Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - West Union during CMS and state inspections, most recent first.
A facility failed to submit a new PASRR assessment for a resident with severe cognitive impairment and multiple diagnoses, including a new diagnosis of paranoid schizophrenia. Despite the facility's policy requiring a Level II screening for new mental disorder diagnoses, the Director of Nursing did not submit the necessary PASRR update, resulting in a deficiency.
The facility failed to provide adequate staffing, resulting in delayed call light responses for several residents. A resident with diabetes and dementia reported falls due to waiting for assistance, while another with paraplegia experienced waits of 15-30 minutes. Staff interviews revealed frequent understaffing, with only three aides working instead of the required four, affecting resident care and meal service.
The facility did not conduct the required tuberculosis (TB) screening for two new Certified Nurses Aides, as per its policy. Staff H did not complete the second step of the TB test, and there was no record of any TB screening for Staff I. The Interim DON confirmed the absence of TB testing records for both staff members.
The facility failed to ensure that four residents were educated about and offered annual Influenza and Pneumococcal vaccinations. The residents' records lacked documentation of education or offers for these vaccines, and the Infection Preventionist confirmed that such documentation should exist.
The facility failed to send appropriate records for a resident's transfer to the ER. The resident's EHR lacked a discharge assessment and documentation of sent paperwork. The Administrator confirmed that the hospital was not updated, and necessary documents were not sent. The facility's policy for completing and sending a Transfer Form was not followed.
The facility inaccurately coded the MDS for two residents by documenting insulin administration when none occurred. The Nurse Consultant mistakenly identified Trulicity as insulin based on incorrect information from a corporate form.
The facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medications to a resident. The resident received the medication on multiple dates without any documented attempts of non-pharmacological interventions, and the Pharmacy Consultant's notes lacked direction for such documentation. The Director of Nursing confirmed the expectation for this documentation, which is also outlined in the facility's policy.
Failure to Update PASRR for Resident with New Diagnosis
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) assessment for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, schizophrenia, and depression. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 3, reflecting severe cognitive impairment. The resident's PASRR Level 1 Screening Outcome had previously referred them for a Level II onsite visit, but the PASRR determination excluded them from further PASRR requirements due to no PASRR diagnosis. However, a new diagnosis of paranoid schizophrenia was documented in the resident's medical records, which should have prompted a PASRR update. The Director of Nursing (DON) acknowledged awareness of the new diagnosis but failed to submit the required PASRR update. The facility's policy mandates that if a resident is diagnosed with a mental disorder while in the facility, the designated individual must contact the state agency for a Level II screening. The policy also requires that PASRR recommendations be incorporated into the care plan and that the state-designated mental health authority be notified promptly when a resident experiences a significant change in mental or physical status. Despite these requirements, the necessary PASRR update was not completed for the resident, leading to the deficiency.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide a sufficient number of staff to ensure timely response to residents' call lights, affecting five out of six residents reviewed. Resident #2, who has diabetes and dementia, reported having to wait for assistance to the restroom, leading to several falls. Resident #3, with thoracic spinal bifida and paraplegia, noted that call light response times varied, with waits of 15-30 minutes when staffing was low. Resident #4, who is dependent on staff for all activities of daily living, reported extended waits to be assisted off the commode. Resident #5, with morbid obesity, experienced waits of up to an hour for call light responses, with staff sometimes turning off the light without returning. Resident #6, who has chronic kidney disease and a history of falls, reported call light waits of over 15 minutes, sometimes up to 40 minutes. Interviews with staff revealed that staffing levels were frequently below the required number, with only three aides working instead of the needed four, leading to delays in resident care and meal service. Staff interviews highlighted the challenges faced due to inadequate staffing, with aides responsible for multiple halls and unable to meet residents' needs promptly. The facility's interim Director of Nurses was unaware of the staffing issues and related complaints. The dining room's meal service was also affected, with residents receiving room trays instead of dining room service due to insufficient staff to assist them in getting to meals on time.
Failure to Conduct Required TB Screening for New Employees
Penalty
Summary
The facility failed to provide tuberculosis (TB) screening for two of three new employees reviewed, specifically Staff H and Staff I, which is a requirement according to the facility's policy. Staff H, a Certified Nurses Aide, was hired on June 25, 2024, and worked full-time without completing the second step of the TB screening test. This was confirmed during an interview with Staff H, who stated that the former Director of Nurses only administered one TB screening test. Staff I, also a Certified Nurses Aide, was hired on December 19, 2023, and there was no record of any TB screening in her archived employee file received from the corporate office. The facility's Tuberculosis Control Plan and Screening for Employees policy, dated December 7, 2023, mandates that new employees undergo baseline TB screening and post-exposure screening according to CDC guidelines prior to employment. The Interim Director of Nurses, Staff F, confirmed the absence of TB testing records for both Staff H and Staff I, acknowledging that the screenings were not conducted as required.
Failure to Educate and Offer Annual Vaccinations
Penalty
Summary
The facility failed to ensure that four out of five residents were educated about immunizations and offered the Influenza and Pneumococcal vaccinations annually. Specifically, Resident #20's Electronic Health Record (EHR) revealed she had not received the Pneumococcal Polysaccharide (PPSV23) and Pneumococcal Conjugated (PCV20) vaccines, and there was no documentation in her progress notes from 2/28/2020 to 5/9/2024 indicating that she was educated about or offered these vaccinations. Similarly, Resident #39's EHR showed he was not up to date with Pneumococcal vaccinations, and his progress notes from 11/30/2023 to 5/9/2024 lacked documentation of education or offers for these vaccines. Resident #15's EHR indicated he was not up to date with Influenza and Pneumococcal vaccinations, and his progress notes from 10/26/2021 to 5/9/2024 also lacked documentation of education or offers for these vaccines. Resident #34's EHR showed he was not up to date with Influenza and Pneumococcal vaccinations, with progress notes from 10/26/2021 to 5/9/2024 similarly lacking documentation of education or offers. During an interview, the facility's Infection Preventionist, who had been working at the facility for one month, confirmed that there should be documentation showing that residents were asked and educated annually about these vaccinations. The facility's policy stated that residents would be reviewed for vaccine eligibility on an ongoing basis as immunization recommendations change.
Failure to Send Appropriate Records During Resident Transfer
Penalty
Summary
The facility failed to send appropriate records for a transfer to the local emergency room (ER) for one resident. Record review of the resident's Minimum Data Set (MDS) indicated that the resident was discharged to the local hospital and had severely impaired cognitive skills for daily decision-making. The resident's Electronic Health Record (EHR) lacked documentation of a discharge assessment and did not specify what paperwork was sent with the resident to the hospital. During an interview, the facility's Administrator revealed that the hospital was not updated, and documents regarding Activities of Daily Living (ADLs), the Care Plan, or personal belongings were not sent with the resident. The facility's policy required completing a Transfer Form in the EHR, printing it, and placing it in an Acute Care Transfer envelope to be sent with the resident, which was not followed in this case.
Inaccurate MDS Coding for Insulin Administration
Penalty
Summary
The facility inaccurately coded the Minimum Data Set (MDS) for two residents by documenting that they received insulin during the look-back period when they did not. Specifically, the MDS for Resident #4 indicated she received one insulin injection between 2/9/24 and 2/15/24, but her Treatment Administration Record (TAR) for February 2024 showed no insulin medications were administered. Similarly, the MDS for Resident #10 indicated she received one insulin injection between 2/16/24 and 2/22/24, but her TAR also showed no insulin medications were administered. During interviews, it was revealed that the Nurse Consultant mistakenly identified Trulicity, an incretin mimetic, as insulin based on incorrect information from a form provided by the corporation, rather than using the Resident Assessment Instrument (RAI) medication websites.
Failure to Document Non-Pharmacological Interventions Before Administering PRN Anti-Anxiety Medications
Penalty
Summary
The facility failed to provide documentation of non-pharmacological interventions attempted prior to administering PRN anti-anxiety medications for a resident. Specifically, Resident #22 received his once-a-day PRN anti-anxiety medication on multiple dates in March 2024 without any documented attempts of non-pharmacological interventions in his Progress Notes. The review of the resident's Progress Notes from 3/4/24 to 3/18/24 showed a lack of documentation regarding these interventions. Additionally, the Pharmacy Consultant's Progress Notes from 2/4/24 to 5/3/24 did not include any direction to staff to document interventions attempted before administering PRN anti-anxiety medications. During an interview, the Director of Nursing confirmed that she would expect such documentation and noted that their Electronic Health Record system has a feature for adding Progress Notes. The facility's policy on Psychotropic Medications, last revised on 12/06/2023, also instructed that non-pharmacological interventions should be attempted and documented before medication interventions.
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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 West Union
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Crest Manor | 9 mi | — | 0 | 0 |
| Ossian Care Center | 12.3 mi | — | 13 | 0 |
| Hillcrest Home | 17.4 mi | — | 0 | 0 |
| Grandview Healthcare Center | 21.2 mi | — | 5 | 0 |
| Oelwein Health Care Center | 21.4 mi | — | 9 | 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 August 2026) and official state health department websites.