Good Samaritan Nursing Home Operator, LLC

Inspectors wroteBased on observation, record review, and interviews with facility staff, it was determined that the facility failed to ensure that residents' personal hygiene needs were adequately met, timely assistance was provided for incontinence care, and assistance with meals was provided. This was evident for 5 (Resident #5, #9, #49, #39, and #1) of 7 residents reviewed for Activities of Daily Living (ADLs) during the recertification/complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to provide necessary respiratory care that consistent with professional standards of practice. This was evident for 4 Residents (Resident #7,#49, #88 and #89) of 4 residents reviewed for respiratory care during the recertification survey.

Inspectors wroteBased on record reviews, observations and interviews, it was determined that the facility failed to ensure that pain management was provided to each resident in a way that was consistent with the professional standards of practice, residents goals and preferences. This was evident for 8 Residents (#80, #7,#97, #2, #4, #10, #127, #12) of 8 Residents reviewed for pain management during the recertification/complaint survey.

Inspectors wroteBased on observation and interviews with facility staff, it was determined the facility failed to provide an environment that promotes resident respect and dignity. This was evident for 2 (Resident #9 and #39) of 2 residents reviewed for dignity during the recertification/complaint survey.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to assess the resident's right to self-administer medication. This was evident for 1 resident (#111) of 1 resident reviewed for medication self-administration during the recertification/complaint survey. Findings Included:On 04/30/2026 at 2:20 PM, in an interview with Resident #111, the resident explained that he/she kept medication (inhaler) at the bedside because he/she alleged that the staff failed to administer medication in a timely manner. The resident explained he/she had a respiratory illness and as a result the resident required his/her respiratory medication timely. The resident reported that he/she has received a lot of opposition from the nurses for keeping the inhaler at the bedside. [...]

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure that call bells were consistently maintained within residents' reach. This was evident for 2 (Residents #61 and #78) of 133 residents observed during the recertification survey.

Inspectors wroteBased on record review, complaint # 2991568 and interviews, it was determined the facility staff 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. This was evident for 1 (Resident #97) of 39 residents records reviewed during the recertification survey process.

Inspectors wroteBased on a review of facility investigative materials, medical records, and staff interviews, it was determined that the facility failed to thoroughly investigate an injury of unknown origin. This was evident for one (Resident #161) of three residents reviewed during this recertification/complaint survey.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to develop and implement a comprehensive care plan addressing the use of a nebulizer and an arm sling. This was evident for 1 (Resident #88) of 36 residents reviewed for care planning during the recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to revise the comprehensive care plan to reflect the resident's current treatment needs. This was true for 1 (Resident #97) of 36 residents reviewed for care planning during the recertification survey. Findings Included:On 4/29/2026 at 11:00 AM, during an interview with the Assistant Director of Nursing (ADON), she confirmed that care plans are initiated upon admission by supervisors or Unit Managers and subsequently reviewed and completed by the Interdisciplinary Team (IDT). The ADON further stated that care plans are updated with new physician orders and changes in condition, as well as during routine quarterly reviews. [...]

Inspectors wroteBased on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to assess and/or document the onset and management of unusual changes in resident condition. This deficiency was evident for one resident (Resident #153) out of three reviewed for injuries of unknown origin during the recertification/complaint survey.

Inspectors wroteBased on complaint investigations, medical record reviews, and staff interviews, it was determined that the facility failed to ensure appropriate wound care, timely specialist consultation, and necessary medication adjustments. This was evident of one (Resident #157) out of five residents reviewed for pressure ulcers during the recertification/complaint survey.

Inspectors wroteBased on a complaint investigation, medical record reviews, and staff interviews, it was determined that the facility failed to ensure a resident received psychotropic medication as recommended by psychiatric consultants. This deficiency affected one resident (Resident #162) out of five reviewed for behavioral health during the recertification/complaint survey.

Inspectors wroteBased on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain sanitary food service operations. This deficiency was identified during multiple observations of kitchen and food service areas throughout the recertification/complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that staff COVID-19 vaccination status was consistently monitored and documented. This was evident for 2 Geriatric Nurse Assistants (GNA) #18 and #9 of 5 randomly selected staff members reviewed during the recertification survey.

Inspectors wroteBased on an observation and facility staff interviews, it was determined that the kitchen failed to store food items, so as to maintain the integrity of the specific item. This was evident during the initial tour of the kitchen, by noting expired food items and undated opened items, observed by the surveyor during the recertification/complaint survey.

Inspectors wroteBased on observation and an interview with Residents and staff, it was determined that the facility failed to maintain Residents' dignity as evidenced by 1) residents (Resident #14, #96, #30, #56) not being served meals at same time, and 2) Staff availability during the dining process to provide sufficient cueing, prompting, serving, and assisting residents to eat. This was evident for 1 of 2 dining observations performed at the main dining room with 5 large dining tables and 1 small dining table.

Inspectors wroteBased on interviews with facility staff and review of medical records, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of a resident's discontinuation from hospice services. This was evident for 1 (Resident # 30) of 47 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on a review of Minimum Data Set (MDS) Assessment documentation and an interview with facility staff, it was determined that the facility failed to complete discharge resident assessments as required. This finding was evident for 1 (Resident # 65) of 33 residents reviewed during the resident assessment task during the recertification/complaint survey.

Inspectors wroteBased on review of the medical record and interviews with facility staff, it was determined that the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #2) of 47 residents reviewed during the facility's recertificaiton/complaint survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on interview with residents, surveyor observations, interview with facility staff, and review of medical records, it was determined that the facility failed to follow physician orders as evidenced by ensuring a resident's peripherally inserted central catheter (PICC line) dressing was changed as ordered by the physician. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility staff failed to provide adequate care to prevent complications from hand contractures. This was evident for 1 (#83) of 3 residents reviewed for limited range of motion (ROM) during a recertification/complaint survey.

Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility staff failed to 1) label oxygen tubing and humidifier bottle when changed, and 2) equip a resident with an incentive spirometer to address their respiratory needs per physicians order. This was evident for 2 (#45, #67) of 3 residents reviewed for respiratory care during a recertification/complaint survey.

Inspectors wroteBased on interviews with residents and staff and medical record reviews, it was determined the facility failed to ensure that residents were given pain medications timely and consistent with professional standards of practice. This was evident for 2 ( #237, #37) of 4 residents reviewed for pain management during a recertification/complaint survey.

Inspectors wroteBased on interview with residents, review of medical records, and interviews with facility staff, it was determined that the facility staff failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 1 (Resident #67) of 47 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on a complaint, record review, resident and staff interviews, it was determined the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for 1 (#37) of 2 residents reviewed for food during a recertification/complaint survey.

Inspectors wroteBased on records review and interviews during a complaint survey, the facility did not ensure each resident had the right to participate in the development and implementation of their person-centered plan of care, including to participate in the planning process and to request meetings for one resident (Resident # 8) out of three residents reviewed for resident rights. Specifically, the facility did not schedule quarterly case plan conferences to evaluate Resident #8's plan of care and to allow for the resident's representative to participate in plan of care decision making.

Inspectors wroteBased on observations, record review, and interviews during a complaint survey the facility failed to ensure the resident environment remained free of accident hazards and adequate supervision was provided to prevent accidents for one resident (Resident #10) out of five residents reviewed for accidents/hazards. Specifically, for Resident #10 the facility failed to ensure the following: new interventions were implemented to prevent accidents after the resident had a fall on 2/3/2022 and sustained a laceration to their head; fall care plan was followed; was not left unattended on their side while they were being changed which resulted in a fall; and the behavioral care plan was followed for staff to not leave plastic items within reach of the resident; this created an environmental hazard due to the resident ' s behavior of eating plastic.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure a resident was administered medication according to parameters (#73). This was evident for 1 out of the 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interviews and review of medical records, it was determined that the facility staff failed to provide showers to the resident as per preference and request. This was found to be evident for 1 (Resident #88) out of the 1 residents reviewed during the survey.

Inspectors wroteBased on review of resident council meeting minutes, residents and staff interview, it was determined that the facility staff failed to give adequate responses to grievances presented by the resident council. This was found evident for 3 of 8 months of resident council meeting minutes and facility responses reviewed during the survey.

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility staff failed to ensure that residents who were dependent on staff for activities of daily living (ADL) had their toenails trimmed. This was evident for 2 (#64 and #79) out of 5 residents reviewed for ADL care.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to have a consistent process in place to ensure that the computer and the physician orders consistently referred to the correct Maryland Order of Life Sustaining Treatments (MOLST). This was evident for 3 of 4 residents (#25, #69 and #38) reviewed during the initial review of residents during the annual survey.