Good Samaritan Health Care Ctr: Medication Failure - WA
That gap, documented during a November 2025 complaint inspection, preceded a resident's transfer to the hospital.
Resident 1 was on a standing order for furosemide, a diuretic used to reduce fluid buildup. The order had two triggers: a weight gain of two pounds or more in a single day, or the presence of swelling in the legs, ankles, or feet. Staff were supposed to watch for either condition and give the medication if they saw it.
They watched for one. They missed the other entirely.
The Licensed Practical Nurse assigned to Resident 1, identified in the inspection report as Staff D, told inspectors on November 14 that she entered the resident's daily weight into the medication administration record and watched for a two-pound increase. She said the weight never crossed that threshold, so she never gave the furosemide. When she reviewed the actual order during the inspection interview, she said she had not been aware it also listed leg swelling as a separate indication for the medication. She had not assessed or documented the presence or absence of swelling in Resident 1's legs, ankles, or feet at any point during the resident's stay.
The weight record told a different story about what was happening with the resident's fluid levels. An 1.8-pound increase had been noted on October 29, 2025, just under the two-pound threshold that staff were tracking. Whether swelling was present during that period, nobody had checked.
The RN on duty when Resident 1 was transferred to the hospital, Staff E, told inspectors she knew the resident's family representative had concerns about weight gain during the stay. She said she did not recall any specific concerns being raised about swelling in the legs. She also said she had not monitored Resident 1's feet for edema and had not noticed the condition of the resident's feet on November 3, 2025, the day the resident was sent to the hospital.
The director of nursing, Staff B, confirmed during her interview that afternoon that staff had not monitored or documented the resident's legs and feet for swelling. She also said she had not known the diuretic order included leg swelling as an indication to administer the medication, not just weight gain.
The director of nursing did not know what the order said.
Furosemide is prescribed specifically because fluid can accumulate in the body in ways that weight alone does not always capture in time. Swelling in the lower extremities is a direct sign of that accumulation. An order that lists it as a trigger exists precisely so that nurses have a second way to catch what a scale might miss on a given day.
Nobody caught it.
The inspection was conducted in response to a complaint. Inspectors cited the facility under F0684, which covers the standard of care residents are owed, and classified the level of harm as minimal harm or potential for actual harm, affecting few residents. That classification sits at the lower end of the federal harm scale, but it does not mean nothing went wrong. It means inspectors determined the outcome had not yet risen to a higher threshold, not that the resident avoided the hospital.
Resident 1 was transferred to the hospital on November 3.
What the inspection leaves unresolved is whether the swelling was present and missed, or whether it developed and went undetected because no one was looking. The nurses weren't checking. The director of nursing didn't know to make sure they were. The order sat in the record with a condition attached to it that three staff members, including the facility's top nursing official, said they were unaware of.
The family representative had been worried about the weight. The staff had been watching the number on the scale. Nobody had been looking at the resident's feet.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Health Care Ctr from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
GOOD SAMARITAN HEALTH CARE CTR in YAKIMA, WA was cited for violations during a health inspection on November 14, 2025.
That gap, documented during a November 2025 complaint inspection, preceded a resident's transfer to the hospital.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.