Good Samaritan Society - Park River

Inspectors wroteBased on record review, review of the facility reported incident (FRI) and investigation, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who displayed sexually inappropriate behaviors towards other residents. Failure to protect residents from sexual abuse placed all residents at risk for psychosocial harm and mental and emotional distress. inappropriate behaviors resulted in sexual abuse.

Inspectors wroteBased on review of facility policy, review of call light logs, and resident, family, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 2 of 8 sampled residents (Resident #30 and #39), one supplemental resident (Resident #26) and 1 confidential resident (Resident A) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents. Findings Include: Review of the facility policy titled Call Light occurred on 08/20/25. This policy, revised 07/08/25, stated, When residents call light is observed/heard, go to the resident's room promptly. Respond to request as soon as possible. [...]

Inspectors wroteBased on observation, review of professional reference, review of facility policy, and staff interview, the facility failed to ensure food is prepared and stored in a clean and sanitary manner in 2 of 2 kitchen/nutrition centers (main kitchen and nutrition center) observed. Failure to ensure cleanliness of the kitchen and proper food storage has the potential for contamination of food and may result in a foodborne illness to residents, visitors, and staff.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the residents' current status for 2 of 14 sampled residents (Resident #12 and #28). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 1 sampled resident (Resident #30) observed during a sit-to-stand lift transfer. Failure to ensure proper use of a leg strap placed Resident #30 at risk for possible injury.

Inspectors wroteBased on observation and staff interview, the facility failed to discard expired medications in 2 of 3 medication storage areas (100-200 Wing Medication Cart and Medication Storage Room) reviewed. Failure to discard expired medications may result in decreased effectiveness of the prescribed medication.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to provide activities of daily living (ADLs) for 1 of 4 sampled residents (Resident #2) and 1 closed record (Resident #1) dependent on staff for personal hygiene and bed mobility. Failure to assist residents who cannot perform personal hygiene and bed mobility independently may result in poor hygiene, skin issues, and decreased self-esteem.

Inspectors wroteBased on observation, record review, policy review, review of a professional reference, and staff interview, the facility failed to provide appropriate toileting for 2 of 4 sampled residents (Resident #4 and #5) and 1 closed record (Resident #1) who required staff assist with toileting. Failure to provide toileting may result in a loss of dignity and placed the residents at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, urinary tract infections, and risk for fall and/or injuries.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 3 sampled residents (Resident #6) observed during cares. Failure to practice infection control standards related to hand hygiene has the potential to spread infection throughout the facility.

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 5 of 12 sampled residents (#1, #3, #13, #15, and #25). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review and review of facility policy, the facility failed to follow physician's orders for 1 of 3 sampled residents (Resident #17) and 1 closed record (Resident #86) reviewed who experienced high and/or low blood sugars. Failure to notify the physician of blood sugar results above and/or below the ordered parameters may result in complications to the resident and prevent the physician from evaluating the need to alter treatment.

Inspectors wroteBased on record review, review of Medicare Part A letters/notices, and staff interview, the facility failed to ensure the resident and/or their representative completed the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 3 supplemental residents (Resident #16) discharged from Medicare Part A in the past six months. Failure to ensure the completion of the SNFABN limited the resident/representative's ability to exercise their rights regarding Medicare Part A services.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE COMPLAINT SURVEY COMPLETED ON 03/12/24. Based on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect residents' current status for 2 of 12 sampled residents (Resident #17 and Resident #25). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 06/08/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 1 of 1 sampled resident (Resident #15) observed during a sit-to-stand lift transfer. Failure to ensure proper use of a leg strap as care planned placed Resident #15 at risk for possible injury.

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

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of medications in 1 of 2 medication carts (300/400 cart) observed during medication administration. Failure to obtain a label for an insulin pen and identify an open date may result in a resident receiving an incorrect or ineffective dose of insulin.

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 2 sampled residents (Resident #1 and #3) 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 transmit infections to residents, staff, and visitors.

Inspectors wroteBased on observation, review of facility grievances, review of the North Dakota Long Term Care Ombudsman Program's Guide to Resident Rights, and staff interview, the facility failed to treat residents with respect and dignity and failed to provide resident care in a manner and an environment that promotes, maintains, or enhances their quality of life on 1 of 1 days of survey. Failure to treat residents with dignity and speak respectfully has the potential to affect the residents' psychosocial wellbeing.

Inspectors wroteBased on observation, review of facility policy, review of facility call light logs, resident interviews, and staff interview, the facility failed to promptly respond to residents' call lights for 4 of 4 confidential residents (Residents A, B, C, and D) who required staff assistance. Failure to promptly respond to resident calls for assistance may result in residents experiencing unmet needs and may negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to provide reasonable accommodation of needs regarding call lights for 1 of 1 sampled resident (Resident #2) observed during cares. Failure to ensure residents can reach/access the call light may result in unmet needs and the inability to call for help.

Inspectors wroteBased on review of facility grievances, review of facility policy, resident interview, and staff interviews, the facility failed to implement an effective grievance system for 1 of 1 sampled resident (Resident #3) with a grievance regarding missing items. Failure to act upon resident and/or their representatives' grievances may result in continued resident dissatisfaction.

Inspectors wroteBased on record review, review of facility policy, and resident interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 4 sampled residents (Residents #1 and #2). Failure to review and revise care plans limits staff's ability to communicate needs and ensure continuity of care.

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

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to use an assistive device necessary to safely transfer a resident and ensure the chair alarm is in place to prevent accidents for 1 of 1 sampled resident (Resident #2) observed during a transfer. Failure to use a gait belt, lock the wheelchair brakes during the transfer, and place the chair alarm may result in falls and/or injuries to the resident.

Inspectors wroteBased on record review, review of professional reference, and staff interview the facility failed to provide appropriate toileting/check and change cares for 1 of 4 sampled residents (Resident #2) who required staff assistance with toileting. Failure to provide toileting/check and change cares as care planned may result in a loss of dignity and placed the resident at risk for skin breakdown and urinary tract infections (UTIs).

Inspectors wroteBased on observation, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 1 of 4 sampled residents (Resident #2) observed during incontinence cares. Failure to follow infection control standards has the potential to spread infections to residents, staff, and visitors.

Inspectors wroteTHIS IS A REPEAT CITATION FROM THE STANDARD SURVEY CONDUCTED ON [DATE] Based on record review, review of facility policy, and staff interview, the facility failed to ensure the residents' rights to request, refuse, and/or discontinue treatment for 5 of 13 sampled residents (Resident #20, #27, #29, #31, and #240) reviewed for advance directives. Failure to discuss the residents' resuscitation status with the resident and/or the resident's representative and ensure the medical record accurately reflected each resident's code level limited the facility's ability to communicate to direct care staff and emergency personnel the residents' choice in the event of a medical emergency.

Inspectors wrote1. Based on observation, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 3 of 5 residents (Resident #2, #7 and #17) observed for insulin pen preparation. Failure to properly prepare insulin pens per policy may result in the resident receiving an inaccurate dose of insulin.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interviews, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 6 sampled residents (Resident #20 and #31) who required a mechanical lift for transfers. Failure to ensure proper use of a mechanical lift placed all residents at risk for accident and/or injury.