Good Samaritan Society - Lakota

Inspectors wroteBased on observation, review of facility policy, confidential resident interviews, and staff interviews, the facility failed to ensure sufficient nursing staff to meet resident needs for four confidential residents (Residents A, B, C, and D) who required staff assistance. Failure to provide sufficient staffing and answer call lights in a timely manner does not promote a resident's right to physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation and record review the facility failed to review and revise care plans to reflect the resident's current status for 2 of 6 sampled residents (Residents #1 and #6). Failure to update care plans limit the staff's ability to communicate residents' needs and ensure continuity of care. Findings Include: - Review of Resident #1's medical record occurred on 06/16/26 and identified a left intertrochanter (hip) fracture. The current care plan stated, . The resident has an ADL [activities of daily living] self-care performance deficit R/T [related to] elzhiemers [sic] E/B [evidenced by] need for staff to anticipate needs and wants. An intervention, revised on 02/09/26 stated, Ambulation: X1 (one person) staff assist, using the standing lift [mechanical sit to stand lift] for all transfers . Resident does not ambulate. [...]

Inspectors wroteBased on observation, record review, review of facility policy, and staff interviews, the facility failed to provide care and services to prevent the development of pressure ulcers for 2 of 6 sampled residents (Residents #1 and #6) with pressure ulcers. Failure to provide repositioning and utilize pressure relief devices appropriately may result in the development/worsening of pressure ulcers.

Inspectors wroteBased on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 13 sampled residents (Resident #2, #10, #23, #35, and #36). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 4 of 5 sampled residents (Resident #10 #23, #24, and #35) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), perineal care, hand hygiene, and cleaning of a mechanical lift has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to provide the necessary services for 1 of 13 sampled residents (Resident #10) and 2 supplemental residents (#11 and #12) who required staff assistance with bathing. Failure to provide bathing as scheduled may result in poor personal hygiene and decreased self-esteem.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment and services to promote healing of a pressure ulcer for 1 of 2 sampled residents (Resident #10) with a pressure ulcer. Failure to provide wound treatment as ordered may result in delayed healing, wound infection, and worsening or development of a new pressure ulcer.

Inspectors wroteBased on record review, review of facility policy, and resident interview, the facility failed to provide necessary services and assistance for 1 of 1 confidential resident (Resident A) who voiced concerns related to toileting assistance. Failure to provide toileting assistance in a timely manner may result in a loss of dignity and placed the residents at risk for incontinence, skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to provide respiratory care in accordance with professional standards and the plan of care for 1 of 1 sampled resident (Resident #25) with a diagnosis of severe obstructive sleep apnea. Failure to obtain or check on the status of a Continuous Positive Airway Pressure (CPAP) device may result in cardiovascular issues, daytime fatigue, impaired cognitive function and affect overall quality of life.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure posting of staff information on 2 of 3 days of survey (June 1-2, 2025). Failure to post staffing data does not allow residents and visitors information related to the number of licensed and unlicensed staff on duty each shift.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing or prevent the development of pressure ulcers for 2 of 3 sampled residents (Resident #1 and #2) identified with pressure ulcers. Failure to apply pressure relieving devices as ordered, complete weekly assessments with measurements of pressure ulcers per facility policy, may result in new pressure ulcers, the deterioration of existing pressure ulcers, and delayed healing.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #1) with an indwelling urinary catheter. Failure to obtain a physician order for an indwelling urinary catheter, and provide catheter care may result in urinary tract infections (UTI's), unnecessary discomfort, unnecessary skin issues, and/or sepsis.

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff and resident interview, the facility failed to provide care and services to maintain the resident's highest level of well-being for 1 of 1 sampled resident (Resident #30) with a change in health status followed by a transfer to the hospital. Failure to monitor and assess the resident's condition on an on-going basis resulted in worsening respiratory symptoms, a delay in treatment, and an admission to the hospital.

Inspectors wroteBased on observation, review of the North Dakota Plumbing Code, and staff interview, the facility failed to provide an air gap for 1 of 1 food-preparation sink (main kitchen) observed. Failure to provide the required air gap for a food-preparation sink has the potential to allow contamination of the sink in the event of sewer back up and bacterial migration.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to prepare, store, and serve food in a sanitary manner in 1 of 1 main kitchen and 1 of 1 resident nutrition center. Failure to label food with date/time, to discard expired food, clean soiled equipment, and use outdated test strips all have the potential to affect food quality/preparation, improper sanitation, and may result in the spread of foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident (Resident #137) with missed blood tests. Failure to notify the physician of unsucessful blood draws may have prevented the physician from altering the treatment/care provided to the resident.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the State Long Term Care Ombudsman a notice of transfer for 1 of 1 sampled resident (Resident #9) reviewed for hospital transfers. Failure to provide a copy of the transfer notice does not allow the ombudsman to be aware of facility practices regarding transfer and discharge or advocate on the resident's behalf.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #2 and #9). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide treatment and services to aid in the healing of pressure ulcers for 1 of 3 sampled residents (Resident #31) with current pressure ulcers. Failure to provide wound treatments as ordered may result in delayed healing or deterioration of a pressure ulcer.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure appropriate gastrostomy tube (G-tube) care and services for 2 of 3 sampled residents (Resident #27 and #31) with a G-tube. Failure to communicate the dietician's recommendations related to tube feedings and label the tube feeding set with identifying information may result in undesired weight gain and complications related to tube feedings.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide respiratory care in accordance with professional standards and the resident's plan of care for 2 of 4 sampled residents (Resident #2 and #30) and one supplement resident (Resident #15) with oxygen therapy. Failure to follow physician's orders related to the flow of oxygen and change tubing regularly may result in complications related to oxygen use.

Inspectors wroteBased on observation, review of facility policy, review of narcotic record counts, and staff interview, the facility failed to recognize a tampered controlled medication container/packaging for 1 of 1 resident (Resident #27). Failure to physically examine the medication container/packaging for tampering in a timely manner increases the potential for medication error, loss, and diversion. Review of the facility policy titled Medications: Controlled occurred on 06/18/24. This policy, dated June 2023, stated, . The on-coming nurse will physically examine the containers/packages of each controlled medication for evidence of tampering (open packages, taped packaging, medications that look different than others .). Observations on 06/18/24 at 1:41 p.m. with a medication aide (#4) showed 16 tablets of Hydrocodone/acetaminophen, an opioid pain medication available for Resident #27. [...]

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 1 of 14 residents (Resident #136) and one supplemental resident (Resident #7) observed during medication administration. Two medication errors occurred during staff administration of 25 medications, resulting in an 8% error rate. Failure to properly administer medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 3 sampled residents (Resident #27 and #31) observed with enhanced barrier precautions (EBP). Failure to practice infection control standards by ensuring staff use the proper personal protective equipment (PPE) has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, staff interviews, and information from a complainant, the facility failed to ensure resident safety for 1 of 1 resident (Resident #1) closed record reviewed for smoking safety. Failure to ensure the safety of a resident who smoked placed the resident at risk for adverse events, serious injury, and death.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise comprehensive care plans to reflect the current status for 4 of 12 sampled residents (Resident #4, #26, #29, and #32). Failure to review and revise the care plan limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wrote- Review of Resident #32's medical record occurred on all days of survey. The quarterly MDS, dated [DATE], identified bed rail used daily as a restraint. The current care plan stated, The resident uses physical restraints assist bars R/T [related to] mobility E/B [evidenced by] independent bed mobility. STRENGTH: Resident is able to: reposition self in bed. A Physical Device and/or Restraint Evaluation and Review form, completed 02/22/23, showed staff checked no to the question, Would the assist/grab bar(s) be a restraint for this resident? During an interview on 05/24/23 at 6:30 p.m., an administrative nurse (#1) confirmed the facility coded Resident #28 and #32's restraint use incorrectly. SECTION N: MEDICATIONS The Long-Term Care Facility RAI User's Manual, revised October 2019, pages N-6 and N7, stated, . Coding Instructions N0410A-H: [...]

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to ensure 1 of 1 sampled resident (Resident #25) on fluid restrictions received the care and services necessary to attain the highest degree of physical well-being possible. Failure to provide the appropriate amount of fluids and monitor accurate intake placed the resident at risk for adverse effects from fluid overload.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary treatment/services to promote the healing and prevent the worsening of pressure ulcers for 1 of 2 sampled residents (Resident #34) with a pressure ulcer. Failure to consistently implement interventions to prevent the worsening of an existing pressure ulcer and failure to notify the physician of identified changes may have resulted in delayed treatment and deterioration of Resident #34's pressure ulcer.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to accurately label 3 of 8 opened multi-dose insulin vials (two vials of Lantus, a long-acting insulin, and one vial of Novolog, a short-acting insulin) in the refrigerator of the medication storage room. Failure to label multi-dose insulin vials with the opened date increases the risk of residents receiving outdated medications with reduced medication efficacy.