Good Samaritan Rehab and Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards for 9 of 28 sampled residents (Residents 2, 27, 30, 34, 52, 65, 71, 81, and 90) when:Resident 2 did not have an updated smoking reassessment. Residents 27 and 81 smoked without supervision and had smoking paraphernalia (items used for smoking, such as cigarettes, lighters, and matches) with them instead of having it secured by staff. Residents 30 and 65 did not have updated smoking reassessments, smoked without supervision, and had smoking paraphernalia with them instead of having it secured by staff. Resident 34 smoked without supervision and did not have a smoking care plan. Resident 52 smoked without supervision, had smoking paraphernalia with them instead of having it secured by staff, and did not have a smoking care plan. Resident 71 smoked without supervision. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food storage and preparation in accordance with professional standards for food safety for the 74 residents who received facility prepared meals when:An opened and unlabeled food item was found in one of the freezers, and;Multiple temperature logs were found with missing documentation. These failures had the potential to place residents who ate the facility prepared meals at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for 5 of 28 sampled residents (Resident 52, Resident 1, Resident 14, Resident 37, and Resident 81) when:Staff failed to perform hand hygiene (cleaning hands with soap and water or alcohol-based hand sanitizer to remove germs and prevent the spread of infection) between delivering meal trays to Resident 52 and Resident 1, and;Multiple urinals (portable, handheld containers designed for men with limited mobility to urinate while in bed or seated) used by Resident 14, Resident 37, and Resident 81 were not labeled. These failures had the potential to spread infection and cause adverse health outcomes for residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to provide education, offer, and document the influenza (commonly known as the the flu, a contagious viral infection that attacks the respiratory system, including the nose, throat, and lungs) vaccinations and pneumococcal (a serious bacterial infection caused by Streptococcus pneumoniae. It spreads via respiratory droplets and can lead to severe illnesses like pneumonia, meningitis, and bloodstream infections) vaccinations for 4 of 5 sampled residents (Resident 27, Resident 81, Resident 37, and Resident 14) when:The influenza vaccine was not given, and education was not provided for Resident 27, Resident 81, and Resident 37, and;The pneumococcal vaccine was not given, and education was not provided for Resident 81, Resident 37, and Resident 14. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide education, offer, and document Covid-19 (Coronavirus Disease 2019, a respiratory viral infection that affects primarily the lungs and results in coughing and difficulty breathing) vaccinations for four (4) of five (5) sampled residents (Resident 27, Resident 81, Resident 37, and Resident 14). This deficient practice placed the residents and staff at risk for possible Covid-19 infection due to missed vaccination dosage and violated the residents and/or responsible parties' rights to make an informed decision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for 3 of 28 sampled residents (Residents 24, 70, and 84) when:Resident 24 was observed lying in bed without lower body clothing or a covering and was visible from the hallway and through the room window while wearing only a fully soaked incontinent brief (a disposable undergarment designed to absorb urine and stool). Certified Nursing Assistant (CNA) 4 stood over Resident 70 and CNA 3 stood over Resident 84 while assisting with meals and did not position themselves at the residents' eye level. These failures had the potential to negatively affect the residents' dignity, privacy, psychosocial well-being (emotional and social functioning), and quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was properly informed of and consented to the use of psychotherapeutic medications (medications used to control behavior or treat thought disorders) for 1 of 28 sampled residents (Resident 52), when Resident 52's informed consent for olanzapine (an antipsychotic medication used to treat mental health conditions that affect a person's thinking, mood, behavior, or perception of reality), signed on 1/22/25, was not renewed within the required timeframe while Resident 52 continued to receive the medication. This failure had the potential to violate Resident 52's right to make informed decisions regarding psychotherapeutic medication use, including understanding the benefits of medication, risks, side effects, and alternative treatment options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 1 of 28 sampled residents (Resident 1) when Resident 1 had a call light (device used to contact staff for assistance) that was not within Resident 1's reach. This deficient practice placed Resident 1 at increased risk for unmet care needs, delayed staff response, falls, and potential injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS - a standardized assessment used to evaluate a resident's physical, mental, and functional status and identify care needs) discharge assessment was completed, encoded (entered into the facility's MDS software), and transmitted (electronically submitted and accepted into the federal MDS system) within the required timeframe for 1 of 28 sampled residents (Resident 41), when Resident 41 was discharged from the facility on 3/6/26. This failure had the potential to result in incomplete resident assessment information and inaccurate information regarding the resident's discharge status being reported to the Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR - a required screening process used to identify residents with serious mental illness or intellectual disabilities and determine whether they need specialized services) was completed for 1 of 28 sampled residents (Resident 17) when Resident 17's PASRR completed on 9/25/23 determined Resident 17 did not require a PASRR Level II evaluation (an in-depth evaluation to determine the need for specialized mental health services), but Resident 17 was later prescribed risperidone (an antipsychotic medication used to treat certain mental health conditions) on 9/30/25 due to increased behavioral symptoms and was not referred for PASRR review. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan with appropriate, resident-specific fall interventions for 1 of 28 sampled residents (Resident 75) following a fall on 5/12/26 when the Interdisciplinary Team (IDT - a group of healthcare professionals from different disciplines who collaborate to provide resident care) did not complete a root cause analysis or identify recommendations related to the cause of the fall, and nursing staff did not complete post-fall monitoring to identify risks and develop resident-specific interventions to prevent future falls. These failures had the potential to place Resident 75 at risk for recurrent falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 28 sampled residents (Resident 75) had their hydration needs addressed when Resident 75, who preferred to have water readily available at the bedside and within his reach, did not have water available to drink at the bedside. This failure had the potential to place Resident 75 at risk for dehydration (when the body does not get enough fluids to function properly), and overall decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration for a census of 78. The facility had a total of four errors out of 55 opportunities which resulted in a facility wide medication error rate of 7.27%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The four medication errors were identified in three residents (Resident 72, Resident 12, Resident 15) out of 8 residents observed for medication administration observation as follows: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe use and storage of medication and labeling practices for a census of 78 when:1. A carton of an opened and unlabeled nutritional supplement was found on a medication cart.2. Personal items and cleaning chemicals were found stored in one of the cabinets.3. The facility did not monitor the temperatures of both medication rooms, and,4. Unauthorized personnel had access to the medication room. These failures could contribute to the risk of using contaminated products on residents, contribute to unsafe medication use, lack of accountability and risk of drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate resident meal preferences and food allergies for 1 of 28 sampled residents (Resident 54) when Resident 54 was served a bread roll on the 6/16/26 lunch meal service. This failure placed Resident 54 at risk for an allergic reaction due to her food allergies to wheat products.

Inspectors wroteBased on interview, and record review, the facility failed to provide pain management consistent with professional standards of practice for one of one sampled resident (Resident 1) who experienced severe pain when:1) Pain medication was not administered consistent with the physician's orders and reported pain levels,2) Resident 1's physician ordered narcotic (a strong medicine that relieves severe pain and has a high addiction potential) pain medication was not available; and,3) The physician was not notified when Resident 1 reported uncontrolled severe pain (high-level pain). This failure caused Resident 1 to endure unnecessary pain and suffering and placed the resident at risk for prolonged discomfort, emotional distress, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents, (Resident 3) who was dependent on staff to carry out activities of daily living, (ADLs, tasks of everyday life including eating, dressing, bathing, showering, and using the bathroom) received services to maintain personal hygiene when Resident 3 was not provided with once weekly showers for two months. This failure had the potential to cause discomfort, skin impairment, infection, and a decline in emotional and psychological well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the confidentiality of two of three sampled residents (Resident 6 and Resident 7) when portions of Resident 6's and Resident 7's medical records were discovered in Resident 3's medical record. This failure had the potential for exposure of Resident 6's and Resident 7's private and confidential information to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the protection to residents' personal information for a census of 81 when meal tray tickets (contained resident names and other identifying information) were thrown into the trash and outside dumpsters. This failure had the potential for identity theft and misuse of personal information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 81 residents who ate facility prepared meals when: 1. Raw chicken was left thawing in the sink without running water; 2. Over-ripe and spoiled produce was available for use in the walk-in refrigerator; 3. Leftover food was kept beyond a safe time frame, incorrectly dated, and the cool down process was omitted; 4. Staff food was stored in the walk-in refrigerator which contained resident food and placed on top of cooked food; 5. Boxes of food, drinks, supplies, and food products were found on the floor in the dry storage room; 6. Non-food items and staff personal items were stored in the dry storage room; 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain equipment in safe operating condition when: 1. The can opener was found with layers of metal shavings and food particles; and 2. The dishwashing machine remained below manufacture required temperature of 120 degrees. These deficient practices had the potential to compromise food safety for the 81 residents receiving food from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of pests for a census of 81 residents when roaches were found in front and beneath the microwave that was used to reheat foods for the residents. This failure had the potential for the cross-contamination of foods stored in the resident's refrigerator, and foods being reheated in the resident's microwave, resulting in food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy and dignity were maintained for 1 of 21 sampled residents (Resident 287) when, Resident 287's urinary catheter bag (a bag that collects urine draining from the bladder) did not have a privacy cover over it. This failure had the potential to negatively impact Resident 287's feelings of dignity and self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 29) was informed in advance by a physician or other professional in charge of Resident 29's care of the risks and benefits of psychotropic medication use (any drug capable of affecting the mind, emotions, and behavior) when Risperidone (medicine which may help symptoms such as aggressive or agitated behavior for some mental health conditions) and Valproic Acid (a medication which may help reduce behaviors that can include agitation, restlessness, combativeness, and verbal aggression) were prescribed and given without consent from Resident 29's Responsible Party (Resident 29's responsible party was a conservator-a person appointed by a court to make medical decisions for another adult who cannot care for themselves). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for two of five residents (Resident 288 and Resident 61) whom smoked when: 1. Resident 288 smoked a cigarette in the facility courtyard without supervision; and 2. Resident 61 kept a cigarette lighter in his room that was accessible to other residents. These failures had the potential to place Resident 288 and other residents in the facilit,y with a census of 81, at risk for accidental burns and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate administration of medication for 1 out of 16 residents (Resident 62) observed during medication administration when, Resident 62's medication was given when her vital signs were outside of prescribed parameters. This failure had the potential for Resident 62 to experience an adverse reaction to her prescribed medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication and medical supplies storage in the medication cart, treatment cart, medication refrigerator, and the medication storge room for a census of 81 when: 1. Staff beverages, and staff belongings were stored in the medication storage rooms; 2. The medication refrigerator in the medication storge room which contained narcotics was not locked; 3. Expired medications and opened unlabeled medications were stored in the medication cart; 4. Multi-use wound care irrigation solutions in the treatment cart were opened but not dated; 5. Expired single use wound care ointment and cream, expired multi-use wound care ointments, and expired wound dressing material were stored in the treatment cart; and, 6. A single use sterile dressing in the treatment cart was opened but not discarded. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Physical Therapy (PT- the treatment of disease, injury, or deformity by physical methods such as message, heat treatment, and exercise) and Occupational Therapy (OT- treatment that helps improve the ability to perform daily tasks) services to one of twenty one sampled residents (Resident 81), when Resident 81 did not receive a PT/OT evaluation and treatment as ordered. This failure had the potential for Resident 81 not to attain, maintain, or restore his highest practicable level of physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and obtain complete medical records for 1 out of 21 sampled residents (Resident 72), when Resident 72's medical record did not contain progress notes from the primary care provider. This failure resulted in an incomplete reflection of Resident 72's progress toward achieving her person-centered plan of care and potentially resulted in insufficient information for the staff to facilitate communication among the interdisciplinary team that provided care for Resident 72.

Inspectors wroteBased on interview, and record review, the facility failed to provide evidence of the ongoing efforts of a Quality Assurance and Performance Improvement (QAPI- a data driven and proactive approach used to continuously identify opportunities for improving the overall quality of life and quality of care and services to nursing home residents) program/plan for a resident census of 81. This deficient practice had the potential for the facility to miss efforts to identify, report, investigate, analyze, and prioritize identified concerns in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from the risk of infection for a census of 81 when staff refilled an empty soda bottle from the water dispenser at Nurse Station #3 with the water dispenser spout touching the mouth of the soda bottle. These failures resulted in the potential for the spread of infection to residents, visitors, and staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- a federally mandated program that includes a set of practices to ensure antibiotics are used appropriately) was followed for one of two sampled residents (Resident 42) on an antibiotic when: 1. Resident 42 developed signs and symptoms of a Urinary Tract Infection (UTI-an infection of the urinary system) and the facility's ANTIBIOTIC STEWARDSHIP GUIDELINE (a set of rules for identifying infections in long-term care facilities) used as part of ASP was not initiated for Resident 42; 2. The Infection Preventionist (IP) was not aware Resident 42 was prescribed antibiotics and did not add Resident 42 to the ANTIBIOTIC STARTS TRACKING log, the MONTHLY SURVEILLANCE REPORT FORM, or the ANTIBIOTIC LOG; and 3. [...]

Inspectors wroteBased on observation and interview, four rooms (rooms 5, 18, 22, and 45) in the facility did not meet the required 80 square feet per resident. This failure placed the residents in rooms 5, 18, 22, and 45 at potential risk to impede their care and highest possible level of functioning due to smaller than required square footage.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was provided dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) care and services consistent with professional standards of practice when: 1. Resident 1 was unable to attend his scheduled dialysis session and his make-up dialysis session due to transport being unavailable; and, 2. Resident 1's monthly labs from the dialysis center were not available in Resident 1's medical record. The failure of unavailable transportation led to a delay in dialysis care for Resident 1 with a potential to alter Resident 1's health status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe practices in handling hazardous medications (Drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) during storage and medication administration with a resident census of 79. The unsafe handling of hazardous medications could pose a health risk to staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 21 sampled resident's (Resident 28) pain was managed, when the facility did not notify the physician of Resident 28's severe pain, and treated Resident 28 with a medication ordered to manage mild to moderate pain. This failure resulted in Resident 28 experiencing unmanaged pain for long periods of time.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prescribed medication unavailability was communicated to the medical doctor and failed to ensure vital medications were available for administration for two residents (Resident 43 and Resident 80), in a sample of 21, when: 1. Anxiety and narcotic pain medications were not available for administration for Resident 43 with Post Traumatic Stress Disorder (PTSD); 2. Insulin (medication in shot form to treat high blood sugar level) was not available for Resident 80 with a diabetic (blood sugar disease) diagnosis. These failures had the potential to negatively impact Resident 43 and Resident 80's health and well-being. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage and labeling practices were based on standards of practice with census of 79 when: 1. The Emergency Kit (or Ekit- a supply of products for use when urgently needed) for IV (Intravenous, into the vein) medications was not labeled with a list of items or the earliest beyond use date (or expiration date) in medication room at Station 3. 2. Expired hand gel (a liquid gel for hand sanitization) bottles were stored in the active storage area in the medication room at Station 3. 3. Undated and opened medication container was stored in the unlocked refrigerator at Station 3's medication room where staff's personal bags were stored at the same time. 4. [...]

Inspectors wrote3. During an interview on 3/7/24 at 11:40 a.m., the Administrator stated the facility did not have a policy and procedure for the required water management program. During an interview on 3/7/24 at 12:00 p.m., the Administrator stated she had worked at the facility for more than 10 years and there had never been a water management program at all during that time. During an interview on 3/7/24 at 12:05 p.m., the Infection preventionist stated the facility not having a water management program placed residents at risk for water borne illnesses. According to a memo released by the Centers for Medicare and Medicaid Services (CMS) to all healthcare facilities, dated 7/6/18, and titled, Requirement to Reduce Legionella [bacteria that can cause serious lung infections] Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD), the memo indicated, . [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST- a written physician's order that documents the types of medical treatment the resident wants to receive during serious illness, for example, chest compressions if the heart stops beating and/or a tube placed down the throat if breathing stops) was fully completed and/or uploaded to the resident's Electronic Health Record ([EHR]- information stored in the facility's computer system) per facility policy for 1 of 21 sampled residents (Resident 64). This failure had the potential for a delay in treatment for Resident 64 during a medical emergency and/or the incorrect life sustaining treatment administered to Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 21 sampled residents (Resident 75 and Resident 81) received care and services safely when Resident 75 and Resident 81 were unable to open bathroom door #7. This failure led to feelings of entrapment (caught, trapped or entangled) and the inability to maintain independence with Activities of Daily Living (ADL - examples: toileting, shaving, brushing teeth).

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement psychotropic (mind altering medications often used to treat mood disorder, anxiety, or depression) and high-risk medication (medication known to cause serious harmful effect due to nature of the product) care plans (a component of care that outlines nursing care to provide coordinated and resident specific care to improve overall health and ensure appropriate nursing actions) for 3 out of 21 sampled residents (Resident 80, Resident 57, and Resident 28) when: 1. Resident 80's psychotropic medication use was not care planned for the licensed staff to monitor the progress and use of the two medications called duloxetine (also known as Cymbalta mind altering medication used to treat depression) and cariprazine (also known as Vraylar, a mind-altering drug used to treat mood disorder), 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment, and adequate supervision for one of four sampled residents (Resident 72) when: 1. Resident 72's fall risk assessment was not completed accurately and fall interventions were not updated after Resident 72 experienced multiple falls in February of 2024; and, 2. Resident 72 eloped (leaving) from the facility on 1/29/24, without staff being aware until they were contacted by the police department. These failures may have contributed to Resident 72's recurrent falls and the potential for serious injury, negatively effecting Resident 72's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the Physician's orders for one of 34 residents receiving supplemental (additional) oxygen (Resident 80). This failure resulted in Resident 80 receiving over twice the ordered amount of supplemental oxygen and could have led to injury due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - long term inflammatory lung disease that causes obstructed airflow from the lungs and too much oxygen could cause a person to lose their drive to breathe).

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply appropriate siderails for 1 of 21 sampled residents (Resident 63), when Resident 63 was ordered half siderails but was found with two full bed siderails in use. This failure had the potential to cause restricted exiting from the bed, increased risk of injury, increased depression, and entrapment.

Inspectors wroteBased on interview and record review, the facility failed to monitor the adverse effects of high-risk medications (medication known to cause serious harmful effect due to nature of the product) in two out of five residents (Resident 80 and Resident 57) sampled for unnecessary drugs when: 1. Resident 80's blood thinner medications (by thinning the blood , the medicine could cause bleeding and at the same time prevent blood clot formation, heart attack or stroke) was not monitored for adverse effects of apixaban (also known as Eliquis, drug used to prevent blood clot by thinning the blood), ticagrelor (also known as Brilinta, drug used to thin the blood to prevent stroke or heart attack) and naproxen (also known as Naprosyn, a pain medication known to have bleeding side effects) with a known adverse bleeding side effects per manufacturer drug information; and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement psychotropic (mind altering medications often used to treat mood disorder, anxiety, or depression) medication side effect and behavior monitoring in one out of five sampled residents (Resident 80) when Resident 80's duloxetine (also known as Cymbalta mind altering medication used to treat depression) and cariprazine (also known as Vraylar, a mind-altering drug used to treat mood disorder) were not monitored based on manufacturer instructions and standards of practice. This failure could have contributed to unsafe medication use and contribute to lack of progress in Resident 80's mental health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a review of the Facility Assessment (document containing information on the resident population, facility resources, and a community-based risk assessment), was conducted at least annually. This failure had the potential to negatively affect the health and well-being of all residents residing in the facility.

Inspectors wroteBased on observation and interview, four rooms (rooms 5, 18, 22, and 45) in the facility did not meet the required 80 square feet per resident. This failure placed the residents in rooms 5, 18, 22, and 45 at potential risk to impede their care and highest possible level of functioning due to smaller than required square footage.