Good Samaritan - Villisca

In the surveyor’s words

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

• Actual harm, isolatedF600Sep 24, 2024

  Based on record review, facility investigative file review, surveillance footage, resident and staff interview and policy review the facility failed to ensure 1 of 3 resident (Resident #1) was free from abuse. The facility reported a census of 37 residents. Findings include: According to the quarterly Minimum Data Set (MDS) assessment tool, with a reference date of 7/2/24, documented Resident #1 had a Brief Interview of Mental Status (BIMS) score of 11. A BIMS score of 11 suggested moderate cognitive impairment. The MDS documented Resident #1 displayed no physical, verbal or other behavioral symptoms during the review period. The MDS indicated he had bilateral upper and lower extremity impairment on both sides and utilized a wheelchair. […]

• No harm, potential for more than minimal, patternF755Jan 29, 2026

  Based on observation, interview, and record review the facility failed to safely secure controlled substances for 13 of 13 residents reviewed. An observation of the medication administration revealed the staff failed to store controlled substances under extra security. The facility reported a census of 34 residents. Findings include: On 1/27/26 at 7:32 AM observed Staff A, Licensed Practical Nurse (LPN), prepare medications for Resident #33. She pulled the clonazepam (anti-anxiety medication) out of the same drawer as the scheduled medication. When asked why they didn't have the controlled substance under a double lock, she replied she didn't know. She added they had the as needed (PRN) controlled substances under a double lock. […]

• No harm, potential for more than minimal, patternF812Jan 29, 2026

  Based on observation, interview and policy review the facility failed to ensure safe food storage. In an initial observation of the kitchen, observed the opened food packages without dates when opened. The facility reported a census of 34 residents. Findings include: The initial observation of the kitchen completed on 1/26/26 at 10:00 AM, revealed the following food items without an opened date: A bag of shredded cheeseA bag of cauliflowerA crock pot of cheese.On 1/27/26 at 3:00 PM, the Dietary Manager said they expected the staff to date the food items at the time they open them. They explained unopened items in the refrigerator would be good for 7 days but opened items were good for no longer than 3 days. […]

• No harm, potential for more than minimal, patternF812Sep 14, 2023

  Based on observations, staff interviews, and facility policy review, the facility failed to maintain sanitary practices by improperly storing food and failed to maintain essential kitchen equipment. The facility reported a census of 39 residents. Findings include: During an initial kitchen observation on 9/11/23 at 8:50 AM, the following findings were identified. a) An accessed, undated carton of Orange Juice. b) An accessed, undated half-gallon of chocolate milk. c) An accessed, undated carton of Apple Juice thickener. d) An unlabeled, small, pink pitcher containing white liquid. e) An opened bag inside an opened box of fish strips. During a follow-up kitchen observation on 9/12/23 at 7:45 AM, the pink pitcher of white liquid was still in the refrigerator with no label. […]

• No harm, potential for more than minimal, patternF947Sep 14, 2023

  Based on employee file review, facility policy review, and staff interviews the facility failed to provide in-service training to nurse aides at least 12 hours yearly. The facility reported a census of 39 residents. Finding include: Review of a document titled Completion Report for Staff C revealed only 9.92 hours of training had been completed in the last 12 months. On 9/14/23 at 8:27 AM Staff D stated the facility's expectation is that the end of the month report was sent by September 1st with the employee that needed to complete training. Staff D stated she emails the facility's exception report to the DON, and the Administrator. […]