Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Nursing Home Operator, Llc during CMS and state inspections, most recent first.
Failure to provide ADL assistance, hygiene care, incontinence care, and meal assistance: Multiple residents who required staff help were observed with soiled or untrimmed fingernails, delayed brief and clothing care after an incontinent episode, and a resident needing 1:1 meal assistance was left with a breakfast tray without staff present. Staff verified the findings and the residents' care plans documented the need for assistance with ADLs, toileting, and feeding.
Respiratory care was not provided as ordered for multiple residents. A nebulizer mask was left on a soiled tray and an unused oxygen cylinder was kept in a room without an oxygen order; another resident’s oxygen tubing and humidifier bottle were unlabeled and the nasal cannula was left uncovered; one resident was receiving 1.5 L instead of the ordered 2 L; and another resident’s oxygen tubing was on the floor while the concentrator was running, so oxygen was not being delivered as ordered.
Pain management was not consistently provided or documented for multiple residents. Surveyors found that residents with PRN opioid and non-opioid pain meds had care plans calling for non-pharmacological interventions such as relaxation, guided imagery, music, distraction, massage, imagery, and deep breathing, but staff often did not document those measures on the TAR or in progress notes. In one case, an oxycodone dose was given that did not match the ordered pain scale, and residents reported ongoing pain despite medication.
Failure to Report Alleged Abuse Incident: The facility did not report an alleged abuse/neglect incident involving a resident who was accused of threatening a roommate and whose behavior included verbal aggression and an alleged statement, "I will kill you." The resident denied the threat, had a hx of mood disturbance related to depression, police were called to evaluate the situation, and the ADON acknowledged the incident was not reported to OHCQ.
Failure to Thoroughly Investigate Injury of Unknown Origin: A resident with intact cognition was found partially off the bed and sustained a skin tear requiring hospital transfer and sutures. The facility concluded the unwitnessed fall could not be determined, but the investigative file lacked a written resident statement, and hospital notes contained a different account than the LPN’s statement that the resident was asleep and did not know what happened.
A resident developed right hip pain and was later found to have an acute right femoral neck fracture on X-ray. The record lacked documentation of the pain onset, the initial nursing assessment, pain interventions while awaiting imaging, and the details of the report made to the physician before the X-ray results were known; the ADON and Regional Clinical Nurse Manager validated the missing documentation.
A resident developed sacral MASD that was documented on skin assessments and later progressed to a stage 2 pressure ulcer. The wound note indicated the resident was signed off while still in the facility, and the wound nurse confirmed there was no evidence of zinc ointment treatment or actual provider evaluation during the period when the wound worsened. The ADON validated that necessary treatment orders and specialist oversight were not obtained.
The facility failed to maintain resident dignity for two residents when one resident was observed with urine-soiled linens and another resident was observed with bowel substance on the bed, wheelchair, and call light. Staff confirmed the conditions, and an LPN and the ADON acknowledged that the soiled linens and bowel matter were dignity issues.
A resident kept an inhaler at the bedside because staff did not always administer respiratory medication in a timely manner and the resident said he/she had the capacity to self-administer. Record review showed the resident used the inhaler at bedside after a nebulizer treatment when the inhaler was not available from the med room, but the chart had no MD order, care plan, or progress notes supporting an assessment for self-administration. The ADON confirmed that bedside meds were not allowed unless the resident was assessed as capable and the MAR identified the med as self-administration.
Call bells were not consistently kept within reach for two residents observed during the survey. One resident using a wheelchair and another resident using a walker both had call bells on the floor and inaccessible, despite care plans identifying self-care deficits and need for staff assistance with ADLs. An LPN stated staff are expected to keep call bells within residents’ reach at all times.
A resident had physician orders for nebulizer treatments for SOB and for a left arm sling related to multiple rib fractures, but the medical record contained no care plan addressing either need. A surveyor observed the nebulizer mask resting on a soiled breakfast tray while the resident sat in a wheelchair with the sling applied and reported discomfort. The ADON confirmed there was no care plan for the resident’s SOB, nebulizer treatments, or sling use.
A resident’s comprehensive care plan was not revised to reflect current behavioral and treatment needs. The resident was observed in underwear at the nursing station and had documented verbal aggression toward a roommate, including a threat to kill the roommate, with police called to evaluate the situation. The NHA acknowledged the resident also had non-compliance with treatment orders and altercations with two roommates, but the care plan was not updated to reflect these issues.
A resident with mental health issues and behavioral disturbances was supposed to receive Depakote 125 mg BID per psych and psychiatric consults, but the medication was started at 125 mg TID instead. The resident received the incorrect dose multiple times, and when the correct BID order was briefly entered it was immediately discontinued without a clinical assessment or justification, leaving the resident without the recommended treatment.
Sanitary food service operations were not maintained. Surveyors found beverages on a cart without dates, resident-labeled food and other items in a refrigerator without storage dates, and a refrigerator with dust and dark stains. A kitchen aide was also observed handling food without a beard cover, despite the Dietary Manager confirming that hairnets and beard covers are required.
Failure to Document Staff COVID-19 Vaccination Status: The facility did not consistently monitor or document COVID-19 vaccination status for 2 GNAs reviewed during survey. Employee health records showed no documented vaccine status for the 2 staff members, and the ADON acknowledged that vaccination status had not been consistently documented despite on-site vaccine clinics and an email showing interest from 3 employees in a prior clinic.
Surveyors identified improper food storage and handling in the kitchen, including expired and undated food items, snack cups stored on the floor, and ice buildup in the freezer. The Food Service Director confirmed these issues, and dietary staff acknowledged that opened food items should be dated and discarded after 72 hours, but this was not consistently followed.
Several residents were not served meals at the same time, and staff only assisted those at their own table, leaving others without needed help during mealtime. A resident with left-sided weakness was observed eating with their fingers due to lack of assistance in cutting food. Dietary staff provided minimal attention and did not interact with residents, and the dining room environment lacked engagement.
A resident was discharged from hospice services, but the facility did not complete a Significant Change in Status Assessment (SCSA) within the required 14-day period. Review of medical records and staff interviews confirmed that the mandated assessment was not performed after the resident's change in hospice status.
A resident admitted for short-term rehab and discharged in stable condition did not have a required MDS discharge assessment completed. This omission was confirmed by MDS staff and the DON during survey review of assessment documentation.
A resident with multiple cognitive and behavioral diagnoses was inaccurately coded on the MDS as needing only setup or clean-up assistance for eating, despite documentation and staff interviews confirming the need for full feeding assistance. The MDS Coordinator relied solely on GNA documentation and did not use other available sources, resulting in an inaccurate assessment.
A resident was not provided with a summary of their baseline care plan or a list of medications within 48 hours of admission, as required. Review of the medical record and interviews with the DON confirmed that the necessary documentation and distribution of the BLCP summary did not occur, despite established procedures assigning this responsibility to nursing staff.
A resident with a PICC line did not receive dressing changes as ordered by the physician, with the dressing remaining unchanged for several weeks. The resident, who was receiving IV antibiotics, and an LPN both confirmed the dressing had not been changed weekly as required, and medical record review supported this finding.
A resident with a left hand contracture and physician orders for a daily resting hand splint was repeatedly observed without the splint in place, and staff could not locate it or confirm its use. Despite documentation indicating the splint was applied, both surveyor observations and the resident's statements showed it was not being used as ordered, resulting in inadequate care to prevent complications from contractures.
Staff failed to label oxygen tubing and humidifier bottles for a resident receiving oxygen therapy, despite physician orders requiring labeling upon each change. Additionally, another resident with a physician order for incentive spirometer use did not have the device at their bedside for several weeks, despite repeated requests and a history of respiratory issues. These deficiencies were confirmed through observations, record reviews, and interviews with staff and residents.
Two residents experienced delays and inconsistencies in pain medication administration, with medications often given outside of ordered parameters or several hours late. Pain assessments were not always documented, and non-pharmacological interventions were not implemented, resulting in inadequate pain management as confirmed by staff and leadership interviews.
A resident experienced ongoing pain and discomfort from missing and damaged teeth due to the facility's failure to obtain timely consent for dental extractions, delayed dental x-rays, and lack of communication with the dental provider. The resident was not scheduled for necessary dental follow-up until after surveyor intervention.
A resident with documented allergies to pork and corn was served meals containing these items because their dietary information was not properly updated during a system transition. Despite allergies being listed on the meal ticket, the resident received pork sausage, bacon, and corn, which did not match their nutritional needs or restrictions.
A facility failed to schedule quarterly care plan conferences for a resident, despite requests from the resident's representative. The resident experienced a cognitive decline, and no conferences were held since June 2024. The facility lacked a Director of Social Work for several months, and no other staff facilitated the conferences. The Nursing Home Administrator confirmed the oversight, acknowledging missed conferences in September and December 2024.
A resident with cognitive impairment and a history of falls experienced multiple incidents due to inadequate supervision and failure to follow care plans. The resident was found on the floor with injuries after attempting to get out of bed unassisted, and was left unattended during care, resulting in another fall. Additionally, plastic items were left within reach despite the resident's behavior of chewing on them, posing a risk. Staff interviews revealed a lack of adherence to the care plan and awareness of safety interventions.
Failure to Provide ADL Assistance, Hygiene Care, Incontinence Care, and Meal Assistance
Penalty
Summary
The facility failed to ensure that residents' personal hygiene needs were adequately met, including nail care, for multiple residents who required assistance with ADLs. Resident #5 was observed with brown substances under the fingernails of the right hand and stated a need for the nails to be cleaned and trimmed; staff later verified the condition and the care plan identified total assistance for ADL care related to stroke. Resident #9 was observed with dark brown/black substances under the fingernails of the right hand, and staff verified the finding and stated the nails would be soaked later; the care plan identified a self-care deficit related to CVA and generalized weakness. Resident #49 was observed with long, untrimmed fingernails, and staff confirmed the nails needed trimming; the care plan identified dependence on staff for all needs related to activity intolerance, impaired balance, and cognitive impairment. The facility also failed to provide timely incontinence care and required meal assistance. Resident #39 had an odor in the hallway near the room, and brown substance was observed on the bed, wheelchair, and call light; the condition remained present on a second observation, and staff later confirmed the resident requested help with a brief and clothing change after an incontinent episode, with assistance provided about 47 minutes later and only after surveyor intervention. Resident #39's care plan required staff assistance with dressing, toileting, and transfers. Resident #1 was observed lying in bed with a breakfast tray and no staff present, despite a care plan calling for 1:1 meal assistance; staff confirmed that 1:1 assistance requires a staff member to be present and assist with the meal, and no staff was assisting the resident at the time of observation.
Respiratory Equipment and Oxygen Therapy Not Managed as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for four residents. For one resident, a nebulizer mask was observed resting on top of a soiled breakfast tray, and an unused portable oxygen cylinder was also observed in the room even though there was no physician order for oxygen therapy. The resident had an active order for Ipratropium-Albuterol solution for shortness of breath. The portable oxygen cylinder remained in the room on a later observation, and the ADON confirmed there was no oxygen order and that oxygen tanks should be stored in the designated oxygen storage area when not in use. For another resident, oxygen tubing and the humidifier bottle were observed unlabeled, and the resident’s nasal cannula was later observed hanging uncovered on the side of the bed. The medical record showed orders to change the humidifier bottle nightly on Mondays and the oxygen tubing weekly on Mondays, and staff stated the equipment should be changed and labeled as ordered and stored in a clean clear bag when not in use. A third resident was observed receiving oxygen via nasal cannula at 1.5 liters when the order was for 2 liters per minute every shift, and the nurse stated she would increase the dose as ordered. A fourth resident’s oxygen tubing was observed on the floor while the oxygen concentrator was on at 3 liters per minute, but the tubing was not delivering oxygen; the medical record showed an order for continuous oxygen at 2 liters per minute and a care plan for impaired gas exchange with continuous oxygen at 2 liters via nasal cannula.
Pain management not consistently documented or provided as ordered
Penalty
Summary
The facility failed to provide safe, appropriate pain management for residents who required pain services, including failure to document or implement non-pharmacological interventions and failure to administer pain medication according to ordered pain scales. Surveyors reviewed records, observed residents, and interviewed staff and found that pain assessments were completed, but the facility did not consistently document what non-pharmacological measures were used before PRN pain medications were given, even when care plans identified interventions such as relaxation, guided imagery, music, distraction, massage, imagery, and deep breathing. For one resident with pain in the legs, ankles, and sacral area, the resident stated that pain medication helped only partially. The record showed PRN oxycodone-acetaminophen and acetaminophen orders, and the care plan called for non-pharmacological approaches every shift, but staff could not show that those interventions were actually used or documented. The ADON stated that non-pharmacological methods were not documented because they were in the care plan, while the Regional Clinical Services Manager later agreed that such measures should be documented on the TAR or in progress notes. For another resident, the record showed PRN tramadol and acetaminophen orders, and the care plan included non-pharmacological interventions for pain related to diabetes. The MAR showed multiple administrations of tramadol over several months without documentation of non-pharmacological interventions before administration. A resident with severe pain after a right hip replacement reported that pain remained poorly controlled, and the MAR showed oxycodone 10 mg was given for an 8/10 pain rating even though a 15 mg dose was also ordered for higher pain levels. Additional residents had PRN opioid or acetaminophen orders, but their records also lacked evidence that non-pharmacological measures were attempted or documented before pain medication was used.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report alleged violations related to neglect and/or abuse, including injuries of unknown source with major injuries, to the Office of Healthcare Quality as required. The deficiency was identified during review of complaint #2991568 and interviews, and it involved Resident #97, one of 39 residents reviewed during the recertification survey process. Resident #97 was interviewed and denied threatening his/her roommate, Resident #166, stating that staff accused him/her of threatening to kill the roommate and that police were called, but the resident denied making the threat. Record review showed that Resident #97 had a care plan diagnosis of mood disturbance related to depression with fluctuations in mood. A change in condition evaluation documented that Resident #97 became verbally aggressive toward the roommate after accusing the roommate of eating his/her food, and it was alleged that the resident stated, "I will kill you," in the presence of staff. The police were called to evaluate the situation, and the ADON and Regional Clinical Services Manager acknowledged that the incident was not submitted to OHCQ and that the facility should have reported it.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin involving Resident #161. On 5/01/25 at approximately 1:00 AM, the resident was found with the head hanging off the side of the bed while the lower body remained on the mattress and sustained a skin tear on the right lateral leg that required transfer to the hospital and seven superficial Prolene sutures. The facility’s internal investigation concluded that because the fall was unwitnessed, the cause could not be determined. Review of the resident’s record showed a BIMS score of 13 out of 15 dated 4/18/25, indicating intact cognitive function, yet the investigative packet contained no written statement from the resident about the cause of the injury. The facility’s documentation included a statement from an LPN who said the resident did not know what happened because they were asleep, but hospital notes documented a different account in which the resident said they were standing on the side of the bed when an aide came in to help and that they had been sleeping before calling for staff assistance. Facility leadership later validated these findings.
Failure to Document Assessment and Pain Management for New Hip Pain
Penalty
Summary
The facility failed to assess and document the onset and management of an unusual change in condition for one resident who was later found to have an acute right femoral neck fracture after an X-ray for right hip pain. The medical record included a Change in Condition note that acknowledged the X-ray results and fracture, but it did not contain documentation of when the pain began, which staff member completed the initial clinical assessment, what interventions were provided to manage the pain while awaiting the X-ray, or the specific details of the report made to the physician before the imaging results were received. During interview, the ADON and Regional Clinical Nurse Manager reviewed the record and validated that there was no documentation of a pain assessment or nursing interventions leading up to the diagnostic imaging.
Failure to Treat MASD and Obtain Timely Wound Oversight
Penalty
Summary
The facility failed to ensure appropriate wound care, timely specialist consultation, and necessary medication adjustments for one resident with moisture-associated skin damage (MASD) to the sacrum. The resident’s first skin assessment on 9/11/25 documented MASD on the sacral area, and a follow-up assessment on 9/15/25 measured the area at 5.5 x 2.5 x 0.1 cm and still identified it as MASD. The wound specialist’s documentation on 9/15/25 stated the resident was being signed off while remaining in the facility, and the wound nurse later confirmed there was no evidence the resident received zinc ointment treatment between the initial identification of MASD and its later progression. A week later, on 9/22/25, the skin assessment and wound specialist documentation identified the sacral area as a stage 2 pressure ulcer measuring 3.0 x 1.0 x 0.1 cm. During interview, the wound nurse explained that MASD requires zinc ointment, which must be ordered by a physician, and acknowledged that the wound physician’s note dated 9/15/25 indicated the resident was not actually evaluated during that visit. The ADON later validated that the facility failed to obtain the necessary treatment orders and specialist oversight required to prevent the MASD from deteriorating into a pressure ulcer.
Failure to Maintain Resident Dignity With Soiled Linens and Bodily Substances
Penalty
Summary
The facility failed to provide an environment that promotes resident respect and dignity for two residents. Resident #9 was observed lying in bed with linens that had multiple areas of yellow dried substance and an odor of urine; staff later confirmed the fitted sheet, top sheet, and white blanket had multiple dried yellow areas and that there was an odor of urine. Staff stated that resident linens are changed every other day or when soiled. Resident #39 was observed with an odor in the hallway near the room and a brown substance on the bed, wheelchair, and call light, while unknown staff walked past the room. On a later observation, the brown substance was still present, and an LPN confirmed it was bowel and that it was a dignity issue. The ADON stated that staff are expected to change residents' linen daily and as needed and agreed that soiled linen constitutes a dignity issue.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident’s right to self-administer medication for a resident who kept an inhaler at the bedside. During an interview, the resident stated that the inhaler was kept nearby because staff did not administer respiratory medication in a timely manner, and the resident reported having a respiratory illness and the capacity to administer the medication independently. The resident also stated that there had been opposition from nurses regarding keeping the inhaler at the bedside for safety and comfort reasons. Record review showed a progress note documenting that the resident complained of shortness of breath, received a nebulizer treatment, requested the inhaler, and then used the resident’s own inhaler at bedside after the medication was not available from the medication room, with shortness of breath decreasing afterward. The medical record contained no physician’s order for self-administration, no care plan, and no progress notes supporting an assessment for self-administration, although the resident reported that the medication was kept at the bedside at all times. The ADON stated that the facility had no residents self-administering medication within the last month and confirmed that bedside medication was not permitted unless the resident was assessed as capable and the MAR identified the medication as self-administration.
Call Bells Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure that call bells were consistently maintained within residents' reach for 2 residents observed during the recertification survey. Resident #61 was observed seated in a wheelchair and asked for help turning on the room light, and the call bell was found on the floor across the room and inaccessible. A review of the medical record showed that Resident #61 used a wheelchair for mobility and required supervision and staff assistance with ADLs, and the care plan identified a self-care deficit related to functional decline. Resident #78 was also observed with the call bell on the floor and not within reach. The medical record showed that Resident #78 used a walker for mobility and was dependent on staff for ADLs, and the care plan identified a self-care deficit. During interview, an LPN stated that staff are expected to ensure call bells are placed within residents' reach at all times. The ADON was informed of the findings and acknowledged the concerns.
Failure to Care Plan Nebulizer Use and Arm Sling
Penalty
Summary
A comprehensive care plan was not developed or implemented for Resident #88 to address shortness of breath and the use of a nebulizer, despite physician orders for Ipratropium-Albuterol solution 0.5-2.5 mg/3 ml every 6 hours for shortness of breath for 7 days. On 4/27/2026, the surveyor observed a nebulizer mask resting on top of the resident’s soiled breakfast tray while the resident was seated in a wheelchair and reported discomfort. A change in condition note dated 4/24/26 documented that the resident experienced shortness of breath and was started on breathing treatments. The resident also had a physician order for the left arm to remain in a sling at all times except for hygiene every shift, related to a closed fracture of multiple ribs. The medical record showed no evidence that a care plan was developed or implemented to address the sling use or management. During interviews, the ADON confirmed that care plans are initiated on admission and updated with new physician orders and changes in condition, but acknowledged that no care plan addressed the resident’s shortness of breath, nebulizer treatments, or sling use.
Failure to Update Care Plan for Behavioral Changes
Penalty
Summary
The facility failed to revise the comprehensive care plan to reflect Resident #97’s current treatment needs. The resident was alert and oriented and was observed by staff ambulating and standing by the nursing station in underwear only. A change in condition evaluation form also documented that the resident became verbally aggressive toward a roommate after accusing the roommate of eating the resident’s food, and the resident stated, “I will kill you,” in the presence of staff. The police were called to evaluate the situation. During interview, the NHA was informed that Resident #97 had multiple behavioral issues, including non-compliance with treatment orders, verbal altercations with two different roommates, and being inappropriately dressed at the nursing station. The NHA acknowledged that the facility failed to revise the care plan to reflect these behavioral issues. The ADON stated that care plans are initiated on admission and updated with new physician orders, changes in condition, and quarterly reviews, but no additional documentation was provided at the time of the findings.
Incorrect Psychotropic Medication Order and Discontinued Treatment
Penalty
Summary
The facility failed to ensure Resident #162 received psychotropic medication as recommended by psychiatric consultants for mental health issues. The resident was admitted to the facility and had an initial psychological evaluation on 4/22/25 that recommended Depakote 125 mg twice daily for mood and behavioral disturbances; psychiatric consultations on 4/23/25 and 4/29/25 confirmed the ongoing need for this treatment. However, on 4/25/25 the medication was started at 125 mg three times daily instead of twice daily, and the MAR showed the resident received this incorrect dose seven times between 4/26/25 and 4/28/25. On 4/28/25, an order for Depakote 125 mg twice daily was briefly entered and then immediately discontinued, and the medication was not restarted, leaving the resident without the recommended treatment. The ADON reviewed the records and confirmed the incorrect dosage and that the correct order was discontinued without a clinical assessment or justification.
Sanitary Food Service Deficiencies
Penalty
Summary
The facility failed to maintain sanitary food service operations during multiple observations of the kitchen and nourishment areas. During the initial kitchen tour, a beverage cart contained apple juice, cups of milk, and cups of water without dates marked on the lids, and the Dietary Manager stated that everything in the kitchen was supposed to have a date before directing a dietary aide to label the lids. In the first-floor nourishment rooms, a paper bag of food labeled with a resident’s name was found in the refrigerator without a storage date, along with an undated plate of cornbread and an unmarked dragon fruit; the refrigerator interior also had dust and dark stains, and the GNA validated these findings. On a later kitchen tour, a kitchen aide was observed handling food for service without a beard cover, and the Dietary Manager confirmed that staff are required to wear hairnets and beard covers while in the kitchen. The NHA was informed of these concerns and validated the findings.
Failure to Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure that staff COVID-19 vaccination status was consistently monitored and documented for 2 Geriatric Nurse Assistants, #18 and #9, out of 5 randomly selected staff members reviewed during the recertification survey. A review of employee health records on 5/01/2026 found no documented evidence of COVID-19 vaccination status for these 2 staff members. During an interview the same morning, the ADON stated that the facility offers COVID-19 vaccinations to all staff during on-site clinics, but acknowledged that vaccination status had not been consistently documented. Later that day, the ADON provided an email from a community pharmacy showing that 3 employees had expressed interest in receiving the COVID-19 vaccine during a 2024 clinic, but no documentation was provided to confirm whether those vaccinations were administered or recorded in the employees' health records.
Deficient Food Storage and Handling Practices in Kitchen
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to improper food storage and handling. During the initial kitchen tour, expired food items and undated opened items were found, including a half-full one-gallon mayonnaise container and corned beef wrapped in plastic wrap, both lacking open dates. Several snack cups were stored directly on the floor under storage shelves, and a container of buttermilk pancake mix was found to be expired. In the walk-in freezer, there was ice buildup on the floor and hanging icicles under the condenser. Dietary staff confirmed that kitchen staff are supposed to date leftover food items after opening and discard them after 72 hours, but the observed items did not comply with this practice. The Food Service Director validated all findings during the review.
Failure to Maintain Resident Dignity and Provide Adequate Mealtime Assistance
Penalty
Summary
Surveyors observed that the facility failed to maintain residents' dignity during mealtime in the main dining room. Several residents at one table were served their meals several minutes after other residents had already received theirs. Staff responsible for assisting residents, including a GNA, only provided help and socialization to residents at their own table and did not offer assistance to residents at other tables. One resident with left-sided body weakness was observed attempting to eat independently with their right hand, using their fingers to eat ham and other food items because their food had not been cut, and no assistance was provided to help with this task. Additionally, dietary staff serving hot food in the dining room gave minimal attention to residents and did not engage in conversation with them. The television in the dining room was turned off for the entire mealtime, and residents from different floors joined the main dining room as hot food was only available there. These actions and inactions resulted in a lack of prompt service, insufficient assistance, and limited social interaction for residents during the dining process.
Failure to Complete SCSA After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) within 14 days after a resident was discharged from hospice services. According to the medical record, the resident was admitted to hospice and an SCSA was completed following this admission. However, after the resident discontinued hospice services, no subsequent SCSA was completed within the required timeframe. This omission was confirmed through review of the resident's medical record and interviews with the MDS Coordinator and the Regional Resident Assessment Coordinator, both of whom verified that the required assessment was not performed after hospice discharge. The deficiency was identified during a recertification and complaint survey, where it was found that the facility did not adhere to federal requirements for timely completion of the MDS assessment following a significant change in the resident's status. The failure to complete the SCSA as mandated was specific to one resident among those reviewed, and the absence of the assessment was corroborated by both documentation and staff interviews.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and encode a discharge assessment for one resident who was admitted for short-term rehabilitation and discharged in stable condition. Review of the resident's medical record showed no evidence that the required Minimum Data Set (MDS) discharge assessment was completed. This omission was confirmed through interviews with both MDS staff and the Director of Nursing, who validated that the discharge assessment was missed. The deficiency was identified during a review of MDS assessment documentation as part of the recertification and complaint survey.
Inaccurate MDS Coding for Resident's Eating Assistance
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident. The MDS is a federally mandated assessment tool used to determine a resident's care needs and to develop an appropriate care plan. In this case, the quarterly MDS assessment for a resident was coded as requiring only setup or clean-up assistance for eating, which means the resident was believed to need help only before or after eating, but not during the activity itself. However, multiple sources of information indicated that the resident actually required more extensive assistance. The resident's medical record included diagnoses such as unspecified dementia, mood disorder, vascular dementia, major depressive disorder, and mild cognitive impairment. Interviews with the resident's family member, the registered dietician, and the unit manager all confirmed that the resident needed to be physically fed by staff, as the resident was unable to feed themselves. The care plan also documented a need for 1:1 assistance with feeding, and the resident was listed among those requiring feeding assistance. Despite this, the MDS Coordinator based the assessment coding solely on documentation from the Geriatric Nursing Assistants (GNAs) and did not utilize other available sources such as direct observation, interviews with other staff, or therapy documentation. This resulted in the resident's MDS being inaccurately coded, failing to reflect the true level of assistance required for eating.
Failure to Provide Baseline Care Plan and Medication Summary Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was provided with a summary of their baseline care plan (BLCP), including a list of medications, within 48 hours of admission. Review of the resident's medical record revealed that there was no evidence of a completed BLCP or documentation that the resident or their representative received a summary of the BLCP and medication list following admission. The process for completing and distributing the BLCP was described by the DON as being initiated by the admitting nurse, completed by any nurse within 48 hours, printed, signed by both the nurse and the resident or responsible party, and uploaded into the electronic medical record. However, for this resident, these steps were not completed or documented. Interviews with the DON confirmed that the responsibility for providing the BLCP summary and medication list to the resident or responsible party lies with the nursing staff, and that documentation should be present in a progress note. Despite these procedures, the DON was unable to provide evidence that the required documentation and distribution occurred for the resident in question. The absence of a completed BLCP and lack of documentation was verified by the DON during the survey.
Failure to Follow Physician Orders for PICC Line Dressing Changes
Penalty
Summary
A deficiency was identified when a resident with a peripherally inserted central catheter (PICC line) did not receive dressing changes as ordered by the physician. The resident was receiving IV antibiotics and reported not knowing why the dressing was left on in a soiled condition, and could not recall the last time it was changed. During an observation, the PICC line dressing was found to be dated from several weeks prior, indicating it had not been changed since the line was placed. Further investigation included an interview with the resident's nurse, an LPN, who confirmed that the dressing was supposed to be changed weekly but acknowledged that this had not occurred. Review of the medical record showed a physician order for weekly dressing changes and as needed, but documentation and direct observation confirmed the dressing had not been changed according to the order.
Failure to Apply Ordered Hand Splint for Resident with Contracture
Penalty
Summary
Facility staff failed to provide adequate care to prevent complications from hand contractures for a resident with a history of left-sided hemiplegia, hemiparesis, and a left wrist contracture. The resident had an active physician order for a left resting hand splint to be applied daily after morning care and removed after lunch, with hand hygiene and passive range of motion (PROM) of digits, as well as a skin check in the evening. Despite these orders, multiple observations by surveyors on different days revealed that the resident did not have the left hand splint in place, and no splint was visible in the resident's room. The resident reported that staff did not regularly apply the splint and was unable to locate it when asked. Review of the Treatment Administration Record (TAR) showed that staff documented the application of the splint daily, which was inconsistent with surveyor observations and the resident's statements. Interviews with nursing and rehabilitation staff confirmed that the splint was ordered to minimize further contracture and reduce pain, but staff could not account for the splint's whereabouts or provide evidence that it was being used as ordered. The lack of splint application and inconsistent documentation indicated a failure to follow physician orders and provide necessary care to maintain or improve the resident's range of motion.
Failure to Label Oxygen Equipment and Provide Incentive Spirometer as Ordered
Penalty
Summary
Facility staff failed to properly label oxygen tubing and humidifier bottles for a resident receiving oxygen therapy. During observation, a resident was found in bed with a nasal cannula connected to an oxygen concentrator and humidifier bottle, but neither the tubing nor the bottle was labeled with the date or time as required by physician orders. The nurse confirmed the lack of labeling and acknowledged that the expectation was to label these items when changed. Medical record review showed active orders for oxygen therapy and specific instructions to change and label the tubing and bottle weekly, with documentation indicating they had been changed, but no labeling was present during the surveyor's observation. Another resident with a physician order for incentive spirometer use was not provided with the device at their bedside, despite repeated requests to staff over several weeks. The resident reported concerns about mucus accumulation and a history of pneumonia, and stated that staff either did not know what an incentive spirometer was or told the resident it was on order. Multiple observations confirmed the absence of the incentive spirometer in the resident's room, and staff interviews revealed a lack of awareness and follow-through regarding the resident's order for the device. The deficiencies were identified through direct observation, medical record review, and staff and resident interviews. The issues included failure to follow physician orders for respiratory care equipment labeling and failure to provide prescribed respiratory therapy equipment to residents in a timely manner.
Failure to Provide Timely and Consistent Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for residents, as evidenced by delayed administration of pain medications and inconsistent adherence to physician orders. One resident reported uncertainty about whether their pain medication was scheduled or as needed, and review of their records showed multiple instances where scheduled pain medications, including hydrocodone-acetaminophen and lidocaine patches, were administered more than two hours late. Facility policy required medications to be given within one hour before or after the scheduled time, but audit reports revealed repeated late administration due to interruptions and staffing issues, as confirmed by staff interviews. Another resident with a history of chronic pain, osteoarthritis, muscle spasm, and peripheral vascular disease reported frequent bilateral leg pain and delays in receiving pain medication, sometimes waiting about an hour. Record review showed that pain medications were administered outside of the ordered pain score parameters, with acetaminophen and hydrocodone-acetaminophen given for pain scores not matching the physician's instructions. Additionally, tramadol was administered multiple times without any documented parameters or pain assessments, and there were no non-pharmacological interventions documented for pain management. Medication administration records for this resident also revealed that scheduled pain medications and other treatments were given several hours late on multiple occasions. These delays and inconsistencies in medication administration were acknowledged by facility leadership during interviews, and documentation confirmed that staff did not consistently follow physician orders or facility policy regarding pain management.
Failure to Ensure Timely Dental Services for Resident
Penalty
Summary
Facility staff failed to ensure that a resident requiring dental services received necessary and recommended care in a timely manner. The resident reported pain and discomfort due to missing and jagged teeth, which was confirmed by direct observation. Dental records indicated multiple missing, non-restorable, and fractured teeth, with recommendations for extractions and a need for a signed consent form from the responsible party. Despite these documented needs, the required consent was not obtained for nearly three months, and the resident was not scheduled for follow-up dental care as recommended by the dentist. Further review revealed delays in obtaining necessary dental x-rays and a lack of communication between facility staff and the dental provider. The resident's pain and dental issues persisted while the facility failed to ensure timely follow-up and did not communicate the urgency of the situation to the dental group. The resident was not placed on the list to be seen by the dentist until after surveyor intervention, and the dental provider was not made aware of the need for an earlier appointment until prompted by the surveyor.
Failure to Follow Resident Dietary Restrictions Due to Incomplete Allergy Updates
Penalty
Summary
A deficiency occurred when a resident with documented allergies to pork and corn was served meals containing these items, despite their allergies being clearly indicated on their meal ticket and in their clinical records. The resident reported being served pork sausage, bacon, and corn, which did not align with their dietary restrictions. The Registered Dietitian confirmed awareness of the incident, and the Food Service Director acknowledged that the resident's allergies were listed on the meal ticket. The incident was traced back to a period when the facility was transitioning systems and had a new Food Service Director, during which some residents' dietary information, including allergies, was not properly updated. The Nursing Home Administrator confirmed that the resident was served pork products due to the failure to update dietary and allergy information during the system change. Documentation reviewed by the surveyor, including a Resident Concern Form, corroborated that the resident received bacon on their tray despite their pork allergy. The resident did not consume the pork items, but the deficiency was established based on the failure to ensure menus and meal tickets accurately reflected and were followed according to the resident's nutritional needs and documented allergies.
Failure to Schedule Care Plan Conferences
Penalty
Summary
The facility failed to ensure that a resident had the right to participate in the development and implementation of their person-centered plan of care. Specifically, the facility did not schedule quarterly care plan conferences for a resident, despite the resident's representative requesting such meetings multiple times. The facility's policy required care plan conferences to be scheduled within one week of the resident's quarterly Minimum Data Set (MDS) assessment or after a significant change MDS assessment. However, the resident's electronic health record showed no care plan conferences had been held since June 2024, even though the resident experienced a cognitive decline from a BIMS score of 14/15 to 0/15. Interviews revealed that the facility had been without a Director of Social Work (DSW) for several months, and no other staff stepped in to facilitate care conferences during this vacancy. The new DSW, who started in November 2024, acknowledged that many residents had gone without care plan conferences. The Nursing Home Administrator confirmed that the resident was due for care plan conferences in September and December 2024, which were not scheduled. The failure to hold these conferences prevented the resident's representative from participating in care planning, as required by the facility's policy.
Failure to Prevent Falls and Manage Behavioral Risks
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to multiple incidents. The resident, who had a history of falls and cognitive impairment, was found on the floor with a head injury after attempting to get out of bed unassisted. The investigation revealed that the resident's bed was not in the lowest position, and no new interventions were documented to prevent future falls. Additionally, the resident was left unattended during care, resulting in another fall and injury. The resident's care plan included specific interventions to prevent falls and manage behaviors, such as keeping the bed in a low position and avoiding plastic items within reach due to the resident's tendency to eat plastic. However, these interventions were not consistently followed. Observations showed the resident's bed was not always in the lowest position, and plastic items were found within the resident's reach, posing a risk due to their behavior of chewing on plastic. Interviews with staff and the resident's representative highlighted a lack of awareness and adherence to the care plan. Staff admitted to stepping away from the resident during care, and the resident's representative noted that the facility did not implement any new measures to prevent falls. The facility's policies required prompt assessment and intervention after falls, but these were not adequately documented or executed, contributing to the resident's repeated accidents and exposure to hazards.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 1,287 citations issued within 25 miles in the last 12 months — including the 7 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Baltimore
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Cold Spring | 1.3 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 1.7 mi | ★★★★★ | 27 | 0 |
| Autumn Lake Healthcare At Homewood | 1.8 mi | ★★★★★ | 28 | 0 |
| Autumn Lake Healthcare At Long Green | 2 mi | ★★★★★ | 33 | 0 |
| Holly Hill Healthcare Center | 2.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Samaritan Nursing Home Operator, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.