Good Samaritan - Red Oak

In the surveyor’s words

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

• Immediate jeopardy, patternF880May 4, 2022

  Based on CDC and CMS recommendations, clinical record review, staff interviews, and policy review, the facility failed to implement infection control practices in order to control and mitigate the spread of COVID-19 infection amongst residents and staff. On 1/15/22, a staff member reported feeling ill yet continued to report to work and provide care for residents throughout the building on 1/15/22, 1/16/22, and the morning of 1/17/22. Facility records showed the staff member worked with signs/symptoms consistent with COVID-19 infection and she provided care for residents who later tested positive. On 1/17/22, the staff member tested positive for COVID-19 infection. […]

• Immediate jeopardy, isolatedF684Aug 12, 2025

  Based on clinical record review, staff interviews, physician interview, physician assistant interview, policy review, and the National Library of Medicine review, the facility failed to provide assessments and interventions timely with a change in resident condition for 1 of 3 residents (Resident #3). The facility also failed to comprehensively care plan the need for assessment of impaired circulation following a history of a great toe amputation in June of 2025 which lead to the skilled placement at the facility. This failure resulted in Immediate Jeopardy to the health, safety and security of the resident. The facility reported a census of 37 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 8/6/25 at 9:50 AM. […]

• Actual harm, isolatedF684Apr 23, 2026

  Based on clinical record review, resident interviews, family interviews, staff interviews, hospital document review and provider interview, the facility failed to provide quality nursing care by not completing an assessment or intervention when a resident had low oxygen saturation (Resident #16) and for a resident who was coughing/spitting up blood (Resident #41) for 2 of 3 residents reviewed. The facility reported a census of 34 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #16 had a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. […]

• Actual harm, isolatedF689Apr 17, 2025

  Based on observations, staff interviews, record review and facility policy review the facility failed to establish and implement interventions to prevent falls and injuries for 2 of 3 residents reviewed. Resident #20 had a history of confusion and many falls. She tripped on the pedals of the wheel chair on 3/1/25 and staff failed to follow through with an intervention to remove those pedals from the wheelchair when not in use. On 4/2/15 the resident again tripped on the wheel chair pedals, fell and sustained head trauma. Resident #6 had many falls and the facility failed to evaluate for risks and hazards and failed to implement interventions for every fall. The facility reported a census of 43 residents. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812May 4, 2022

  Based on observations, document review, policy review, and staff interviews, the facility failed to store food under sanitary conditions, failed to maintain proper temperature of the dish washer and to prepare and serve food in accordance with professional standards for food service safety to prevent possible foodborne illnesses to residents. The facility reported a census of 40 residents. Findings Include: 1. Observation of the lunch meal service on 4/19/22, revealed the following on Staff K, Dietary Cook: a. At 11:46 a.m., Staff K put on a pair of gloves prior to start of meal service. Staff K touched multiple surfaces with the gloves, such as dishes, utensils, refrigerator, food containers, and kitchen equipment. […]