Good Samaritan Living Center

Inspectors wroteBased on record review and interview, the facility failed to electronically submit payroll based staffing information for direct care staff as required. The deficient practice had the potential to affect the 48 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to ensure staff:1. Properly utilized EBP PPE during high contact resident care activities for 2 (#2 and #38) of 3 residents observed and required EBP; and 2. Properly dispose of soiled linens after bed linen change and remove soiled PPE prior to exiting a resident's room for 1 (#38) of 3 resident observed receiving ADL care.1. Resident #2 Review of the Clinical Record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region, stage 4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately coded the correct discharge location for 1 (#55) of 1 resident reviewed for closed record. Review of Resident #55's Discharge Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 03/26/2026 revealed Resident #55 was discharged to home/community. Review of Resident #55's Nurse's Notes revealed the following, in part:03/26/2026 Resident discharged today with home health services. An interview was conducted on 05/13/2026 at 3:15 p.m. with S11MDS. S11MDS confirmed Resident #55 discharged home with home health services. S11MDS reviewed Resident #55's Discharge MDS with an ARD of 03/26/2026. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility's staff failed to implement pressure ulcer prevention interventions per physician orders and plan of care for 1 (#2) of 2 sampled residents with pressure ulcers. Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE], with diagnoses which included Pressure Ulcer of Sacral Region Stage 4. Further review revealed she had limited bed mobility. Review of Resident #2's current Physician Orders revealed the following, in part:Wound Prevention: Ensure bilateral heel boots are in place at all times, every day and night shift. Review of Resident #2's current Plan of Care revealed the following, in part:Problem:Potential for risk of skin breakdown related to decreased mobility. Intervention:Ensure heel protector boots are applied to bilateral feet at all times when in bed. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's Minimum Data Set accurately reflected their status for 1 (#3) of 5 residents in the sample. The facility failed to ensure Resident #3 was coded correctly for Urinary Tract Infection in the last 30 days. Review of Resident #3's Clinical Record revealed an admission date of 06/26/2025 with diagnoses, which included Cerebral Infarction, Urinary Tract Infection, Aphasia following Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction. Review of Resident #3's Significant Change Minimum Data Set with an Assessment Reference Date of 10/31/2025 revealed the following in part:Section I-Active Diagnoses:Infections:I2300. Urinary Tract Infections (last 30 days): No Review of Resident #3's latest Care Plan revealed the following in part:Focus: [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure services were provided to meet quality professional standards by failing to: 1. Transcribe physician's orders accurately for 1 (#2) of 5 (#2, #14, #18, #34, and #36) residents reviewed for medication administration; and 2. Follow physician orders for 1 (#9) of 12 residents reviewed in the final sample.

Inspectors wroteBased on observations and interviews, the facility failed to store food under sanitary conditions by failing to ensure food was properly labeled and stored in unit refrigerators. This deficient practice had the potential to affect 40 residents who were able to store and consume food in the facility's unit refrigerator.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure all medical records regarding the resident's code status reflected the resident's wishes for 1 (#14) of 16 residents reviewed in the initial screening for advanced directives.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure: 1. S6CNA wore proper Personal Protective Equipment (PPE) while providing care for Resident #15 who was on Enhanced Barrier Precautions (EBPs); and 2. S4LPN used appropriate hand hygiene between administering medications to 5 (#1, #3, #5, #16 and #29) of 5 (#1, #3, #5, #16 and #29) resident's observed during medication pass.

Inspectors wroteBased on interviews and record review, the facility failed to employ staff with appropriate competencies and skills sets to carry out the functions of the food and nutrition service by failing to have a certified dietary manager on staff.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the food items served from the menu met the resident's personal dietary choices for 1 (#15) of 16 sampled residents reviewed in the initial pool.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure Resident #1's significant change in condition was communicated to the physician after having a fall with head injury for 1 (#1) of 4 (#1, #2, #3, and #R5) residents reviewed for notification of change. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively intact resident without confusion, on [DATE] at 7:46 a.m., when the resident returned from the emergency room after a fall and exhibited new onset signs of confusion. Nursing staff verbalized and documented Resident #1's increased confusion from [DATE] through [DATE] and failed to identify the change as a potential for head injury, implement new interventions, or notify the physician. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident remained free from neglect for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for falls with major injury. The facility failed to ensure: 1. Nursing staff identified a change in condition for Resident #1 after a fall with head injury. 2. Nursing staff implemented appropriate interventions after Resident #1 began showing signs of a change in status after a fall with head injury; 3. Nursing Staff communicated the change in condition with Resident #1's physician. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively intact resident without confusion, on [DATE] at 7:46 a.m., when the resident returned from the emergency room after a fall and exhibited new onset signs of confusion. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure a system was in place for nursing staff to identify, intervene and communicate a change of condition in Resident #1. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1, a cognitively intact resident without confusion, on [DATE] at 7:46 a.m., when the resident returned from the emergency room after a fall and exhibited new onset signs of confusion. Nursing staff verbalized and documented Resident #1's increased confusion from [DATE] through [DATE] and failed to identify the change as a potential for head injury, implement new interventions, or notify the physician. [...]