Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 - Superior during CMS and state inspections, most recent first.
Surveyors observed a thick, yellow-white flakey buildup on the ice machine in the common dining area, affecting areas where ice and water are dispensed. The Dietary Manager confirmed the buildup made the machine uncleanable and unsanitary, and acknowledged there was no process in place to ensure regular cleaning by the dietary department. This unsanitary condition had the potential to affect all residents in the facility.
Two staff members began working and completed multiple shifts before their required pre-employment health assessments were completed and reviewed, contrary to facility policy and licensure requirements. The Facility Administrator confirmed that the assessments were not done prior to the staff starting their job duties.
Multiple resident bathroom exhaust fans were found to be non-functional in several halls, with maintenance staff confirming the issue had persisted for years and some fans producing excessive noise or failing to operate. The problem affected the majority of residents, and staff noted foul odors in rooms after toileting, while administration was previously unaware of the extent of the ventilation failure.
The facility did not provide or retain required Advance Beneficiary Notices (ABN) for two residents whose Medicare Part A coverage ended, as confirmed by the Facility Administrator and record review.
A resident was administered psychotropic medications without clear medical necessity or was given medications that restricted their ability to function, resulting in a deficiency related to the inappropriate use of such drugs.
The facility did not document a resident or representative's decision regarding bed hold during a hospital transfer, and also failed to notify the Ombudsman of another resident's discharge, as confirmed by record review and staff interviews.
The facility inaccurately coded the MDS for three residents by documenting respiratory therapy minutes for treatments administered by nurses without proper respiratory credentials and by recording an insulin injection that was not ordered or given. These errors were confirmed through record review and staff interviews.
A resident with multiple serious diagnoses was admitted to hospice, but the facility did not update the comprehensive care plan to include specific hospice-related objectives, goals, or interventions as required. The care plan only noted a terminal prognosis and listed a hospice nurse's contact, without further detail. The DON confirmed the care plan was not revised to address hospice needs.
A resident with dementia and constipation did not have their provider notified of repeated pharmacist recommendations to review and modify their bowel regimen, despite ongoing use of as-needed cathartic medications. Additionally, after an incident resulting in arm injury, the facility failed to document or monitor the injury for several days, with assessment and provider notification only occurring later.
Two residents were involved in a physical altercation after a verbal exchange, with one resident using a walker to make contact with another. Staff intervened, but the facility did not conduct or document an investigation, nor did it submit the required report to the state agency. The DON confirmed the absence of an investigation and reporting, despite facility policy and state requirements.
The facility failed to provide written transfer notices to two residents or their representatives when they were transferred to the hospital. Despite verbal notifications, the required written documentation was not provided, as confirmed by the Social Services Designee.
The facility failed to provide a notice of bed hold policy to two residents upon their transfer to the hospital. Despite the facility's policy requiring notification and documentation, there was no record of this being done for a resident with a history of stroke and another with TIA and dementia. Interviews confirmed the lack of communication and documentation regarding the bed hold policy.
A facility failed to maintain accurate medical records for a resident who passed away. The resident, with multiple health issues and a DNR status, was found deceased by a Medication Aide. Despite the Registered Nurse's assessment confirming the absence of vital signs, the details of the death and preceding events were not documented in the progress notes, highlighting a deficiency in record-keeping.
An LPN at the facility failed to follow proper hand hygiene protocols during medication administration for two residents. The LPN did not wash hands for the required 20 seconds and neglected to sanitize hands between glove changes, contrary to the facility's policy. Interviews confirmed these lapses, resulting in a deficiency in infection prevention and control.
Unsanitary Ice Machine Maintenance
Penalty
Summary
The facility failed to maintain the ice machine in a sanitary condition, as observed during a survey. A thick, yellow-white flakey buildup was present on the front of the ice machine where ice is dispensed, as well as in the black water dispensing area, the fluid drain area, and the black grate covering the drain. The Dietary Manager confirmed that the buildup rendered the machine's surfaces uncleanable and unsanitary. It was also confirmed that the dietary department was responsible for cleaning these areas, but there was no process in place to ensure this cleaning was completed. The unsanitary condition of the ice machine had the potential to affect all residents in the facility, which had a census of 32 at the time of the observation.
Failure to Complete Pre-Employment Health Assessments Prior to Staff Start Date
Penalty
Summary
The facility failed to ensure that pre-employment health assessments were completed prior to the first day of employment for two of five sampled staff members, as required by facility policy and licensure regulations. Record reviews showed that both Food Service Assistants began working and were scheduled for shifts before their Communicable Disease Screening forms were completed and reviewed by a nurse. Specifically, one staff member started work and completed several shifts before the health assessment was signed and reviewed, while the other also worked multiple shifts prior to the completion of their health assessment. Interviews with the Facility Administrator confirmed that new staff typically undergo two days of online orientation followed by on-the-job training, and acknowledged that the required pre-employment health assessments for these two staff members were not completed before they began their job duties. The failure to complete these assessments prior to employment was in direct violation of the facility's own hiring and screening policy, which mandates that employment is contingent upon successful completion of a pre-employment health assessment to prevent the potential for transmissible diseases.
Non-Functioning Bathroom Ventilation Fans in Resident Rooms
Penalty
Summary
The facility failed to ensure that ventilation in all resident rooms was in working order, specifically in the bathrooms of rooms located in the 100 and 200 halls, as well as some rooms in the 400 hall. Multiple observations were made where the bathroom exhaust ventilation fans did not function, as evidenced by their inability to pull up a 1-ply square of toilet paper. Staff confirmed that these fans had not worked for at least three years, and maintenance staff acknowledged that the fans in the affected halls either did not operate or produced excessive noise due to burned-out bearings. During one observation, a foul odor was noted in a resident's room after toileting assistance, further indicating the lack of effective ventilation. Interviews with the Maintenance Director confirmed longstanding knowledge of the non-functioning fans in the 100 and 200 halls, and additional confirmation was provided that some fans in the 400 hall were also inoperable. The Interim Administrator was unaware of the issue prior to the survey and acknowledged that non-working bathroom fans could cause resident embarrassment due to odors. The deficiency affected 27 out of 37 sampled residents, with a total facility census of 37.
Failure to Issue and Retain Advance Beneficiary Notices for Medicare Coverage
Penalty
Summary
The facility failed to provide the required Advance Beneficiary Notices (ABN) to two of three sampled residents whose Medicare Part A coverage ended during their stay. For one resident, who was re-admitted after an acute hospitalization with diagnoses of generalized muscle weakness and fatigue, there was no evidence that the ABN was issued or retained when Medicare Part A coverage began and ended. Similarly, for another resident admitted with Medicare Part A as the payor source, the facility did not retain a copy of the ABN to show it was provided to the resident or their representative. The Facility Administrator confirmed in interviews that there was no documentation to support that the required notices were given, as mandated by facility policy and Medicare regulations.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear medical justification or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Document Bed Hold Choice and Ombudsman Notification
Penalty
Summary
The facility failed to obtain and document the resident or resident representative's choice regarding bed hold during a hospital transfer for one resident. Specifically, although the facility's policy requires that written information about the bed hold policy be provided and that the resident or representative be contacted to document their decision, the record for a resident with COPD and heart failure showed that while the bed hold policy was sent with the resident to the hospital, there was no documentation of any contact with the resident or representative to obtain their decision. The relevant form was incomplete, lacking both the resident or representative's choice and signatures, and there was no evidence of attempts to reach the representative. Additionally, the facility did not document notification to the Ombudsman regarding the discharge of another resident with COPD and hypertension. The facility administrator confirmed that there was no documentation reflecting that the Ombudsman was notified of the resident's discharge, as required. These findings were based on record review and staff interviews.
Inaccurate MDS Coding for Respiratory Therapy and Injections
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, resulting in deficiencies related to the assessment and documentation of care. For two residents, the MDS was coded to indicate that respiratory therapy was provided by a respiratory therapist or respiratory nurse, when in fact, the therapy consisted of nurses administering ultra-sonic nebulizer treatments. The nurses had only completed a brief online course and did not hold formal certification as respiratory nurses, nor did the facility employ a respiratory therapist. The minutes spent by these nurses administering the treatments were incorrectly counted as respiratory therapy on the MDS, contrary to the requirements outlined in the Resident Assessment Instrument User's Manual. Additionally, for another resident, the MDS was coded to reflect that an insulin injection was administered during the look back period. However, a review of the resident's medical record revealed there were no physician orders for insulin during that time. Instead, the resident had an order for Ozempic, a non-insulin injectable medication. Both the MDS Coordinator and the DON confirmed that this was a coding error and that the resident did not receive insulin. These inaccuracies in MDS coding were identified through record review and staff interviews.
Failure to Update Comprehensive Care Plan with Hospice Objectives and Interventions
Penalty
Summary
The facility failed to update and implement objectives, goals, and interventions related to hospice care on the comprehensive care plan for a resident who was admitted to hospice. The facility's policy requires a coordinated care plan to be jointly developed with hospice, including directives for managing pain and other symptoms, and mandates that the care plan be revised as necessary to reflect the resident's current condition. Despite these requirements, the comprehensive care plan for the resident only noted a terminal prognosis and listed a hospice nurse's phone number, without including specific hospice-related objectives, goals, or interventions. The resident involved had multiple significant medical diagnoses, including chronic pulmonary embolism, pressure-induced deep tissue damage, malignant neoplasm of the lung, chronic kidney disease stage 3, dementia, and pain. The deficiency was confirmed through record review and an interview with the DON, who acknowledged that the care plan was not updated with measurable goals and interventions after the resident was placed on hospice care.
Failure to Notify Provider of Pharmacist Recommendations and Inadequate Injury Monitoring
Penalty
Summary
The facility failed to notify the provider of pharmacist recommendations regarding a resident's bowel regimen and did not monitor or document an injury sustained by the resident. Specifically, the consulting pharmacist repeatedly documented concerns about the resident's use of as-needed cathartic medications and recommended that the bowel regimen be reviewed and possibly modified. Despite these recommendations, there was no documentation that the provider was notified or that any changes were made to the resident's medication orders. The Director of Nursing confirmed that there was no evidence of provider notification or review of the pharmacist's recommendations, as required by facility policy. Additionally, the facility did not adequately monitor or document a resident's injury following an incident in which the resident's arm was bent behind their back, resulting in swelling and bruising. There was no documentation of the incident or monitoring of the resident's arm or psychosocial state for several days after the event. Documentation of the injury and assessment only began several days later, when swelling and bruising were noted and the resident was seen by a provider. The Director of Nursing confirmed that there was no investigation or continued monitoring documented between the time of the incident and the later assessment.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and report an incident of resident-to-resident abuse as required by policy and state regulations. On the date of the incident, staff observed one resident using a walker to make physical contact with another resident after a verbal exchange in the hallway. Staff intervened to prevent further confrontation. Both residents involved had incident reports completed, but these reports did not include any investigation of the event. Additionally, there were no progress notes or documentation in either resident's medical record regarding the incident or any investigation. The facility's policy requires that all alleged or suspected abuse be promptly reported, thoroughly investigated, and submitted to the state agency within five working days. However, the Director of Nursing confirmed that no investigation was conducted or submitted to the state agency for this incident. The care plan for the resident who initiated the contact indicated a history of aggressive behavior and the need for supervision in public areas, but there was no evidence that these interventions were followed up in response to the incident.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of transfer to residents or their representatives upon transfer to the hospital for two residents. Resident 8, who had a history of transient ischemic attack and cerebral infarction with hemiparesis and hemiplegia, was sent to the emergency room with shortness of breath and admitted to the hospital. There was no documentation of a written notice of transfer being provided to Resident 8 or their representative. Similarly, Resident 21, with a history of TIA, cerebral infarction, high blood pressure, and dementia, was sent to the emergency room for diarrhea, weakness, and low blood pressure, and admitted to the hospital. Again, there was no documentation of a written notice of transfer being provided to Resident 21 or their representative. Interviews with the Social Services Designee (SSD) revealed that while residents and/or their representatives were verbally notified of transfers, they were not provided with a copy of the Transfer or Discharge Notice form. The facility's policy requires that residents and their representatives be notified in writing of transfers or discharges, including the reason for the move, and be given information on how to obtain and submit an appeal form. The SSD confirmed that these discussions were not being documented, leading to the deficiency in providing the required written notices.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide a notice of bed hold policy to two residents, Resident 8 and Resident 21, upon their transfer to the hospital. This deficiency was identified through a review of the facility's policies and resident records, as well as interviews with the Social Services Designee (SSD). The facility's policy requires that the Social Worker or designated individual provide the Notice of Bed-Hold Policy to the resident and/or their representative at the time of transfer, and document this action. However, there was no documentation that this policy was followed for either resident. Resident 8, who had a history of transient ischemic attack and cerebral infarction with hemiparesis and hemiplegia, was transferred to the hospital with shortness of breath and returned to the facility without any record of the bed hold policy being communicated. Similarly, Resident 21, with a history of TIA, cerebral infarction, high blood pressure, and dementia, was transferred to the hospital for diarrhea, weakness, and low blood pressure, and also returned without documentation of the bed hold policy being provided. Interviews with the SSD confirmed the lack of documentation and communication regarding the bed hold policy for both residents.
Incomplete Documentation of Resident's Death
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records for one resident, identified as Resident 38, out of three residents surveyed. The deficiency was identified during a review of Resident 38's medical records, which revealed a lack of documentation regarding significant events surrounding the resident's death. The resident had multiple diagnoses, including expressive language disorder, developmental disorder of scholastic skills, dysphagia, a history of falling, essential hypertension, mild intellectual disabilities, pain, fever, complete loss of teeth, xerosis cutis, and an unspecified cataract. The Medication Administration Record indicated that the resident was a DNR (Do Not Resuscitate). However, the Progress Notes lacked detailed information about the circumstances leading to the resident's death, such as who found the resident, the resident's condition, and position at the time of discovery. Interviews with facility staff, including the Director of Nursing, Medication Aide D, and Registered Nurse B, confirmed the absence of comprehensive documentation. Medication Aide D found the resident unresponsive and cold to the touch, and subsequently contacted RN-B, who assessed the resident and confirmed the absence of vital signs. Despite these actions, RN-B did not document the assessment and vital signs in the resident's progress notes. The lack of detailed documentation regarding the resident's death and the events leading up to it constitutes a failure to maintain medical records in accordance with accepted professional standards.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration, affecting two residents. The facility's hand hygiene policy, reviewed on 03/29/2022, requires health care workers to use alcohol-based hand sanitizer or soap and water after removing gloves and to wash hands for at least 15-20 seconds. However, observations revealed that an LPN did not adhere to these guidelines. During an injection for one resident, the LPN washed their hands for only ten seconds after removing gloves. In another instance, while administering a nebulizer treatment to a different resident, the LPN washed their hands for eight seconds before putting on gloves and for seven seconds after removing them. Additionally, the LPN failed to sanitize their hands between glove changes. Interviews with the LPN and the Director of Nursing confirmed the handwashing should be done for 20 seconds and that hand sanitizing should occur between glove changes. The LPN acknowledged the inadequacy of their handwashing duration and the omission of hand sanitizing between glove changes. These actions were inconsistent with the facility's hand hygiene policy, leading to a deficiency in infection prevention and control during medication administration.
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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 Superior
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Haven Nursing Home | 19.5 mi | ★★★★★ | 0 | 0 |
| Heritage Of Webster County | 24.1 mi | ★★★★★ | 17 | 0 |
| Blue Valley Lutheran Nursing Home | 26.6 mi | ★★★★★ | 0 | 0 |
| Belleville Healthcare And Rehabilitation Center | 27.4 mi | ★★★★★ | 17 | 0 |
| Adept Nursing & Rehab Of Blue Hill | 28.8 mi | ★★★★★ | 0 | 0 |
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