Good Samaritan Society - Specialty Care Community

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society - Specialty Care Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 8, 2021

  Based on observation, interview, and document review, the facility failed to assess elopement risk, implement interventions, and prevent an elopement for 1 of 3 residents (R1) reviewed for elopement who successfully eloped from the facility. This deficient practice resulted in immediate jeopardy (IJ) to resident health and safety. R1 eloped from the facility on 10/3/21, at 3:40 p.m. and was found by staff on the street near the facility. In addition, the facility failed to complete elopement assessments, and identify and implement interventions for 2 of 3 residents (R2, R3) who had documented exit seeking behavior, wandering, and/or elopement attempts. […]

• Actual harm, isolatedF600Aug 25, 2026

  Based on observation, interview, and document review, the facility failed to monitor and develop additional person-centered care plan interventions to protect a resident's right to be free from physical abuse for 1 of 4 residents (R1) resulted in actual harm when R1 who had dementia, hallucinations, agitation, and a habit of wandering into other residents' rooms on eight different occasions leading to resident-to-resident altercations. During the eighth incident, R1 suffered a Subdural Hematoma (a serious condition where blood collects between the layers of the brain after a head injury.) The severity of the injury resulted in the inability to walk, feed himself, and needed total care from staff. His prognosis was poor and required end of life hospice care. […]

• Actual harm, isolatedF684Aug 25, 2026

  Based on interview and document review, the facility failed to complete neurological assessments as indicated after a head injury sustained during a resident-to-resident altercation for 1 of 1 resident (R1) who sustained a significant head injury. R1 suffered actual harm resulting in a subdural hematoma (a collection of blood between the brain and its outer covering) and was sent to emergency department and returned on hospice care. Findings include: R1's July medication administration record (MAR) dated [DATE] through [DATE], indicated he received his scheduled Tylenol order for 1000 milligrams (mg) at 8:00 a.m. and 8:00 p.m. In addition, R1 had an order for additional as needed (PRN) Tylenol 1000 mgs once a day for pain but, no additional doses were given from [DATE] through [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Based on observation, interview, and document review the facility failed to ensure staff consistently wore hair restraints and gloves while serving food. Additionally, the facility failed to maintain food temperatures within the desired range. The facility also failed to consistently cover food items placed in the freezer and date the items with the date placed and the date food items were to be used by. This had the potential to affect all 88 residents who resided at the nursing home. Findings include: On 6/1/26 at 5:11 p.m., dietary aide (DA)-A was observed setting up kitchenette area for evening meal service. DA-A had her hair pulled back in a ponytail, with strands of hair hanging free from the ponytail on the sides of her head. DA-A was wearing a standard uniform top. […]

• No harm, potential for more than minimal, widespreadF880Jun 4, 2026

  Based on interview and document review the facility failed to implement routine surveillance of signs and symptoms of illness/infection which were not currently being treated with antibiotic therapy or other treatment. This had the potential to impact all 88 residents who resided at the facility, as well as staff, and visitors. Findings include: A review of the Infection Surveillance Reports was completed for the months of March, April, and May of 2026. The documents included the total number of infections, whether facility or community acquired infections, the facility acquired infection incidence rates, and the number of multidrug resistant organisms (MDROs). The surveillance logs further classified the types by category of infection. […]