Good Samaritan Society - Mountain Lake

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Feb 12, 2025

  Based on observation, interview, and document review the facility failed properly assess and monitor blood sugars, failed to identify signs and symptoms of hyperglycemia, and failed to follow continuous glucose monitor (CGM) manufacturer recommendations for placement and rechecking blood sugars for 1 of 4 residents (R1) who was admitted to intensive care unit with a blood sugar of over 1000 mg/dl (milligrams/deciliter). This resulted in an immediate jeopardy (IJ) for R1. The IJ began on 1/29/25, when R1 was demonstrating symptoms of hyperglycemia but R1's blood sugar according to the CGM was 52 mg/dl and was administered glucose tablets without confirming blood sugar via finger stick. […]

• Actual harm, isolatedF689Apr 29, 2026

  Based on interview and document review the facility failed to follow care planned fall interventions for 1 of 3 residents (R5) reviewed for falls. This resulted in actual harm when R5 fell and required a visit to the emergency department resulting in a fractured left femur and needed surgical intervention. The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance. Findings include:R5's quarterly Minimum Data Set (MDS) dated [DATE], indicated R5 had moderate cognitive impairment, needed substantial to maximal assistance with toileting, and needed partial to moderate assistance with toilet transfersR5's Face Sheet dated 6/23/23, indicated R5 had dementia.R5's care plan with intervention revision dated… […]

• Actual harm, isolatedF760Apr 29, 2026

  Based on interview and document review, the facility failed to ensure medications were administered to the correct resident for 1 of 3 residents (R3) reviewed for medication errors. This failure resulted in actual harm for R3 when she developed bradycardia (abnormally slow heart rate) which required ongoing monitoring and intravenous therapy in the emergency department (ED). The facility had implemented appropriate corrective action prior to the onsite investigation, so the deficiency is being cited at past non-compliance. R3's Face Sheet dated 10/23/25, indicated R3 had dementia and Alzheimer's Disease. R3's [NAME] Accountability For Excellence (SAFE) Event Incident Report dated 3/25/26, indicated R3 was found with another resident's crushed medications in a drink. […]

• No harm, potential for more than minimal, widespreadF812Jun 26, 2024

  Based on observation, interview, and policy review, that facility failed to ensure beverageware and metal pans were completely dry before storing to prevent bacterial growth. This had potential to affect all 47 residents who resided in the facility. Findings include: During an observation and interview on 6/24/24 at 11:37 a.m., with cook (C)-A observed multiple metal steam table pans stacked upside down, one on top of the other, on a wire shelving rack. When C-A removed the top pan, it had visible water on the inside surface. C-A acknowledged staff should not have put pans away while still wet as that could promote bacterial growth. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2022

  Based on observation, interview and document review, the facility failed to monitor the condition of food storage containers in the walk-in kitchen refrigerator resulting in mold growing on the outside of multiple containers. In addition, the facility failed to date-mark open containers of food stored in the walk-in kitchen refrigerator, and failed to ensure expired food was identified and removed. In addition, the facility failed to prevent cross-contamination when egg shells were stored with whole eggs. In addition, the facility failed to ensure the trained dietary manager oversaw and supervised all aspects of dietary services and ensured dietary cooks received comprehensive training upon hire and on-going. […]