Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 - Grand Island Village during CMS and state inspections, most recent first.
The facility failed to obtain documented consent and fully inform two residents or their representatives before administering psychotropic medications. One resident received Rexulti and Trintellix without consent or documentation of risks, benefits, or alternatives, and another resident’s psychotropic consent form for Zoloft and Alprazolam was incomplete, with no symptoms or nonpharmacological alternatives documented and no education provided.
A resident with complex medical needs, including a Pleurex catheter, did not receive scheduled catheter drainage because the assigned nurse lacked the necessary training. The order to drain the catheter was delayed in being entered, and the only preparation provided to staff was a printed policy, with formal education occurring much later.
Staff did not follow infection prevention protocols during wound care for a resident, including failing to perform hand hygiene between glove changes and not wearing required gowns, despite facility policies mandating these practices for Enhanced Barrier Precautions (EBP).
A resident with a history of falls and multiple risk factors was left unattended in the bathroom on multiple occasions, despite care plan interventions requiring staff presence. This resulted in repeated falls with significant injuries, including head lacerations and spinal fractures. Staff interviews and observations revealed inconsistent knowledge and implementation of fall prevention measures, lack of a specific toileting schedule, and failure to keep the call light within reach.
A resident with multiple medical conditions fell during a transfer due to the use of an incorrect sling size. The incident was not documented, and the facility's fall protocol was not followed, leading to a deficiency in accident prevention and response procedures.
The facility failed to implement proper infection control measures for a COVID-19 positive resident, with staff not wearing required PPE and incorrect signage. Additionally, oxygen tubing for several residents was not changed weekly or stored properly, and a nebulizer kit was not cleaned or stored according to policy, posing risks of cross-contamination.
A facility failed to safely store medications, as 12 medications were found unattended on a resident's bedside table. The medications were supposed to be administered the previous day but were left unsecured, contrary to the facility's policy requiring locked storage. The DON confirmed this breach in protocol.
A resident with Alzheimer's disease received peri and catheter care that did not follow infection control guidelines. Supplies were placed on the bed without a barrier, the catheter bag was improperly positioned, and the catheter tubing was cleansed incorrectly. Hand hygiene was not performed, and gloves were not used when applying a new incontinence brief. The DON confirmed these actions violated facility policy, and the facility had reported an increase in UTIs in previous months.
Failure to Obtain Consent and Document Education for Psychotropic Medications
Penalty
Summary
The facility failed to fully inform residents and obtain documented consent before administering psychotropic medications for two residents. The report states that the facility policy required a signed consent form for non-emergency psychotropic medications, but no consent was found in the record for Resident 3’s Rexulti 3 mg daily order that began on 7/22/25, and no documentation was found showing the resident or representative was informed of the risks, benefits, or alternatives before the medication was given. The DON confirmed on interview that the facility did not have a consent for Rexulti for Resident 3. Resident 3’s record also showed a later order for Trintellix 10 mg daily beginning 12/16/25, and the December MAR documented daily administration through 12/30/25. The medical record again contained no documented consent for Trintellix and no documentation that the resident or representative was informed of the risks and benefits of the proposed treatment or treatment alternatives. The DON confirmed that the facility did not have a consent for Trintellix for Resident 3 as required. For Resident 4, the record showed admission with diagnoses of major depressive disorder and generalized anxiety disorder, and physician orders included Zoloft and Alprazolam. A facility form titled Permission for Use of Psychotropic Medications listed those medications under antidepressant medication, but the sections for symptoms being treated and nonpharmacological alternatives attempted were left blank. The SSD confirmed that no symptoms were listed, no alternatives were documented, the form was not completed and signed until after admission, and no education was provided regarding the symptoms or alternatives to the medications.
Failure to Ensure Nurse Competency for Pleurex Catheter Care
Penalty
Summary
The facility failed to ensure that a licensed nurse had the necessary knowledge and training to provide care for a Pleurex catheter for one resident. The resident, who had multiple diagnoses including an infection to the left arm, kidney failure, heart disease, irregular heart rate, COPD, type 2 diabetes mellitus, and pleural effusion, was admitted with a physician's order to have the Pleurex catheter drained on specific days of the week. The order to drain the catheter was not entered into the system until two days after the resident's admission, and documentation showed that the catheter was not drained as ordered on two scheduled days. The Director of Nursing confirmed that the nurse assigned on one of the scheduled days did not perform the procedure because they did not know how to drain the Pleurex catheter. Prior to the resident's admission, the only preparation provided was printing out the policy and procedure for the device, with no additional education or training given to the nursing staff. Nursing education on the Pleurex drainage system was not documented until over a month after the resident's admission.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during wound care for a resident with a left heel wound. The RN and NA assisting with the procedure performed initial hand hygiene and donned gloves, but the RN did not perform hand hygiene between glove changes while providing wound care. The RN changed gloves multiple times without washing hands in between, contrary to facility policy. Additionally, both the RN and NA did not wear gowns during the dressing change, despite facility policy requiring gown and glove use for wound care as part of Enhanced Barrier Precautions (EBP). The resident involved was cognitively intact and required assistance with footwear and repositioning. Physician orders indicated daily wound care for the left heel, use of Tubi-grip for edema, and foam booties for pressure reduction. Staff interviews confirmed awareness that gowns should have been worn and hand hygiene performed between glove changes during wound care. Facility policies reviewed specified the need for hand hygiene before clean tasks and after glove removal, as well as the use of gowns and gloves for high-contact activities such as wound care.
Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to implement and follow fall prevention interventions for a resident with a significant history of falls and multiple risk factors, including cerebral infarction, traumatic subdural hemorrhage, repeated falls, parkinsonism, vertigo, muscle weakness, and lack of coordination. The resident required assistance with transfers, toileting, and personal care, and had documented care plan interventions specifying that staff should not leave the resident alone in the restroom and should maintain a toileting schedule. Despite these interventions, the resident experienced multiple falls, including two with major injuries, during the review period. On two separate occasions, staff left the resident unattended in the bathroom, directly contrary to the care plan. In one instance, a nursing assistant left the resident standing in the bathroom to assist another staff member, resulting in the resident falling and sustaining a head laceration and a lumbar compression fracture. In another incident, a nursing assistant left the resident on the toilet to retrieve a bandage, and the resident fell, suffering a thoracic compression fracture and a rib fracture. Interviews confirmed that staff were aware of the care plan interventions but did not consistently follow them, and some staff were unclear about the specific interventions or how to access them in the electronic medical record or on report sheets. Additionally, the facility failed to implement a specific toileting schedule for the resident, despite this being an intervention listed in the care plan and facility policy. Staff interviews revealed that toileting was generally performed at routine times or as needed, rather than according to an individualized schedule. Observations also showed that the resident's call light was not always within reach, another care plan intervention that was not consistently followed. These failures to implement and adhere to established interventions contributed to the resident's repeated falls and injuries.
Failure to Use Correct Sling Size and Document Fall Incident
Penalty
Summary
The facility failed to use the correct sling size during the transfer of a resident, leading to a fall. The resident, who had a history of significant medical conditions including an above-knee amputation, encephalopathy, sepsis, diabetes with polyneuropathy, and chronic obstructive pulmonary disease, was being transferred using an EZ Stand device. The staff member assisting the resident did not have the appropriate size sling, resulting in the resident slipping out of the sling and being lowered to the floor. The resident reported significant pain and swelling in the left shoulder and stump, which affected the fitting of their prosthetic appliance. The incident was not documented in the resident's medical record, and there was no incident/accident report filed. Interviews with staff revealed that the fall was not reported or documented as per the facility's protocol. The Licensed Practical Nurse (LPN) involved did not document the fall, as they believed there was no injury, despite the resident's complaints of pain and swelling. The Director of Nursing confirmed that all falls should be reported and documented, but this procedure was not followed in this case. The lack of documentation and failure to follow the facility's fall protocol indicate a deficiency in the facility's handling of the incident. The resident's medical record did not reflect the fall, and the facility's fall prevention team was not informed, which could have led to a lack of appropriate follow-up care and monitoring for the resident. This oversight highlights a significant gap in the facility's accident prevention and response procedures.
Infection Control and Equipment Maintenance Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident who tested positive for COVID-19. Observations revealed that staff, including a nursing assistant, a licensed practical nurse, a social worker, and a physical therapist, entered the resident's room without wearing the required personal protective equipment (PPE) such as gloves, gowns, N-95 masks, and eye protection. The signage on the resident's door was incorrect, failing to indicate the necessary precautions for COVID-19 isolation, and there was no signage at the facility's entrance to inform visitors and staff of the presence of a COVID-19 positive resident. Additionally, the facility did not adhere to its policy for changing and dating oxygen tubing weekly for residents requiring oxygen therapy. Several residents' oxygen tubing was found undated, not changed weekly, and improperly stored, leading to potential cross-contamination. The facility's electronic medical records did not reflect the orders for changing the tubing, resulting in staff not completing the task as required. The facility also failed to maintain proper hygiene and storage for a resident's nebulizer kit. The nebulizer kit was observed to be undated, not rinsed, and improperly stored, contrary to the facility's policy that requires cleaning and air-drying the nebulizer parts after each use. These deficiencies in infection control practices posed a risk of cross-contamination and infection spread within the facility.
Unattended Medications Found at Resident's Bedside
Penalty
Summary
The facility failed to safely store medications, as evidenced by an observation of an unattended medication cup containing 12 medications on a bedside table in a resident's room. This incident involved a resident who was admitted to the hospital for severe back pain. The medications were identified as the resident's morning pills, which were documented as administered by a medication aide the previous day. However, the medications were left unattended, suggesting they were not properly administered or stored. The facility's policy requires medications to be stored in a locked medication cart, drawer, or cupboard, which was not adhered to in this case. An interview with the LPN revealed that the medications were not left by them and were likely from the weekend. The Director of Nursing confirmed that medications should not be left unattended, indicating a breach in the facility's medication storage protocol.
Infection Control Deficiency in Peri and Catheter Care
Penalty
Summary
The facility failed to adhere to infection control guidelines during the provision of peri and catheter care for a resident diagnosed with Alzheimer's disease and cognitive/communication deficits. During an observation, it was noted that a medical assistant (MA-A) placed supplies directly on the resident's bed without a barrier and positioned the catheter bag on the bed, not below the bladder level. MA-A also incorrectly cleansed the catheter tubing towards the urethra instead of away from it. Additionally, MA-A did not change gloves or perform hand hygiene during the peri and rectal care, and both MA-A and another medical assistant (MA-B) applied a new incontinence brief with ungloved hands. The Director of Nursing (DON) confirmed that the observed practices did not align with infection control guidelines or facility policy, which requires cleansing away from the urethral opening and performing hand hygiene at specific moments. The facility's infection preventionist reported an increase in urinary tract infections (UTIs) in the months preceding the observation, with six cases in July and eight in August. The facility's policies on catheter and perineal care emphasize the importance of proper hygiene practices, including glove use and hand hygiene, to prevent contamination and infection.
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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 Grand Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tiffany Square | 0.2 mi | ★★★★★ | 7 | 0 |
| Adept Nursing & Rehab Of Grand Island | 0.7 mi | ★★★★★ | 0 | 0 |
| Chi Health St. Francis | 0.7 mi | ★★★★★ | 0 | 0 |
| Eventide Prairie Commons Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Lakeview | 3 mi | ★★★★★ | 19 | 1 |
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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.