Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Nursing Home Operator, Llc during CMS and state inspections, most recent first.
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.
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 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.
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.
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Illustrative
What surveyors actually found near you
We read the 1,618 citations issued within 25 miles in the last 12 months — including the 5 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
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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 | ★★★★★ | 29 | 0 |
| Autumn Lake Healthcare At Perring Parkway | 1.7 mi | ★★★★★ | 17 | 0 |
| Autumn Lake Healthcare At Homewood | 1.8 mi | ★★★★★ | 12 | 0 |
| Autumn Lake Healthcare At Long Green | 2 mi | ★★★★★ | 36 | 0 |
| Holly Hill Healthcare Center | 2.1 mi | ★★★★★ | 1 | 0 |
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