Samaritan Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Samaritan Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 20, 2026

  Based on observation, staff interview, and record review, the facility did not ensure the resident environment was free of abuse for 2 residents (R) (R1 and R10) of 10 sampled residents.On 2/15/26, Certified Nursing Assistant (CNA)-J observed R1 crying and R6's hand in R1's shirt touching R1's breast. The facility did not implement preventative safety measures to ensure the safety of R1. In addition, the facility did not complete thorough behavior monitoring and behavior tracking for R6. On 2/11/26, CNA-N observed R10 in R9's room touching R9's private area inside R9's upper thigh. […]

• Immediate jeopardy, isolatedF684Nov 11, 2025

  Based on observation, staff, resident, and resident representative interview, and record review, the facility did not provide the necessary care and services to promote healing and/or prevent wounds from worsening for 3 residents (R) (R1, R2, and R4) of 3 sampled residents reviewed for non-pressure related wounds.R1 had a left total knee arthroplasty (a surgical procedure that replaces the damaged surfaces of the knee joint with artificial parts made of metal and plastic) in 2016. On 10/31/24, R1 reported pain, redness, and swelling in the left knee and lower leg. On 10/31/24, Wound Care Physician (WCP)-F recommended a magnetic resonance image (MRI) scan and an orthopedic consult. An MRI was ordered on 11/7/24 and scheduled for 12/5/24. The MRI was canceled due to insurance concerns. […]

• Immediate jeopardy, isolatedF689Oct 16, 2025

  Based on staff interview, resident representative interview, and record review, the facility did not ensure adequate assistance and supervision to prevent falls was provided for 1 Resident (R) (R4) of 7 sampled residents.R4 had left-sided hemiparesis (paralysis on one side of the body) because of a cerebrovascular accident (CVA) and required assistance for bed mobility. On 8/26/25 at approximately 8:00 AM, R4 rolled out of bed while Registered Nurse (RN)-C was providing care and sustained an orbital floor blowout fracture with herniated extraconal fat (a trauma-induced break in the thin bone separating the eye socket from the sinuses, allowing fat from around the eye to bulge into the sinus cavity). […]

• Immediate jeopardy, isolatedF600Oct 16, 2024

  Based on staff interview and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R1) of 6 sampled residents. During the night (NOC) shift on 9/24/24-9/25/24, Licensed Practical Nurse (LPN)-D observed R2 touch R6's leg and try to kiss R6. LPN-D immediately separated R2 and R6 and documented the incident in R2's medical record. Following the incident, no interventions were put in place to ensure the safety of R6 or other residents. On 9/25/24 at approximately 11:00 AM, Registered Nurse (RN)-C observed R1 and R2 in the lounge. R2 had one arm around R1's shoulders and the other hand inside R1's brief. R2 moved R2's hand back and forth while R1 attempted to push R2's hand away. […]

• Actual harm, isolatedF689Dec 15, 2022

  Based on observation, record review, and interview, the facility did not ensure the environment remained free from accident hazards and assistive devices to prevent accidents for 2 (R1 and R3) of 3 residents reviewed for falls. R1 had a fall while using a sit-to-stand lift on 10/12/2022 that was not reported, documented, or investigated. No interventions were put in place to prevent future falls or injuries. On 10/13/2022, R1 was using a sit-to-stand lift and had an unresponsive episode while sitting on the toilet with the sit-to-stand lift in place and R1 sustained a fractured humerus. […]