Above average — CMS composite of the measures below.
A standard survey is most likely before 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 - Colonial Villa during CMS and state inspections, most recent first.
Hand hygiene was not performed as required during medication administration and resident care. An MA passed medications to multiple residents without cleaning hands between residents or after handling used cups and glasses, despite policy requiring hand hygiene before and after each resident. During care for a resident with severe cognitive impairment who was dependent for toileting, transfers, and personal hygiene, two staff entered without hand hygiene, donned gloves without hand hygiene, failed to clean hands after glove removal, and completed handwashing for only 10 seconds and 5 seconds instead of the required 15-20 seconds.
Incomplete discharge documentation and missing ombudsman notification: A resident admitted with DM, malnutrition, and anxiety was discharged home, but the discharge summary was largely blank and no recapitulation of stay was found in the record. The SSD said the facility emails monthly Emergency Transfers from Facility forms to the state ombudsman, but the resident’s discharge was not included and notification did not occur.
A facility failed to follow physician orders for a resident with dementia, resulting in a deficiency. The resident's care plan required bowel management, but records showed no bowel movements for several days on two occasions. Despite this, no medications were administered, and the physician was not notified. Staff interviews confirmed the oversight.
The facility failed to review monthly medication drug regimen reports, affecting a resident with potentially duplicate orders for ropinirole. The June 2024 reports were not received by the DON, delaying necessary actions. The consulting pharmacist confirmed the reports were sent, but the facility staff did not act on the information promptly.
A facility failed to conduct AIMS monitoring for a resident prescribed Geodon for dementia-related behaviors. Despite policy requirements for AIMS assessments every six months, no monitoring was completed. The resident's care plan noted behaviors like being argumentative and disruptive, yet the necessary assessment was not initiated. The MDS Coordinator confirmed the oversight.
Two residents in a LTC facility were found to have discrepancies between their medication labels and physician orders, posing a risk to safe medication administration. One resident's Venlafaxine and Fluticasone labels did not match the prescribed dosages, while another resident's Albuterol inhaler lacked proper labeling with administration instructions. The facility's DON confirmed these discrepancies, highlighting the need for accurate labeling to ensure correct medication administration.
Hand Hygiene Not Performed During Medication Pass and Resident Care
Penalty
Summary
The facility failed to ensure that hand hygiene occurred between residents during medication administration. Medication Aide A was observed preparing and administering medications to Residents 19, 8, and 2 without using alcohol-based hand sanitizer or washing hands before preparing medications, between residents, or after handling used cups and glasses. The facility’s Medication Administration policy required hand hygiene prior to beginning the med pass and following administration for each resident, and the Hand Hygiene policy required hand hygiene before preparing or administering medications. Record review showed that Medication Aide A had received multiple education sessions related to hand hygiene, infection prevention, and medication administration. During the observation, the aide completed medication administration for one resident, handled the empty medication cup and water glass, then proceeded directly to prepare medications for the next resident without hand hygiene. This pattern continued across the observed medication pass, and the aide confirmed that hand hygiene had not been performed between the residents while medications were prepared and administered. The facility also failed to ensure that staff performed hand hygiene before and after glove use and failed to ensure proper handwashing duration during resident care for Resident 21. Resident 21 was admitted on 7/3/25, had severely impaired cognition with a BIMS score of 3, was dependent on staff for toileting hygiene, transfers, and repositioning, and required assistance with personal hygiene. During observed care, NA-K and MA-J entered the room without hand hygiene, put on gloves without hand hygiene, and performed multiple tasks involving the resident’s body, sling, brief, wipes, and lift equipment. After glove removal, hand hygiene was not consistently performed, and one handwashing episode lasted 10 seconds and another lasted 5 seconds rather than the required 15-20 seconds. The Infection Preventionist and MA-J confirmed that staff were expected to follow the hand hygiene policy and that hand hygiene and handwashing were not completed as required during the care of Resident 21.
Incomplete discharge documentation and missing ombudsman notification
Penalty
Summary
The facility failed to complete a recapitulation of stay for a resident who was admitted with diagnoses of diabetes, malnutrition, and anxiety and later discharged home. The record showed the resident’s discharge summary was incomplete, with the admission diagnoses section left blank and multiple sections left blank, including hearing/speech/vision, cognitive patterns, mood and behavior, preferences, functional status, bladder and bowel, active disease diagnoses, health conditions, swallowing/nutritional status, oral/dental status, skin conditions, medications, special treatments and procedures, restraints, and strengths and goals. The discharge admission record also had a blank miscellaneous section, and the medical record contained no recapitulation of stay. The DON confirmed that the discharge summary did not contain all required information and that the facility did not have a recapitulation of stay for the resident. The facility also failed to notify the state ombudsman of the resident’s discharge. The facility policy required that, when a transfer or discharge occurs, a copy of the required form be sent to a representative of the Office of the State Long-Term Care Ombudsman. The SSD stated that the facility sends Emergency Transfers from Facility forms to the ombudsman monthly by email, but the June form provided during survey did not include this resident’s discharge. The SSD later confirmed that ombudsman notification of the discharge did not occur.
Failure to Follow Bowel Protocol for Resident with Dementia
Penalty
Summary
The facility failed to adhere to physician orders regarding bowel protocols for a resident with dementia, leading to a deficiency. The resident's care plan indicated cognitive impairment and a need for assistance with activities of daily living due to confusion. The standing orders for bowel management included medications such as Dulcolax, Fleet Enema, Milk of Magnesia, and Senna-S, with instructions to contact the provider if there were three days without a significant bowel movement. During a review of the resident's records, it was found that the resident did not have a bowel movement for three or more consecutive days on two separate occasions. Despite this, no medications from the standing orders were administered, and there was no communication with the physician regarding the lack of bowel movements. Interviews with facility staff confirmed that the necessary actions were not taken, resulting in a failure to follow the established bowel protocol for the resident.
Failure to Review Monthly Medication Drug Regimen Reports
Penalty
Summary
The facility failed to ensure that monthly medication drug reviews were properly received and reviewed by facility staff, leading to a deficiency in addressing priority irregularities. This issue affected one resident, who had potentially duplicate orders for the medication ropinirole, used for restless leg syndrome. The Pharmacy Consultation report for this resident was time-sensitive and required action by a specific deadline, which was not met due to the facility not receiving the necessary reports. Interviews revealed that the June 2024 Medication Drug Regimen Review (MRR) was completed by a different pharmacist than usual, and the reports were sent to the Director of Nursing (DON) and the Facility Administrator. However, the DON did not receive these reports and therefore did not review them. Consequently, the physician also did not review the reports until a later date, delaying necessary actions. The consulting pharmacist confirmed that the reports were sent, and a nurse was notified about the urgent order, but the facility staff did not act on this information in a timely manner.
Failure to Implement AIMS Monitoring for Antipsychotic Medication
Penalty
Summary
The facility failed to implement AIMS monitoring for a resident who was prescribed an antipsychotic medication, Geodon, for dementia-related behavioral symptoms. The facility's policy requires that a registered nurse complete the Abnormal Involuntary Movement Scale (AIMS) in the electronic medical record every six months for residents on antipsychotic medications. However, a review of the resident's assessments revealed that no AIMS monitoring was conducted during the duration of the prescribed antipsychotic. The resident's care plan indicated the use of psychopharmacological medications due to dementia with behaviors such as being argumentative, striking out at staff, and being disruptive. Despite these behaviors and the ongoing administration of Geodon, the necessary AIMS assessment was not initiated or completed. An interview with the Minimum Data Set Coordinator confirmed that the AIMS assessment should have been triggered and completed for the resident, but it was not.
Medication Labeling Discrepancies in LTC Facility
Penalty
Summary
The facility failed to ensure that resident medications were labeled in accordance with the physician's orders, which posed a potential risk to resident safety during medication administration. During an observation, Medication Aide-A (MA-A) was setting up medication for a resident and found discrepancies between the medication labels and the physician's orders. The label for Venlafaxine HCl ER indicated a dosage of 75mg daily, to be taken with a 150mg dose for a total of 225mg daily, which did not match the physician's order of 150mg twice a day, totaling 300mg daily. Similarly, the label for Fluticasone Propionate instructed two sprays intranasally daily, whereas the physician's order was for one spray in each nostril once a day. Another observation revealed that Medication Aide-B (MA-B) was preparing medication for another resident and found that the Albuterol Sulfate inhaler lacked a proper label with administration instructions. The inhaler was not stored in a labeled plastic bag, and the label on the inhaler itself only contained the resident's name and medication name, without the physician's order instructions. This lack of labeling prevented MA-B from verifying the medication administration instructions against the MAR as required. Interviews with the facility's Director of Nursing (DON) confirmed the discrepancies in medication labeling for both residents. The DON acknowledged that the labels did not match the physician's orders and that the expectation was for pharmacy labels to align with the physician's instructions to ensure correct medication administration by the staff.
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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 Alma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Franklin | 21.3 mi | ★★★★★ | 0 | 0 |
| Christian Homes Health Care Center | 23.1 mi | ★★★★★ | 13 | 0 |
| Holdrege Memorial Homes, Inc | 23.5 mi | ★★★★★ | 0 | 0 |
| Phillips County Retirement Center | 24.3 mi | ★★★★★ | 11 | 0 |
| Beaver City Manor | 24.6 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.