Good Samaritan - Lemars

In the surveyor’s words

From the most serious findings on record at Good Samaritan - Lemars, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Apr 17, 2025

  Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 1, 2025 (October 1 - December 31) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in three metrics. The facility reported a census of 57 residents. Findings include: The PBJ Staffing Data Report with a run date of 4/9/25 triggered submitted weekend staffing data excessively low within the quarter. Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. […]

• No harm, potential for more than minimal, patternF755Jan 11, 2023

  Based on observations, interviews and record review the facility failed to maintain safegaurds and systems to control and account for scheduled medications for 4 of 6 residents reviewed. Resident #254 and Resident #306 had orders for Ativan to be used as needed for seizure disorders. The medication cassettes were tampered with and replaced with different medications. Staff removed 2 Hydrocodone tabs from the emergency kit (ekit) for Resident #307 and the Medication Administration Record (MAR) lacked documentation that these had been given. On 1/12/23, a medication cart contained a cassette with an as needed (PRN) Tramadol for Resident #43, the medication had been discontinued the end of December. The facility reported a census of 52 residents. […]

• No harm, potential for more than minimal, patternF880Jan 11, 2023

  Based on observation, clinical record review, and staff interviews the facility failed to ensure staff followed infection control policy and procedures for 1 out of 16 residents, (Resident #50). The facility also failed to follow infection control policy and procedures by not covering clean linen carts. The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 identified a Brief Interview for Mental Status (BIMS) of 13 which indicated cognitively intact. The MDS documented diagnoses of cognitive loss/dementia and cancer. Observation on 1/9/23 at 2:53 PM showed Staff A delivering snacks in 100 hall. […]

• No harm, potential for more than minimal, isolatedF641Apr 17, 2025

  Based on record review and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 14 resident's reviewed (Resident #38). The facility reported a census of 54 residents. Findings include: According to the MDS assessment dated [DATE], Resident #38 demonstrated long and short term memory problems and severely impaired skills for daily decision making. The resident had diagnoses including non-Alzheimer's dementia. The MDS documented the resident exhibited no behaviors in the 7 day look back period. […]

• No harm, potential for more than minimal, isolatedF656Apr 17, 2025

  Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for 1 out of 14 residents included in the comprehensive care plans (Resident #53). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #53 documented diagnoses of depression and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Resident #53's April Medication Administration Record (MAR) revealed the following orders: a. Furosemide tablet (diuretic medication) daily with a start date of 12/12/24 b. […]