ELLIS, KS — Federal health inspectors found Good Samaritan Society - Ellis failed to meet required pharmacy oversight standards during a December 2025 inspection, citing the facility for inadequate monthly drug regimen reviews among three total deficiencies — none of which have an approved correction plan on file.
Monthly Drug Reviews Not Performed as Required
During the standard health inspection conducted on December 11, 2025, surveyors determined that Good Samaritan Society - Ellis did not ensure a licensed pharmacist performed monthly drug regimen reviews as mandated by federal regulations. The review process, governed by regulatory tag F0756, requires that a qualified pharmacist examine each resident's complete medication profile and medical chart on a monthly basis, flag any irregularities, and follow established facility policies for reporting those findings.
The deficiency was classified at Scope/Severity Level D, meaning the issue was isolated in nature and no actual harm to residents was documented at the time of the survey. However, inspectors determined there was potential for more than minimal harm, a designation that signals real risk to resident health if the gap in oversight continues uncorrected.
Monthly drug regimen reviews exist for a specific and important reason. Nursing home residents are among the most medically vulnerable populations in the country. The average long-term care resident takes seven to eight medications simultaneously, and many take considerably more. Each additional medication increases the probability of harmful drug interactions, adverse side effects, and dosing errors. A pharmacist's monthly chart review serves as a critical safety net — catching problems that may develop gradually and go unnoticed by direct care staff managing dozens of patients.
What a Proper Drug Regimen Review Involves
Under federal regulations, the monthly review is not a cursory glance at a medication list. A licensed pharmacist is expected to examine the resident's full medical chart, evaluate whether each prescribed medication remains appropriate given the resident's current diagnoses and condition, check for potential drug-drug interactions, assess whether dosages need adjustment based on changes in weight or organ function, and identify any medications that may no longer be necessary.
When irregularities are identified, the pharmacist must report them to the attending physician and the facility's director of nursing according to the facility's own written policies and procedures. The physician then has a defined window to act on or acknowledge those findings. This cycle of review, reporting, and response is designed to prevent medication-related harm before it occurs.
Without this process functioning properly, residents face elevated risk of adverse drug reactions, which are a leading cause of emergency hospitalizations among nursing home populations nationally. Missed interactions between blood thinners and antibiotics, inappropriate use of antipsychotic medications in dementia patients, and failure to adjust dosages for declining kidney function are among the most common — and most dangerous — errors that monthly reviews are designed to catch.
Three Deficiencies, No Correction Plan
The pharmacy oversight failure was one of three deficiencies identified during the December inspection. Perhaps more concerning than the citation itself is the facility's response: as of the most recent update, Good Samaritan Society - Ellis has not submitted a plan of correction to address the findings.
Federal regulations require that cited facilities submit a detailed correction plan outlining specific steps they will take to remedy each deficiency, designate responsible staff members, and establish target completion dates. The absence of a correction plan means there is no documented commitment from the facility to resolve the identified gaps in pharmacy oversight.
Good Samaritan Society is a national nonprofit senior care organization affiliated with Sanford Health, operating facilities across multiple states. The Ellis location serves residents in northwestern Kansas, a rural area where long-term care options are limited and families may have few alternatives if quality concerns arise.
What Families Should Know
For families with loved ones at the facility, the inspection results underscore the importance of asking direct questions about medication management. Residents and their representatives have the right to request information about when the most recent pharmacist review was conducted, whether any irregularities were identified, and what actions were taken in response.
The full inspection report, including details on all three cited deficiencies, is available through the Centers for Medicare & Medicaid Services and on NursingHomeNews.org's facility profile for Good Samaritan Society - Ellis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Ellis from 2025-12-11 including all violations, facility responses, and corrective action plans.
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