Good Samaritan Home

In the surveyor’s words

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

• Immediate jeopardy, patternF880Sep 8, 2022

  Based on observation, interview, and record review, the facility failed to ensure the facility's COVID-19 (Coronavirus Disease 2019) Infection Prevention and Control Program policy was followed, failed to screen all staff for COVID-19 symptoms before the start of their scheduled shifts, filed to remove symptomatic employees from work immediately, failed to test and quarantine employees who had symptoms of COVID-19 immediately, and failed isolate residents who were unvaccinated or not up to date with the COVID-19 vaccination immediately after exposure to COVID-19 positive employees. […]

• Immediate jeopardy, isolatedF689Aug 19, 2023

  Based on observation, interview, and record review, the facility failed to respond immediately to a sounding exit door alarm, failed to adequately supervise a known wandering resident (R8), failed to re-assess R8 as high risk for elopement once R8 started to exit seek, failed to develop and implement interventions and plan of care to address R8's exit-seeking behaviors after R8 attempted to exit seek, and failed investigate and report R8's elopement thoroughly for one of three residents (R8) reviewed for elopement in the sample of 41. […]

• Actual harm, isolatedF686Feb 25, 2026

  Based on observation, interview, and record review the facility failed to implement an initial care plan on admission to prevent pressure ulcers, failed to implement pressure relieving interventions to prevent the development of pressure ulcers, failed to initiate a pressure ulcer care plan as soon as a pressure ulcer was identified, and failed to obtain a treatment as soon as a pressure ulcer was identified for one resident of four residents (R79) reviewed for pressure ulcers in the sample of 37. […]

• Actual harm, isolatedF689Feb 25, 2026

  Based on Observation, Interview and Record Review, the facility failed to provide a resident with adequate supervision and assistance with footwear to prevent a fall and conduct a thorough investigation with staff interviews after a resident suffered a fall with fracture for one of two residents (R7). This failure resulted in R7's footwear being worn unsafely, and R7 suffering an unwitnessed fall, experiencing swelling and pain in her right wrist and resulting in a distal radius bone fracture requiring cast application.Findings include:The facility's Program for Reduction of Falls Risk policy, dated 4/9/25, documents As part of the program for the prevention of falls, all newly admitted residents and those residents experiencing a change in function will be assessed for the risk of falls. […]

• Actual harm, isolatedF580Sep 19, 2025

  Based on interview and record review, the facility failed to ensure a resident was provided timely provider notifications to ensure medical intervention was received with an acute change in condition for one of four residents (R1) reviewed for change in condition in the sample of four. This failure resulted in R1 experiencing a delay in evaluation and treatment while experiencing an acute ischemic stroke.Findings include:The facility's Change in Resident Condition Policy, dated 10/8/24, documents, Standard: The attending physician, resident representative, and RCC (Resident Care Coordinator) will be notified of any change in the condition of a resident. […]