STOCKTON, CA - State inspectors discovered significant infection control, medication management, and food safety violations at Good Samaritan Rehab and Care Center during a February 2025 survey, raising concerns about resident safety and care quality at the 81-bed facility.
Antibiotic Monitoring Program Failures Compromise Patient Safety
One of the most serious violations involved the facility's failure to properly implement its federally mandated Antibiotic Stewardship Program (ASP). Inspectors found that a resident prescribed antibiotics for a urinary tract infection was not properly tracked or monitored according to established protocols.
The resident, identified as Resident 42, developed symptoms of a urinary tract infection on February 7, 2025, and was prescribed Ciprofloxacin on February 11. However, the facility's infection preventionist was unaware the resident was receiving antibiotic treatment and failed to add the case to required tracking logs including the Antibiotic Starts Tracking log, Monthly Surveillance Report Form, and Antibiotic Log.
Perhaps most concerning was the absence of an "antibiotic time-out" - a critical safety measure that requires healthcare providers to reassess antibiotic prescriptions 48-72 hours after the first dose. This review process helps ensure the medication is working effectively and prevents unnecessary antibiotic use.
The infection preventionist acknowledged during interviews that antibiotic time-outs were not being conducted for any residents receiving antibiotics at the facility. This oversight violates the facility's own policy, which requires time-outs at 72 hours after antibiotic initiation to assess "antibiotic need, duration, selection, and de-escalation potential."
Proper antibiotic stewardship is crucial in nursing homes, where studies show 40-75% of antibiotic prescriptions may be unnecessary or inappropriate. Without proper monitoring, residents face increased risks of serious complications including antibiotic-resistant infections, adverse drug reactions, and Clostridium difficile infections that can cause severe diarrhea and colon inflammation.
Kitchen Equipment and Food Safety Violations
Inspectors identified multiple food safety violations that could expose residents to foodborne illness. The facility's can opener was found covered with metal shavings, food debris, and chipped paint, creating conditions where harmful bacteria could multiply and contaminate food.
The Registered Dietician confirmed the equipment posed risks to residents, stating "a can opener in this condition could harbor pathogens that could be unsafe for the residents." According to FDA guidelines, can openers that become pitted or have surfaces that cannot be adequately cleaned must be replaced.
Additionally, the facility's dishwashing machine was operating below the manufacturer's required temperature of 120 degrees Fahrenheit. During inspection, the machine consistently reached only 117 degrees even during complete wash cycles. This temperature deficit compromises the sanitization process, as chlorine-based sanitizers require the minimum temperature to effectively eliminate harmful bacteria and viruses.
The Registered Dietician emphasized the safety implications, explaining that dishes are not "hygienically sanitized" below 120 degrees Fahrenheit. Proper dish sanitization is essential in nursing homes where many residents have compromised immune systems and are particularly vulnerable to foodborne pathogens.
Pest Control Failures Create Health Hazards
A significant pest infestation was discovered in the facility's food preparation areas. Inspectors found cockroaches in front of and beneath the microwave used to reheat residents' food. The microwave itself was found with multiple layers of food splatters that had accumulated over several days.
When housekeeping staff moved the microwave during the inspection, "multiple roaches began to run in various directions," according to the report. The housekeeping supervisor confirmed the microwave was supposed to be cleaned twice daily but acknowledged the cleaning schedule was not being followed.
Cockroaches pose serious health risks in healthcare facilities as they can transmit diseases by contaminating food and food-contact surfaces. The Physical Plant Supervisor acknowledged the severity, stating the roaches "bring diseases, can make the residents sick" and noted they "multiply fast."
Records showed the facility had previous pest issues, with treatment provided in November 2024 for cockroaches reported in a resident's room. However, the presence of roaches in food preparation areas represents a more serious threat to resident health and safety.
Infection Control Protocol Breaches
The inspection also revealed basic infection control violations. A medical records assistant was observed refilling a personal soda bottle directly from a resident water dispenser, allowing the bottle's mouth to contact the dispenser spout. This practice creates cross-contamination risks, particularly concerning given that the staff member could potentially transmit illness to residents who subsequently use the water dispenser.
The Director of Nursing confirmed this violated facility policy and explained the contamination risk, noting that if staff were ill, "the residents who drank water from the dispenser would be ill, too." Proper infection control protocols require staff to use disposable cups or maintain separation between personal containers and facility water sources.
Room Size Requirements Fall Short
Four resident rooms at the facility failed to meet federal square footage requirements, though this violation was categorized as having minimal impact on care. Rooms 5, 18, 22, and 45 measured between 1.5 to 8.6 square feet below the required minimums, with some providing only 71.4 square feet per resident instead of the mandated 80 square feet.
Despite the deficiency, interviews with residents and staff indicated the smaller room sizes did not significantly impact care delivery or resident comfort. Multiple residents stated they had adequate space and could receive necessary care without difficulty.
Additional Issues Identified
Inspectors also found deficiencies in the facility's Quality Assurance and Performance Improvement program documentation. While the facility had policies in place, some documentation was outdated and the overall quality improvement framework needed strengthening to meet current federal requirements.
The violations collectively represent systemic issues in infection control, medication management, and food safety that could potentially compromise resident health and safety. The facility must develop comprehensive corrective action plans to address each deficiency and prevent recurrence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Rehab and Care Center from 2025-02-21 including all violations, facility responses, and corrective action plans.
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