Good Samaritan Society - Woodland

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 4, 2025

  Based on observation, interview and document review, the facility failed to ensure staff responded to resident request for toileting assistance in a timely manner for 1 of 4 residents (R23) reviewed for falls. This resulted in actual harm for R23 who fell while attempting to transfer independently, resulting in a head laceration which required emergency medical care. The facility implemented corrective action prior to the survey, therefore, the deficient practice was issued at past non-compliance. Findings include: R23's admission Minimum Data Set (MDS) dated [DATE], identified R23 had intact cognition. R23 was occasionally incontinent of bladder, continent of bowel and required maximum assistance to transfer and toilet. R23 was unable to ambulate. […]

• No harm, potential for more than minimal, patternF921May 14, 2021

  Based on observation and interview, the facility failed to maintain the walls, ceiling, floor, and floor mat in the ice machine alcove in good repair and/or a clean and sanitary condition within the resident dining room for 13 of 13 residents (R2, R7, R8, R13, R14, R15, R18, R21, R22, R23, R24, R25, R26) who dined regularly in the dining room. Findings include: On 5/10/21, at 5:56 p.m. the ice machine alcove in the dining room was observed. A large piece of wallpaper was removed and the sheet rock was missing from the kitchen-side of the space exposing the pipes and supply lines which were [NAME] out from the opening. Another smaller piece of sheet rock was missing from the same wall closer to the ceiling. […]

• No harm, potential for more than minimal, isolatedF657Feb 11, 2026

  Based on observation, interview and document review, the facility failed to update care plans to reflect contact precautions for 2 of 3 residents (R1, R40) reviewed for transmission-based precautions.Findings include:R1R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 was cognitively intact, diagnoses included non-pressure chronic ulcer of the right lower leg/extremity (RLE), and multidrug-resistant organism (MDRO - microorganism that is resistant to one or more classes of antibiotics). […]

• No harm, potential for more than minimal, isolatedF677Apr 24, 2024

  Based on observation, interview and document review, the facility failed to ensure timely toileting assistance for 1 of 1 resident (R16) reviewed for activities of daily living and was dependent on staff. Findings include: R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 had moderately impaired cognition. R16 was dependent on staff for all toileting needs and was always incontinent of bowel and bladder. R16's care plan with revision date 2/15/24, directed staff to check and change for total incontinence every two hours. Continuous observations were conducted on 4/23/24, from 2:00 p.m. through 5:05 p.m. the following was identified: -At 2:04 p.m. R16 was sitting in his wheelchair waiting for the activity program Bingo to begin. -At 2:30 p.m. […]

• No harm, potential for more than minimal, isolatedF550Mar 16, 2023

  Based on observation, interview and document review, the facility failed to provide timely meal assistance to promote a dignified dining experience for 3 of 4 residents (R13, R21) observed who required staff assistance. Findings include: R13's significant change Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and needed extensive assistance from staff to eat. R13's undated, face sheet included diagnoses of hemiplegia (paralysis of one side of the body), weakness, dementia, and a contracture of the right hand. R13's care plan dated 12/28/22, identified R13 had an activities of daily living (ADL) deficit and directed staff to set up the meal, R13 needed assistance of one, and directed staff to encourage R13 to participate with eating with cueing. […]