Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to perform and document required testing of backup generator batteries in accordance with NFPA 110. During record review, no documentation of generator battery testing was available, and the Maintenance Director acknowledged both the lack of records and a lack of knowledge of the NFPA 110 battery testing requirements. The report notes that this failure could result in loss of power affecting life support and life safety features for occupants.
Surveyors found that smoke/fire barriers in three of fourteen smoke compartments, including the hot water room, the barrier between the kitchen and a smoke compartment, and the smoke wall leading to the Alzheimer’s unit, had penetrations that were not properly fire-stopped. During the on-site interview, the Maintenance Director acknowledged that recent electrical work had been completed and that the contractor failed to seal these penetrations, resulting in noncompliance with NFPA 101 smoke barrier construction requirements.
Surveyors found unsanitary conditions in the kitchen and multiple nourishment and dining areas, including accumulated food debris, grease buildup, and dried residue on the kitchen floor under and around food preparation and cooking equipment, as well as food spillage and residue inside several refrigerators and food debris inside multiple microwaves. Review of facility policy showed staff were required to follow a comprehensive cleaning schedule, and interviews with the RD, kitchen manager, administrator, and DON confirmed that the cleanliness of these areas was not acceptable and did not meet expectations.
Surveyors found that two residents’ bathrooms had damaged and deteriorated walls and baseboards, with peeling paint, staining, gaps, and missing baseboards, despite prior entries in the maintenance log noting needed repairs. In the memory care common area, a recliner actively used by a resident had torn and cracked upholstery with exposed underlying material, and a built-in cabinet had a drawer missing its front panel, leaving unfinished wood exposed. The Administrator reported relying on verbal communication rather than consistent use of the maintenance log, and the Director of Environmental Services acknowledged awareness of these unrepaired environmental issues and described delays in completing the work.
A resident was admitted with documented diagnoses of panic disorder and hallucinations, supported by a patient summary, psychiatric provider note, and physician orders for Seroquel to treat hallucinations. However, the Level I PASRR completed prior to admission did not include these mental health diagnoses, despite the facility’s policy requiring all new admissions to be screened for mental disorders, ID, or related conditions through the PASRR process. The Administrator later acknowledged that the resident’s Level I PASRR needed to be updated, confirming that the preadmission screening was incomplete and inaccurate.
Surveyors found multiple hazardous cleaning and disinfectant chemicals stored in unlocked lower cabinets in two nourishment areas, one adjacent to a common living area and one within a dining room, both accessible to residents. Products such as disinfectants, insecticide aerosol, bleach germicidal wipes, hydrogen peroxide wipes, an acidic delimer, and other cleaners were observed without secure storage or access controls, despite SDS guidance that they be stored securely. The Dietician and the Administrator acknowledged that all chemicals were expected to be locked and secured, but this was not implemented in these dietary service areas.
Surveyors found that nurses failed to follow physician-ordered vital sign parameters for antihypertensive medications for two residents. One resident with multiple chronic conditions, including essential hypertension and mild cognitive impairment, received metoprolol doses despite heart rates below the ordered hold threshold. Another resident received hydralazine even when systolic blood pressures were outside the specified parameters. Nursing staff acknowledged administering these medications outside the prescribed limits, and the DON confirmed that facility policy requires medications to be given in accordance with physician orders and associated vital sign checks.
Surveyors found multiple instances where medications and biologicals were left unsecured at bedside, contrary to facility policy and staff expectations. A resident with type 2 DM and hyperglycemia had a metformin tablet left in a cup on the bedside table, while another resident’s zinc oxide ointment was left on the bedside table when the resident was not present. In a third case, three ampules of ipratropium-albuterol were left at bedside next to a nebulizer for a resident with a PRN order for SOB/wheezing, also while the resident was absent. Staff, including an LPN and the DON, acknowledged that medications and treatments should not be left unattended and that medications are to be stored in locked compartments with access limited to authorized personnel.
Surveyors found persistent unsanitary conditions in the kitchen and multiple nourishment rooms, including accumulated food debris, grease buildup, and dried food residue on floors, refrigerators, and microwaves. Staff, including the RD and kitchen manager, acknowledged that cleanliness was not acceptable. Leadership confirmed that a PIP focused on dietary sanitation and regulatory compliance had been initiated but that no meaningful progress or documented audits and education had occurred, and sanitation problems continued. The facility’s own QAPI plan and dietary sanitation policies required systematic monitoring, data use, and performance improvement for housekeeping and infection control, but these processes were not effectively implemented to correct the identified deficiencies.
A facility failed to conduct a Discharge MDS Assessment for a resident discharged with multiple diagnoses, including a fracture and chronic conditions. Despite the discharge plan being documented and agreed upon, the MDS Coordinator admitted the assessment was not completed, violating OBRA regulations.
The facility failed to ensure accurate MDS assessments for residents, leading to discrepancies in dietary orders, discharge statuses, and medication documentation. A resident's mechanically altered diet was not reflected in the MDS, while two residents had incorrect discharge statuses recorded. Additionally, a resident's antiplatelet medication was not documented under high-risk drug classes. These inaccuracies were acknowledged by the MDS Coordinator and Registered Dietitian.
A facility failed to develop a comprehensive care plan for a resident with behaviors affecting their dining experience. Despite the resident's preference for eating in the dining room, they were consistently seated alone due to behaviors like wandering and interfering with others' meals. Staff interviews confirmed this practice, although the care plan did not address these behaviors. The facility's policies require individualized care plans, but these were not adequately implemented for the resident.
Failure to Perform and Document Required Generator Battery Testing
Penalty
Summary
The deficiency involves the facility’s failure to maintain and inspect the backup generator batteries in accordance with NFPA 110 requirements. During a record review, surveyors requested documentation of generator battery testing and the facility was unable to provide any records demonstrating that such testing had been performed. The cited standards require testing of generator batteries to ensure the reliability of the prime mover starting system, but no evidence of compliance with these testing requirements was available in the facility’s maintenance records. During an interview conducted at the same time as the record review, the Maintenance Director acknowledged the absence of generator battery testing documentation and stated that she did not know the requirements for battery testing under NFPA 110. The report notes that failure to conduct these tests could result in the loss of power to the facility, which would endanger occupants due to loss of power to life support and life safety features. No specific residents or individual patient conditions are mentioned in the report.
Unsealed Penetrations in Smoke/Fire Barriers After Electrical Work
Penalty
Summary
Surveyors identified a deficiency in the facility’s maintenance of smoke/fire-rated enclosures, specifically related to unsealed penetrations in smoke/fire barriers. During an observation on 4/27/2026 between 2:30 PM and 2:45 PM, surveyors found that the hot water room, the smoke barrier dividing the kitchen and smoke compartment 1, and the smoke wall leading to the Alzheimer’s unit all had penetrations that were not properly fire-stopped. These conditions were determined to affect 3 out of 14 smoke compartments in the building. During an interview conducted at the time of the observation, the Maintenance Director acknowledged the findings. The Maintenance Director stated that new electrical work had been performed and that the contractor had forgotten to properly seal the penetrations. The Maintenance Director also acknowledged the specific issues identified in the hot water room. The deficiency was cited under NFPA 101 (2021 Edition) 19.3.7.3 and 8.5.6, Class III, for failure to maintain the required smoke/fire barrier construction.
Unsanitary Kitchen and Nourishment Room Conditions Affecting Food Safety
Penalty
Summary
Surveyors identified a deficiency in food safety requirements related to unsanitary conditions in the main kitchen and multiple nourishment and dining room areas. During an initial observation, the kitchen floor was found with accumulated food debris, grease buildup, and dried residue under and around food preparation and cooking equipment. In the Camellia Dining Room, the interior walls and bottom surface of the refrigerator had food spillage and residue, and the microwave contained food debris on the turnplate and interior surfaces. In the Magnolia Nutrition Room, the refrigerator also had food spillage and residue on the interior walls and bottom surface, and the microwave had food debris on the turnplate and interior surfaces. In Camellia Nutrition Room 1, the refrigerator had food spillage and residue on the interior walls and bottom surface, and in Camellia Nutrition Room 2, the microwave had food debris on the turnplate and interior surface. A follow-up observation showed that the kitchen floor remained in an unsanitary condition with ongoing accumulated food debris, grease buildup, and dried residue under and around food preparation and cooking equipment, demonstrating that the lack of cleanliness persisted over time. Review of the facility’s Dietary Services Policies and Procedures Manual indicated that staff were required to maintain kitchen sanitation through compliance with a written comprehensive cleaning schedule. During interviews, the Registered Dietician stated that the cleanliness of the kitchen and nourishment rooms was not to expectations and required improvement, and the Kitchen Manager acknowledged that the condition of the kitchen floor was not acceptable and required cleaning. In a subsequent interview, the Administrator and DON confirmed that a Performance Improvement Plan related to kitchen sanitation had been initiated prior to the survey but that no progress had been made before the survey occurred.
Failure to Maintain Clean, Homelike Resident Rooms and Memory Care Common Area
Penalty
Summary
Surveyors identified a failure to maintain a safe, clean, comfortable, and homelike environment on one of three units, including resident rooms and a memory care common area. In one resident’s bathroom, the lower wall and baseboard area were in poor repair, with visible discoloration or staining, peeling or damaged wall finish, and cracked or deteriorated caulking or paint along the baseboard line, as well as separated or poorly sealed baseboard sections creating gaps. In another resident’s bathroom, the wall showed visible damage with peeling loose paint, gaps or holes, staining, and broken or missing sections, and there was no baseboard present. The facility maintenance log contained prior entries referencing needed repairs in both of these bathrooms. In the memory care common living area, surveyors observed a beige upholstered recliner in use by a resident, with both armrests torn and underlying material exposed; on a later observation, the same recliner’s seat cushion and armrests showed extensive cracking, peeling, and splitting of the upholstery. A built-in cabinet unit in the same memory care common area had a drawer with the front panel missing, exposing unfinished wood. During interviews, the Administrator acknowledged having observed the recliner but not consistently using the maintenance log to track such issues, and the Director of Environmental Services and Plant Services acknowledged awareness of the damaged cabinet, the unrepaired bathroom drywall and baseboards, and the worn recliner, noting delays in repair and that a blanket was usually placed over the recliner to cover the damage.
Failure to Complete Accurate PASRR for Resident With Serious Mental Disorder
Penalty
Summary
The deficiency involves the facility’s failure to ensure completion of an accurate Preadmission Screening and Resident Review (PASRR) prior to admission for a resident with a serious mental disorder. The resident was originally admitted with documented diagnoses including panic disorder and hallucinations. A PASRR Level I form dated one day prior to admission did not include either the panic disorder or hallucinations diagnoses, despite other clinical records at that time confirming these conditions. The facility’s own “Admission Criteria” policy required that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders per the Medicaid PASRR process, with a Level I PASRR conducted for all potential admissions regardless of payer source. Record review showed that the resident’s patient summary, dated two days before admission, listed hallucinations as a confirmed diagnosis. A psychiatric provider note dated the day after admission documented diagnoses of panic disorder without agoraphobia and unspecified hallucinations, with instructions for staff to monitor and report worsening anxiety symptoms and an order to increase Seroquel to 50 mg BID. A physician order dated on the admission date prescribed Seroquel 50 mg by mouth twice daily for unspecified hallucinations. During an interview, the Administrator acknowledged that the resident’s Level I PASRR needed to be updated, confirming that the PASRR completed prior to admission did not reflect the resident’s known mental health diagnoses.
Unsecured Hazardous Chemicals in Nourishment Areas Accessible to Residents
Penalty
Summary
The deficiency involves unsecured hazardous chemicals in two nourishment areas within the dietary service department that were accessible to residents. In the Dogwood nourishment room, which was adjacent to a common living area where eight residents were present, surveyors observed Odoban Deodorizer and Disinfectant and Aero Assault II Insecticide Aerosol stored in an unlocked lower cabinet. The nourishment room itself was not secured, lacked a locking mechanism or other access controls, and was not intended for resident use, yet residents had the opportunity to inadvertently enter and access these chemicals. Safety Data Sheets (SDS) for these products documented potential hazards including skin and eye irritation, inhalation toxicity, and flammability, and indicated they should be stored securely to prevent unintended exposure. In the cafe nourishment area located within the dining room, surveyors observed seven additional chemicals stored in an unlocked lower cabinet: Fabuloso Multipurpose Cleaner, Clorox Bleach Germicidal Wipes, Odoban Deodorizer and Disinfectant, Micro-Kill Bleach Germicidal Wipes, Clorox Healthcare Hydrogen Peroxide Cleaner Disinfectant Wipes, and two clear spray bottles labeled "Delimer" and "Vinegar and Water Window Cleaner." This nourishment area was accessible to residents walking through or eating in the dining room, creating an opportunity for inadvertent access to these chemicals. SDS information for each product described various hazards such as skin and eye irritation, potential skin burns, eye damage, and respiratory irritation, and specified that the products should be clearly labeled and stored securely. During interviews, the Dietician and the Administrator both stated that all chemicals were expected to be kept locked and secured to ensure resident safety, which was not occurring in these two nourishment areas.
Failure to Follow Physician-Ordered Parameters for Antihypertensive Medications
Penalty
Summary
The deficiency involves failure to follow physician-ordered parameters for cardiovascular medications, resulting in administration of drugs outside specified vital sign limits. For one resident with diagnoses including essential primary hypertension, anemia, depression, hyperlipidemia, essential tremor, vitamin B12 deficiency anemia, insomnia, generalized anxiety disorder, history of falling, hypothyroidism, overactive bladder, personal history of healed traumatic fracture, and mild cognitive impairment, the physician ordered metoprolol tartrate 12.5 mg by mouth twice daily with instructions to hold the dose if heart rate was less than 65 or systolic blood pressure was less than 100. Medication Administration Records for March and April 2026 showed that metoprolol was administered multiple times when the resident’s heart rate was below the ordered hold parameter, including documented heart rates of 61, 63, 64, 56, 58, 60, and 62. In interviews, an LPN and an RN acknowledged administering the metoprolol outside the ordered parameters and stated they should have followed the physician’s order. A second resident had a physician order for hydralazine 10 mg by mouth every 8 hours with instructions to hold the medication if systolic blood pressure was greater than 115. Review of this resident’s Medication Administration Records for March and April 2026 showed hydralazine was administered when systolic blood pressures were 112/73, 108/62, 108/66, and 104/58, which were outside the ordered parameters. The DON stated it was the expectation that nurses administer medications in accordance with physician orders, including adherence to ordered parameters. The facility’s “Administering Medications” policy required medications to be administered as prescribed and for vital signs to be checked or verified as necessary prior to administration, but the documented medication passes did not comply with the specific hold parameters ordered by the physicians.
Unsecured Medications and Biologicals Left at Bedside
Penalty
Summary
Surveyors identified a failure to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles on two of three units. In one room, a white oval tablet was observed in a medication cup on a bedside table; the resident stated it was metformin, and the physician’s order documented metformin 1000 mg by mouth twice daily for type 2 diabetes mellitus with hyperglycemia. Nursing staff and the DON both stated that medications should not be left at a resident’s bedside and that staff are expected to remain with residents until medications are taken, indicating that the presence of the metformin tablet at bedside was inconsistent with facility expectations and that this resident would not be allowed to self-administer this medication. In another room, zinc oxide ointment was observed on top of a bedside table while the resident was not present, and an LPN acknowledged that the ointment should not have been there. In a third room, three ampules of ipratropium-albuterol were found at the bedside next to a nebulizer machine while the resident was not in the room; the resident had a physician’s order for ipratropium-albuterol inhalation every six hours as needed for shortness of breath or wheeze. The LPN stated that the ipratropium-albuterol should not have been in the room. The facility’s written policy on “Medication Labeling and Storage” stated that all medications and biologicals are to be stored according to manufacturer recommendations in locked compartments under proper environmental controls, with access limited to authorized nursing and pharmacy personnel, which was not followed in these instances.
Failure to Implement QAPI and PIP for Kitchen and Nourishment Room Sanitation
Penalty
Summary
The deficiency involves the facility’s failure to fully and effectively implement its QAPI/QAA program and an existing Performance Improvement Plan (PIP) to correct identified quality deficiencies in kitchen sanitation. Surveyors observed that the main kitchen floor was in an unsanitary condition, with accumulated food debris, grease buildup, and dried residue under and around food preparation and cooking equipment. These unsanitary conditions were first observed during an initial tour and were still present on a subsequent observation, demonstrating that the facility did not maintain ongoing sanitation practices in the kitchen. Additional unsanitary conditions were observed in multiple nourishment and dining areas. In the Camelia Dining Room, there was food spillage and residue on the interior walls and bottom surface of the refrigerator, as well as food debris on the turnplate and interior surfaces of the microwave. In Camelia Nutrition Room 1, food spillage and residue were present on the interior walls and bottom surface of the refrigerator. In the Magnolia Nutrition Room, there was food spillage and residue on the interior walls and bottom surface of the refrigerator and food debris on the microwave turnplate and interior surfaces. In Camelia Nutrition Room 2, food debris was present on the microwave turnplate and interior surface. These findings showed that sanitation issues extended beyond the main kitchen into multiple nourishment areas. Interviews with facility staff confirmed awareness of the sanitation problems and the lack of effective corrective action. The Registered Dietician and the Kitchen Manager both acknowledged that the cleanliness of the kitchen and nourishment rooms, including the kitchen floor, was not acceptable and required improvement. The Administrator and DON confirmed that a PIP related to kitchen sanitation had been initiated on 04/06/2026, following concerns identified through rounding and a Department of Health inspection, but no progress had been made prior to the survey. The facility’s own policies and QAPI plan required comprehensive cleaning schedules, systematic data collection, monitoring, and performance improvement activities focused on sanitation and infection control, yet the facility did not provide documentation of audits, education, or sustained corrective actions, and unsanitary conditions persisted at the time of survey. The facility’s QAPI and PIP documents showed that kitchen sanitation and regulatory compliance had been identified as ongoing concerns, including inconsistent compliance with food safety regulations, inappropriate food safety and storage practices, and lack of follow-up on deficiencies from internal audits and infection control observations. The PIP outlined expectations for maintaining full compliance with dietary and sanitation regulations, conducting weekly sanitation and infection control audits, and holding dietary leadership accountable for monitoring and addressing identified concerns. However, during interviews, the Administrator reported that audits showed only minimal improvements and that there was no evidence that identified issues were consistently corrected. As of the time of the survey, no additional documentation of effective implementation of the PIP or QAPI-driven corrective actions was provided, and the observed unsanitary conditions remained uncorrected, demonstrating a failure to implement the facility’s QAPI program and PIP to address kitchen sanitation deficiencies.
Failure to Conduct Discharge MDS Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment in accordance with the specified submission timeframes for a resident reviewed for discharge status. The resident, who was admitted with multiple diagnoses including a fracture of the upper end of the right humerus, hypertension, chronic pain syndrome, GERD, and anxiety disorder, was discharged to home with home health care. The physician's order indicated the discharge plan, and the interdisciplinary notes confirmed the resident's agreement to the discharge plan. However, the facility did not complete a Discharge MDS Assessment when the resident was discharged. During an interview, the MDS Coordinator, a registered nurse, acknowledged that the discharge assessment was not opened for the resident. The facility's policy and procedure on resident assessments, which aligns with OBRA regulations, mandates that a comprehensive assessment, including a Discharge Assessment, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. The failure to conduct the required Discharge MDS Assessment constitutes a deficiency in adhering to these regulations.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their records. For one resident reviewed for nutrition, the MDS did not reflect the prescribed mechanically altered diet, as confirmed by both the MDS Coordinator and the Registered Dietitian. This oversight was acknowledged during interviews, indicating that the dietary section should have been coded to reflect the resident's dietary order. Additionally, two residents reviewed for discharge had incorrect discharge statuses recorded in their MDS assessments. One resident, who was transferred to a hospice facility, was incorrectly coded as discharged to a short-term general hospital. Another resident, who had passed away, was mistakenly coded as discharged to an Intermediate Care Facility instead of being marked as deceased. Furthermore, the facility failed to accurately document the medication regimen for a resident reviewed for unnecessary medication. The resident was prescribed Plavix, an antiplatelet medication, but the MDS did not reflect this under the section for high-risk drug classes. The MDS Coordinator admitted that the system should have automatically triggered the correct classification, indicating a need for modification. The facility's policy requires that all individuals completing any portion of the MDS sign the document to attest to its accuracy, ensuring consistency with progress notes, care plans, and resident observations, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plan for Resident's Dining Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with behaviors affecting their nutritional services. The resident, who was admitted with diagnoses including mood disorder, anxiety disorder, dementia, and chronic congestive heart failure, had a care plan that addressed nutritional status and risk for social isolation but did not include interventions for behaviors related to eating in the dining room. Observations revealed that the resident was consistently seated alone in a common area away from other residents during meal times, despite a preference for dining in the dining room. Staff redirected the resident to eat alone due to behaviors such as wandering and interfering with other residents' meals. Interviews with staff, including a CNA and an LPN, confirmed that the resident was isolated during meals due to these behaviors, although the care plan did not reflect this practice. The Director of Nursing acknowledged that the resident was often seated alone for behavioral reasons but noted that the care plan should have addressed these behaviors, whether the resident ate in the dining room or not. The facility's policies on care area assessments and comprehensive person-centered care plans emphasize the need for individualized care plans that address residents' physical, psychological, and functional needs, including behavioral implications, but these were not adequately implemented for the resident in question.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Live Oak
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lafayette Nursing And Rehabilitation Center | 14.8 mi | ★★★★★ | 11 | 0 |
| Surrey Place Nursing Center | 16 mi | ★★★★★ | 6 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 16.4 mi | ★★★★★ | 1 | 0 |
| Madison Health And Rehabilitation Center | 17.9 mi | ★★★★★ | 0 | 0 |
| Lake Park Of Madison Nursing And Rehabilitation Ce | 18.8 mi | ★★★★★ | 2 | 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.