despite the facility's policy requiring evaluation of behavioral interventions before using psychotropic medications, residents were prescribed such medications without adequate monitoring or non-pharmacological interventions. The Director of Nursing confirmed these deficiencies, highlighting a lack of adherence to guidelines and regulatory requirements.
Failure to Follow Meatloaf Recipe During Meal Preparation
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature when the facility failed to follow the meatloaf recipe during meal preparation. During observation on 01/22/2026 at 11:16 AM, the Lead Cook began preparing meatloaf for the following day by removing 20 lbs. of ground beef from the walk-in refrigerator, applying gloves, removing the beef from its outer wrap, and then washing hands after removing the gloves. The cook referred to the recipe, which called for 17.5 lbs. of ground beef for 70 servings along with specific amounts of liquid eggs, milk, tomato paste, garlic, salt, onion, breadcrumbs, and pepper. The Lead Cook placed the 20 lbs. of ground beef into a pan, poured the liquid eggs directly over the beef instead of combining eggs and milk in a separate mixing bowl as directed, and stated that because the recipe called for 17.5 lbs. of beef and there were 20 lbs. in the pan, more of each ingredient would be added and the amounts would be eyeballed. The cook then measured each ingredient and added extra amounts, mixed the ingredients with gloved hands instead of using the mixer, covered the meatloaf with foil, and placed it in the walk-in refrigerator. The cook stated the meatloaf would sit overnight and, if it looked too dry the next day, extra eggs or milk would be added. The cook also stated that recipes are sometimes adjusted by taste testing and changing seasoning or broth, and that the extra 2.5 lbs. of beef were not removed because it would go to waste unless it could be browned for another meal. The cook confirmed the recipe should have been followed as written but was not. The Food Service Director stated that cooks are expected to follow the recipes provided.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to maintain and serve food at a safe and appetizing temperature on unit 1. During observation, an insulated food cart was brought from the main kitchen to the 100's dining room with hot lunch items in stainless steel pans. The hot foods were initially measured at temperatures including breaded chicken at 150 degrees Fahrenheit, pureed chicken at 115 degrees Fahrenheit, potato casserole at 160 degrees Fahrenheit, un-breaded chicken at 140 degrees Fahrenheit, peas at 140 degrees Fahrenheit, and cauliflower at 140 degrees Fahrenheit. The food service staff then obtained drinks, performed hand hygiene, applied gloves, and began plating food at 11:45 AM, but the pan lids were left off and were not replaced during service. For room trays, the staff member could not locate insulated covers and placed a Styrofoam plate over the food instead. The dessert, a room temperature mixed fruit cobbler with ice cream, was delivered to rooms uncovered. When temperatures were rechecked later, the breaded chicken was 120-130 degrees Fahrenheit, the potato casserole was 138-140 degrees Fahrenheit, and the peas were 120 degrees Fahrenheit. At the time of tasting, the breaded chicken was 110 degrees Fahrenheit, the potato casserole was 106 degrees Fahrenheit, and the peas were 105 degrees Fahrenheit; the survey team noted the chicken was tough and all items were barely warm. The staff member confirmed that serving temperatures should be over 135 degrees Fahrenheit, and the facility policy stated hot foods should be held above 135 degrees Fahrenheit and served at an appetizing temperature.
Nonfunctioning Bathroom Ventilation in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure bathroom ventilation systems were operational in seven resident bathrooms, including rooms 120, 301, 303, 305, 308, 309, and 313, out of 24 resident rooms sampled in a facility with a census of 60. During the initial tour on 1.21.2026, surveyors observed that the bathroom ventilation was not functioning in these seven rooms. On a later tour on 1.26.2026 with Water Management, the same bathrooms were again observed to have nonfunctioning ventilation. In interview, Water Management confirmed the bathroom ventilation was not working in those rooms and stated it should be functioning. Water Management also confirmed the HVAC service company had been notified and reported the bathroom vents were not working because cold temperatures caused the coils to freeze. It was further confirmed that the bathroom vents were not checked when temperatures dropped below freezing, and the issue would have been identified when the vents were checked that month; the vents were checked quarterly. A record review showed the most recent bathroom vent check was completed in October 2025.
Missing discharge summaries and transfer notifications
Penalty
Summary
The facility failed to complete required discharge documentation and notification related to two residents who were transferred out of the facility. For Resident 67, record review showed an admission date of 10/16/2025 and a hospital discharge summary listing sepsis, severe thrombocytopenia, and cirrhosis of the liver with ascites. The EMAR contained no documentation of a transfer notice or discharge summary with the resident’s medical information, emergency contact information, special instructions for ongoing care, or other required details. The Social Service Director stated the facility transported the resident to an appointment in [NAME], and the clinic then sent the resident to the hospital due to kidney failure. For Resident 69, record review showed the resident was admitted on [DATE] and discharged on 12/19/2025, but no facility Discharge Summary was completed in the EHR. The DON confirmed in interview on 01/27/2026 that the facility did not complete a Discharge Summary for Resident 69. The DON also confirmed the facility did not notify Resident 67’s representative in writing of the transfer to the hospital or the subsequent discharge from the facility.
Missing Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain a physician's order for Resident 2's CPAP machine and pressure settings. Resident 2 was admitted with a diagnosis of obstructive sleep apnea, and observation of the resident's room on 01/21/2026 showed a CPAP machine on the bedside table, a CPAP mask in the drawer, and the water chamber 1/4 full of water. Record review showed the resident's order summary contained no order for CPAP pressure settings, while the MDS dated 12/30/2025 indicated the resident used a noninvasive ventilator or CPAP. Resident 2's care plan, revised on 07/10/2025, identified the resident as at risk for altered respiratory status related to sleep apnea. During interviews, an LPN stated the resident wore the CPAP every night and that the CPAP was removed in the morning, and confirmed there was no order in the EMR. The DON confirmed there was no physician's order for the CPAP settings, later stating the facility could not locate an order because the resident was admitted from home with the CPAP. The CCL stated the facility did not have a system in place to ensure residents admitted with a personal CPAP had an order.
Infection Control Lapses During Catheter and Wound Care
Penalty
Summary
The facility failed to follow infection control practices during catheter care for 2 residents and during wound care for 2 residents. The facility’s hand hygiene policy required alcohol-based hand rub or soap and water for 15 to 20 seconds and stated that hand hygiene should be performed between changing gloves. The catheter care policy stated that catheter tubing should never touch the floor and that gloves should be removed, hand hygiene performed, and new gloves donned before touching the catheter. The wound dressing change policy stated that after removing and discarding the old dressing, staff should remove gloves and perform hand hygiene before putting on clean gloves. One resident had diagnoses including skin cancer, obstructive uropathy, and urinary retention and was on enhanced barrier precautions because of an indwelling medical device. During observed wound and catheter care, an LPN removed gloves, performed hand hygiene, then put on new gloves; one glove fell on the floor and was picked up and used. The LPN later washed hands with soap and water for six seconds before catheter care. The LPN confirmed the glove that fell on the floor should have been discarded and that handwashing should have been done for 20 seconds. The infection preventionist confirmed that PPE that touches the floor should be thrown away and that hand hygiene should have been performed when gloves were changed. Another resident had urinary retention and a stage 2 pressure ulcer on the right buttock, and a wound clinic note identified open areas on both buttocks as MASD rather than pressure ulcers. During observed wound and catheter care, the LPN changed gloves multiple times without performing hand hygiene, placed the catheter drainage bag on the floor, and later washed hands for seven seconds and four seconds during separate glove changes. The LPN also used the same gloves while washing and dressing both buttocks, then performed suprapubic catheter site care with glove changes that were not followed by hand hygiene, and later left the room without performing hand hygiene after removing gown and gloves. A third resident had MS and a chronic wound on the left heel; during wound care preparation, the LPN dropped a gown on the floor, picked it up, and wore it during wound care. The LPN confirmed the gown should not have been used, and the infection preventionist confirmed PPE that touches the floor should be discarded.
Improper Hand Hygiene in Food Preparation
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols, which could potentially lead to foodborne illness affecting all 60 residents served by the kitchen. During an observation, a lead cook (LC-B) was seen preparing a meal without following the facility's hand hygiene policy. After handling raw chicken, LC-B washed their hands for only 10 seconds instead of the required 20 seconds, as per the facility's policy and CDC guidelines. This improper handwashing occurred after removing gloves and before touching other kitchen surfaces, which could lead to cross-contamination. Interviews with LC-B and the Dietary Manager (DM-C) confirmed the deficiency in hand hygiene practices. LC-B acknowledged not washing their hands for the required duration and admitted to not following the correct procedure after handling raw chicken. The Dietary Manager also confirmed that the handwashing procedure was not performed as indicated in the facility's policy, highlighting a lapse in maintaining professional standards for food safety.
Infection Control Deficiencies in Wound and Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during wound care and catheter care for two residents. For Resident 208, the LPN did not change gloves or perform hand hygiene between tasks while providing wound care and catheter care. The LPN used the same gloves to handle clean supplies and perform tasks that required clean gloves, such as cleansing the urethral meatus and catheter tubing. This was confirmed by the LPN and the Director of Nursing, who acknowledged that the facility's policy was not followed. Resident 208's medical history included Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and a non-pressure chronic ulcer of the right ankle. The resident was at risk for pressure ulcers and had specific physician orders for wound care, which included using specific dressings and maintaining cleanliness. However, during the observed care, the LPN did not adhere to the required hand hygiene and glove-changing protocols, potentially compromising the resident's care. Similarly, for Resident 8, the LPN did not change gloves or perform hand hygiene after handling various items and before starting the wound dressing change. The LPN also failed to use a barrier on the tray table, which was used to hold supplies. The Regional Educator intervened during the procedure to remind the LPN to change gloves. Resident 8 had a history of contusions and open wounds on the lower legs, requiring careful wound management. The facility's policy for wound dressing changes was not followed, as confirmed by interviews with the LPN and the Regional Educator.
Failure to Maintain Proper Oxygen Tubing Care
Penalty
Summary
The facility failed to maintain proper respiratory care for a resident by not keeping the oxygen tubing nasal cannula off the floor and failing to date the tubing. This deficiency was observed for one resident, who was admitted on December 4, 2023, and had a BIMS score of 15, indicating full cognitive function. The resident's medical history includes chronic systolic heart failure and chronic obstructive pulmonary disease, and they use oxygen at night and as needed. Observations on multiple occasions revealed that the oxygen tubing was undated and the nasal cannula was touching the floor. The facility's policy requires that oxygen equipment be kept clean and maintained in good condition, with disposable equipment changed weekly and marked with the date and initials. The Director of Nursing confirmed that nurses are expected to date the oxygen tubing weekly and ensure the nasal cannula does not touch the floor, storing it in a protective bag when not in use. Despite these guidelines, the facility did not adhere to the policy, resulting in the observed deficiency.
Failure to Monitor Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide a stop date for the use of as-needed antianxiety medication and did not monitor specific target behaviors for antipsychotic medications, nor did it implement non-pharmacological interventions for four residents. The facility's policy on psychotropic medications emphasizes evaluating behavioral interventions and alternatives before using such medications and ensuring that PRN orders have clear parameters and are limited to 14 days unless extended with documented rationale. However, the facility did not adhere to these guidelines, as evidenced by the lack of stop dates and monitoring for the residents involved. Resident 29, who is cognitively intact with a BIMS score of 15, was prescribed multiple psychotropic medications, including Abilify and Lorazepam, without a stop date for the PRN Lorazepam. The resident's care plan did not identify specific target behaviors or non-pharmacological interventions, and there was no documentation of behavior monitoring for the continued use of antipsychotic medication. Similarly, Resident 19, who is cognitively impaired, had a PRN order for Ativan cream without a stop date and no non-pharmaceutical interventions in place. The Director of Nursing confirmed these deficiencies during an interview. Resident 212, diagnosed with generalized anxiety disorder and other conditions, also lacked behavior documentation and non-pharmacological interventions for antianxiety and antidepressant medications. The resident's PRN Lorazepam did not have a stop date, and there was no monitoring of targeted behaviors. Resident 32, with diagnoses including anxiety disorder and unspecified dementia, was prescribed Seroquel and Sertraline without specific target behaviors or non-pharmacological interventions documented in the care plan. The facility's failure to adhere to its policy and regulatory requirements resulted in these deficiencies, as confirmed by the Director of Nursing.
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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 Beatrice
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beatrice Health And Rehabilitaion | 1.2 mi | ★★★★★ | 0 | 0 |
| Gold Crest Retirement Center | 16.9 mi | ★★★★★ | 0 | 0 |
| Wilber Care Center | 19.9 mi | ★★★★★ | 2 | 0 |
| Jefferson Community Health & Life Gardenside | 24.9 mi | ★★★★★ | 11 | 0 |
| Heritage Care Center | 24.9 mi | ★★★★★ | 0 | 0 |
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