Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Home & Rehabilitative Center during CMS and state inspections, most recent first.
Restorative Services Not Initiated After Rehab Discharge: A resident with COPD and healing pelvic fractures was cleared to WBAT with a walker and was to be discharged to restorative and nursing staff, but no restorative plan was initiated. Nursing notes lacked any reference to therapy or restorative care, and staff interviews confirmed the order was missed and no restorative services had been set up. The DON later cited therapy refusal, but the screen tool did not document the resident's refusal.
The facility failed to maintain sanitary conditions in food storage and preparation. Observations revealed improperly labeled or expired items in the refrigerator and dry storage, including sausage links, cheese, chicken soup, and various spices. The dietary manager confirmed that containers should be dated and expired items removed, as per the facility's food storage policy.
A resident's body was mistakenly released to an unauthorized funeral home, despite records indicating a specific crematorium as the preferred choice. The error was discovered when the resident's POA contacted the crematorium, which had not received the body. Interviews revealed a lack of verification procedures by the facility staff.
The facility failed to notify family or physicians of changes in condition for two residents. One resident with Alzheimer's ingested blanket pieces, and another with intellectual disabilities had a ruptured mass. In both cases, there was no documentation of notification or follow-up, despite facility policies requiring such actions.
A resident with Alzheimer's disease continued to receive hospice-related medications after hospice services were discontinued. The facility did not follow pharmacy recommendations to clarify and potentially discontinue these medications. The clinical record lacked physician review of the pharmacist's recommendations, contrary to the facility's policies on medication regimen reviews and psychotropic management.
A facility failed to follow proper infection control procedures during wound care for a resident with a stage four pressure ulcer. An LPN and a QMA did not adhere to the facility's hand hygiene policy, washing their hands for less than the required 20 seconds before and after the procedure. The facility's policy, aligned with CDC guidelines, emphasizes the importance of hand hygiene to prevent infection transmission.
Restorative Services Not Initiated After Rehab Discharge
Penalty
Summary
The facility failed to ensure restorative services were provided for a resident after discharge from rehabilitation services. Resident 9 had diagnoses including chronic obstructive pulmonary disease, an unspecified fracture of the left acetabulum with routine healing, and another specified fracture of the left pubis. The current Quarterly MDS indicated the resident was cognitively intact, was independent with eating, needed substantial to maximum assistance for dressing and for lying to sitting at the bedside, and needed partial to substantial assistance for transfers from sitting to standing and for walking 10 feet with a walker. The resident also required a walker and wheelchair for mobility during the 7-day look-back period and had a history of falls. A physician note from orthopedics stated the resident could weight bear as tolerated with a walker and work with therapy, and a physical therapy note indicated the resident was to be discharged to restorative and nursing staff. However, nursing progress notes from 2/3/26 through 3/25/26 contained no reference to therapy or implementation of a restorative plan. During interviews, the resident stated he had been cleared to walk for a while but no one had been around to help him get started. The Therapy aide stated he was assigned to residents with restorative care plans, the Occupational Therapist stated no restorative services had been set up and she was not aware why the orders were missed, and the Regional Physical Therapy Support person stated the order was missed from the physician treatment note. The DON later provided a Quarterly Therapy Screen Tool indicating no evaluation was indicated and stated the resident refused therapy options, but the document did not include the resident's response of refusal.
Deficiency in Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions during two kitchen observations. During the initial tour, several items in the reach-in refrigerator were found to be improperly labeled or expired. These included a container of sausage links with a discard date that had passed, containers of cheese, chicken soup, grape jelly, and pasta with no open dates, and a bag of salad with a use-by date that had passed. In the dry storage area, bags of dry noodles and a box of potatoes were found with no open dates, an empty bread rack was on the floor, and a moldy onion was present in a box with no open date. Further observations revealed issues with the spice rack and metal preparation table. Items such as Karo Syrup, Soy Sauce, Lemon Pepper, Pork Base, and Basil were found with no open dates, while a container of Ground Mustard had a use-by date that had passed. Additionally, a flour bin and a container of Leaf Basil were found with no open dates. During an interview, the dietary manager acknowledged that containers should be dated with open dates and that expired items should not be present in the refrigerator. The facility's current food storage policy requires leftover prepared food to be labeled with the product name, preparation date, and a consumption date, and dry storage containers to be labeled and dated on both the container and the lid.
Failure to Honor Resident's Funeral Home Choice
Penalty
Summary
The facility failed to honor a resident's choice of funeral home, resulting in the release of the resident's body to an unauthorized funeral home. Resident 218, who had intellectual disabilities, passed away at the facility. The resident's clinical records and physician orders indicated a specific crematorium as the preferred funeral home. However, despite the facility's records showing that the crematorium was contacted, the body was mistakenly released to a different funeral home. This error was discovered when the resident's Health Care Power of Attorney (POA) attempted to make arrangements with the designated crematorium and found that they had not received the body. Interviews with facility staff and the funeral homes involved revealed a lack of verification procedures when releasing the body. The Director of Nursing admitted that staff did not confirm the identity of the person picking up the body, as the Burial Transit Permits were signed as the body was leaving the facility. The general managers of both the crematorium and the funeral home confirmed that there was no shared staff or answering service between them, indicating a miscommunication or error on the part of the facility. The facility's Administrator acknowledged the mistake, noting that the paperwork indicated the crematorium as the intended recipient, but the signature on the permit was from the unauthorized funeral home.
Failure to Notify Family and Physicians of Changes in Resident Conditions
Penalty
Summary
The facility failed to notify family or physicians of changes in condition for two residents, leading to deficiencies in care. Resident 58, diagnosed with Alzheimer's disease, was found to have ingested pieces of his blanket, which were discovered in his stool. Despite this significant change, there was no documentation of family or physician notification, nor were any labs conducted to rule out a urinary tract infection or intestinal blockage. Additionally, when Resident 58 exhibited congested coughing and low oxygen saturation, there was again no notification or follow-up documented. Resident 218, who has intellectual disabilities, experienced a change in condition when a mass under the left armpit ruptured. The facility canceled a scheduled medical appointment without notifying the resident's representative. The representative only became aware of the missed appointment through a no-show message from the doctor. Despite the resident's intellectual disability, the facility's policy did not require notification of appointment cancellations if the resident's cognitive assessment score was above a certain threshold. Interviews with staff and the administrator revealed a lack of adherence to the facility's policies regarding notification of changes in resident conditions. The Director of Nursing acknowledged the absence of follow-up for Resident 58, and the administrator confirmed that notifications were not made for Resident 218 due to the resident's cognitive score. The facility's policies clearly state the requirement for timely communication with family and physicians, which was not followed in these cases.
Failure to Address Pharmacy Recommendations Post-Hospice
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident who was previously receiving hospice services. The resident, diagnosed with Alzheimer's disease, was completely dependent on staff for daily activities such as toileting, bathing, and transfers. After the discontinuation of hospice services, the resident continued to receive medications that were initially prescribed for hospice care, including lorazepam, hyoscyamine, and morphine. A pharmacy consultation report requested clarification on these medications, suggesting that orders for these hospice-related medications be discontinued. However, the clinical record did not show any physician review or action taken in response to the pharmacist's recommendations. The facility's policy on Medication Regimen Reviews and Pharmacy Recommendations requires that consultant pharmacist recommendations be reviewed by the Director of Nursing and that the attending physician be notified promptly of any recommendations needing immediate attention. Additionally, the facility's policy on Psychotropic Management states that PRN orders for psychotropic drugs are limited to 14 days unless extended by the physician with documented rationale. Despite these policies, the facility did not ensure that the pharmacist's recommendations were addressed, leading to the continued administration of medications without proper physician oversight after the resident's hospice services were discontinued.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during a wound care observation for Resident 13, who had a stage four pressure ulcer. The resident's clinical record indicated a physician's order for wound care, which included cleansing the coccyx pressure ulcer with a wound cleanser and applying Hydrofera Blue, an antibacterial foam dressing. During the observation, an LPN washed her hands for only nine seconds before putting on gloves, and after completing the wound care, she washed her hands for just seven seconds. Similarly, a QMA assisting in the procedure washed her hands for only ten seconds after removing her gloves and gown. The facility's Infection Prevention RN confirmed that hand hygiene should be performed for at least 20 seconds, as per the facility's Hand Hygiene Policy, which follows CDC guidelines. The policy outlines the 'Five moments of hand hygiene' to prevent infection transmission, including before touching a resident, before clean/aseptic procedures, after body fluid exposure risk, after touching a resident, and after touching resident surroundings. The failure to adhere to these guidelines during the wound care procedure for Resident 13 represents a deficiency in infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Petersburg Care Center | 10.6 mi | ★★★★★ | 13 | 0 |
| Amber Manor Care Center | 10.8 mi | ★★★★★ | 4 | 0 |
| Waters Of Princeton, The | 12.8 mi | ★★★★★ | 24 | 0 |
| Riveroaks Health Campus | 13.8 mi | ★★★★★ | 8 | 0 |
| North River Health Campus | 18.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.