Good Samaritan Nursing Home Operator, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1601 East Belvedere Avenue, Baltimore, Maryland 21239
- CMS Provider Number
- 215241
- Inspections on file
- 16
- Latest survey
- May 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Good Samaritan Nursing Home Operator, Llc during CMS and state inspections, most recent first.
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.
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.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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