Good Samaritan - Ellis

In the surveyor’s words

From the most serious findings on record at Good Samaritan - Ellis, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 6, 2026

  The facility identified a census of 37 residents, with three residents reviewed for accidents and hazards. Based on record review, observation, and interview, the facility failed to prevent a hot liquid burn to Resident (R) 1. The facility failed to evaluate the temperature of the liquid from the hot water/coffee machine, relying on a temperature regulator that had failed, and allowed the hot water dispensed from the machine to be too hot.Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), gastroparesis (a chronic digestive disorder where the stomach muscles weaken, slowing or stopping food from moving into the small intestine), epilepsy (brain disorder… […]

• No harm, potential for more than minimal, widespreadF801Mar 11, 2024

  The facility had a census of 35 residents. The sample included 14 residents. Based on observation, interview, and record review the facility failed to employ a full-time Certified Dietary Manager (CDM) to supervise the preparation of meals and sanitation in the facility's kitchen. This deficient practice placed the 35 residents of the facility at risk for inadequate nutrition or food-borne illness. Findings included: - On 03/05/24 at 810 AM, observation revealed Dietary Staff (DS) DD and EE served breakfast to the residents in the dining room. On 03/05/24 at 08:35 AM, Administrative Staff A verified the Dietary Manager was not certified. […]

• No harm, potential for more than minimal, widespreadF851Mar 11, 2024

  The facility had a census of 35 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) 2023 Quarter 2 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on the following days: 01/14/23, 02/05/23, 02/26/23, and 03/19/23. The PBJ report for FY 2023 Quarter 3 indicated no licensed nurse coverage on 04/08/23, 04/30/23, 05/20/23, 05/21/23 and 06/11/23. […]

• No harm, potential for more than minimal, widespreadF947Mar 11, 2024

  The facility had a census of 35 residents. Based on record review and interview, the facility failed to ensure one of the five Certified Nurse Aides (CNA) employed at the facility for at least one year completed the minimum 12 hours of in-service training per year and lacked a system for accurately tracking CNA education. Findings included: - A review of the facility's CNA Training Records for CNA staff who had been employed at the facility for over one year revealed a lack of 12-hour in-service training for CNA M, hired 02/15/22. […]

• No harm, potential for more than minimal, widespreadF812Aug 29, 2022

  The facility had a census of 31 residents. The sample included 14 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 31 residents who resided in the facility and received their food from the facility kitchen when the facility failed to ensure dietary staff followed hand hygiene and failed to ensure clean and sanitary food prep areas. This placed the 31 residents at risk for foodborne illness. Findings included: - On 8/24/22 at 11:30 AM observation in the kitchen revealed the following: During serving of the noon meal, Dietary Staff (DS) BB applied gloves, touched her face, steam table, and undercounter fridge door handle. […]