Good Samaritan - Decatur County

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 28, 2024

  The facility identified a census of 31 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from abuse and/or neglect. On 02/09/24, Certified Nurse Aide (CNA) M forcefully grabbed R1's wrist, took the glass of orange juice out of R1's hand, and slammed the orange juice on the table. Then CNA M aggressively grabbed R1's wheelchair to start moving her, and R1 put her foot down on the floor. CNA M yelled at R1 and aggressively placed R1's feet on the foot pedals. Social Services X attempted to intervene, but CNA M ignored Social Services X and continued to try and wheel R1 out of the dining room. […]

• Actual harm, isolatedF689Sep 11, 2023

  The facility identified a census of 30 residents with three reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure interventions were implemented to prevent Resident (R) 1 from falling out of bed and failed to ensure intervention in place to prevent injuries for R1 who had multiple falls from her bed. As a result, R1 fell out of bed and sustained an acute left hip fracture. This deficient practice also placed R1 at risk for further falls and injuries. […]

• Actual harm, isolatedF686Jul 14, 2022

  The facility had a census of 35 residents. The sample included 13 residents of which five were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, record review, and interview, the facility failed to identify the risk for pressure injuries and implement preventive interventions for Resident (R)8 who had pressure areas on her buttocks and had a decline in health. As a result, R8 developed a pressure injury to her left heel, which progressed to an open wound. […]

• Actual harm, isolatedF686Jan 27, 2021

  The facility had a census of 40 residents. The sample included 12 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a boney prominence, due to pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development of Resident (R) 13's facility acquired, unstageable pressure ulcer (partial thickness loss of skin and the wound bed is viable) to the left scapula/vertebrae. Findings included: - R13's Physician order [REDACTED]. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded the resident had short- and long-term memory loss with severely impaired cognition. […]

• No harm, potential for more than minimal, widespreadF725Nov 17, 2025

  The facility had a census of 18 residents. Based on the interview and record review, the facility failed to submit complete and accurate staffing information through Payroll Based Journaling (PBJ) as required. Findings included:- The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (FY) Quarter 4 2024 (July 1 - September 30) indicated the facility did not have licensed nurse coverage 24 hours a day on the following dates:07/07/24 (SU), 07/27/24 (SA), 07/28/24 (SU)08/11/24 (SU)09/29/24 (SU).Review of the facility's daily nursing staff coverage revealed the facility had licensed nurse coverage 24 hours a day on the above dates, and revealed the facility had adequate licensed nurse coverage.On 10/21/25 at 08:37 AM, Administrative Staff A stated the… […]