Good Samaritan - Red Oak

Inspectors wroteBased 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.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to post in a prominent place, readily available to residents, staff, and visitors, the facility's daily staff data consisting of the total number of staff (registered nurses (RNs), licensed practical nurses (LPNs), certified nurse aides (CNAs), certified medication assistants (CMAs)), actual hours worked by the staff, and resident census. The facility reported a census of 34 residents.

Inspectors wroteBased on observations, staff interviews, and policy review the facility failed to prepare, serve and distribute food in accordance with food service safety for general practices of mealtime service. The facility failed to identify and date opened packages of food in the kitchen, properly store food, and complete infection control practices while assisting residents during mealtimes. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, policy review, pharmacist interview and staff interviews the facility failed to offer the residents at the facility COVID-19 immunizations and the residents did not receive the COVID-19 immunizations for 2025 year for 5 of 5 residents reviewed (Resident #9, #10, #12, #14, and #15). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to fully inform the resident and/or representative of alternative psychotropic medication options by failing to identify target behaviors or non-pharmacological interventions on psychotropic medication (medications that affect a person's mental state, emotions, and behavior) consent forms for 3 of 5 residents (#4, #7, and #30) reviewed. The facility reported a census of 34 residents. 1. Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was admitted to the facility on [DATE]. It also identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of anxiety and depression. [...]

Inspectors wroteBased on observations, staff interviews, clinical record review, and policy review the facility failed to provide a clean and homelike environment when a visibly soiled pillow case was observed two days in a row for 1 of 3 residents reviewed (Resident #6). The facility reported a census of 35 residentsFindings Include:Review of Resident #6 Minimum Data Set (MDS) dated [DATE] revealed an admission date of 7/31/20. The MDS documented Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact mental status. The MDS indicated diagnoses of stroke, hemiplegia and hemiparesis. Observation on 4/20/26 at 9:18 AM noted a large u-shaped body pillow present on Resident #6's bed on top of the comforter with the white pillow case observed to have yellow and brown discoloration to both bottom sections of the u-shaped body pillow's white pillow case. [...]

Inspectors wroteBased on clinical record review, staff interview, and policy review, the facility failed to identify and consistently document non-pharmacologic behavior interventions for 3 of 5 residents (#4, #7, & #30) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications for 1 of 3 residents reviewed (Resident #40). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to complete a Pre-admission Screening and Resident Review (PASRR) for 1 of 1 residents (Resident #33), who was diagnosed with a new mental disorder diagnosis since admission to the facility. The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record reviews, staff interview, and policy review, the facility failed to develop a personalized Care Plan that included resident specific target behaviors or non-pharmacological interventions for 3 of 5 residents (#4, #7, & #30) who received psychotropic medications (medications that affect a person's mental state, emotions, and behavior). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record review, observations, family interview, staff interviews, and policy review, the facility failed to ensure 1 of 14 residents (Resident #28) activities of daily living (ADL) abilities were maintained or improved. The facility failed to cut a resident's meat prior to serving as the family had requested. The facility reported a census of 34 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to provide appropriate toileting hygiene assistance to prevent a urinary tract infection (UTI) for 1 of 1 resident (#7). The facility reported a census of 34 residents.

Inspectors wroteBased on clinical record, observations, resident interview, staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 1 of 1 residents (Resident #14) reviewed, requiring the use of oxygen. The facility failed to provide a resident's oxygen at the amount as documented in the physician's orders. The facility reported a census of 28 residents.

Inspectors wroteBased on clinical record review, family interview, staff interviews and facility policy review, the facility failed to report an allegation of abuse to the appropriate entity for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, family interviews, staff interviews and policy review, the facility failed to complete a comprehensive investigation immediately when an allegation of abuse was reported for 1 of 2 residents reviewed (Resident #1). The facility reported a census of 40 residents.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, staff interviews, and policy review the facility failed to provide a well balanced diet that meets nutritional and special dietary needs by use of incorrect serving size portions for meals. The facility reported a census of 43 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to prepare, serve and distribute food in accordance with safe food handling practices. The facility reported a census of 43 residents.

Inspectors wroteBase on observations, staff interviews and record review the facility failed to use infection control practices for 3 of 13 records reviewed. Resident #39 had an open pressure ulcer on his coccyx that was exposed to pathogens as it came into contact with the mechanical lift sling. Staff failed to use adequate hand hygiene while caring for Resident #3, and Resident #33 was found to have his catheter bag resting on the floor. The facility reported a census of 43 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for a resident (Resident #6) with suicidal ideations. The facility further failed to implement interventions for a smoking resident (Resident #18) listed on the care plan. The facility reported a census of 43 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, staff interview, policy, and Medication Administration Records - Treatment Administration Records (MAR-TAR) review the facility failed to provide needed services in accordance with professional standards by leaving medications in the residents room for self administration without visualization by the nurse for 1 of 8 residents (Resident #3). The facility reported a census of 43 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oral cares for 1 of 3 residents reviewed (Resident #28). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, resident interview, staff interview and physician interview, record review, and facility policy review the facility failed to provide adequate pressure ulcer care for 2 of 3 residents reviewed (Resident #39, #28). Resident #39 had a Stage IV pressure on his coccyx and staff failed to complete the treatments as ordered. He was found to have 3 areas of skin breakdown that staff failed to document and measure. Resident #28 had a Stage II pressure on his buttocks and was found to be without the ordered dressing. The facility reported a census of 43 residents.

Inspectors wroteBased on Electronic Health Records (EHR), staff interview, observation and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral medication with a piston syringe into enteral tube for 1 of 1 residents (Resident #3). The facility reported a census of 43 residents.

Inspectors wroteBased on observations, staff interviews, and policy reviews the facility failed to prepare, serve, distribute, and store food in accordance with professional standards. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, resident interviews, observation, staff interviews, and policy review the facility failed to provide food at an appetizing temperature to 3 of 15 residents reviewed (Resident #31, #30 and #40). The facility reported a census of 29 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to implement infection control practices to prevent cross contamination of invasive medical devices. The facility reported a census of 40 residents.

Inspectors wroteBased on observations, staff interview, and policy review the facility failed to complete and post on a daily basis the nursing staffing data. The facility reported a census of 40 residents.

Inspectors wroteBased on clinical record review, staff interviews and family interviews the facility failed to notify 1 of 3 resident's (Resident #1) family when a bruise developed. The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, staff interviews, family interview and facility policy review the facility failed to notify facility management timely when 1 of 3 residents (Resident #1) was found to have a bruise to her right hip/thigh on 11/5/23. Management not notified until 11/6/23. The facility reported a census of 44 residents.

Inspectors wroteBased on observations, resident interview, family interview, staff interviews and facility policy review the facility staff failed to supervise medication administration by leaving 1 of 3 resident's (Resident #3) medication on their bed side table. The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, hospice documentation review and staff, family and hospice staff interview the facility failed to assess and intervene timely for a bruise for 1 of 3 resident (Resident #1) reviewed. The facility reported a census of 44 residents.

Inspectors wroteBased on clinical record review, staff interviews, resident interview, family interview, hospice staff interview, and hospice agreement contract the facility failed to notify 1 of 3 resident's (Resident #1) hospice provider when they found a bruise on her right hip and thigh. The facility reported a census of 44 residents.