Good Samaritan Society - Specialty Care Community

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure staff consistently wore hair restraints and gloves while serving food. Additionally, the facility failed to maintain food temperatures within the desired range. The facility also failed to consistently cover food items placed in the freezer and date the items with the date placed and the date food items were to be used by. This had the potential to affect all 88 residents who resided at the nursing home.

Inspectors wroteBased on interview and document review the facility failed to implement routine surveillance of signs and symptoms of illness/infection which were not currently being treated with antibiotic therapy or other treatment. This had the potential to impact all 88 residents who resided at the facility, as well as staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving psychotropic medications were adequately monitored for potential adverse consequences, including failure to implement side effect monitoring for 4 of 6 residents (R7, R10, R41, and R91) reviewed for psychotropic medication monitoring, and failure to obtain and document orthostatic blood pressures as ordered for 3 of 6 residents (R10, R41, and R91) reviewed for psychotropic medication use.

Inspectors wroteBased on interview and record review, the facility failed to revise comprehensive care plans to reflect significant changes in resident status, conditions, preferences, and interventions, for 3 of 3 residents (R111, R7, and R75) reviewed for care plan revision. Further, the facility failed to update the care plan with specific interventions for 2 of 2 residents (R1 and R122) reviewed for privacy of care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assure medication labels properly reflected provider orders for 2 of 7 residents (R110, R89) observed during medication administration.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident grooming needs were met for 1 of 1 resident (R83) in the sample reviewed for nail care. Finds include: R83's admission Record (Face Page - print date of 6/4/26), documented the following diagnoses: Muscle weakness, disorientation, atrial fibrillation and essential hypertension. R83's Comprehensive Minimum Data Set (MDS) dated [DATE], assessed resident to be moderately cognitively impaired and required set-up to maximal assist with activities of daily living (ADLs). R83's Care Area Assessment for ADLs (CAA) dated 3/30/26, documented resident's limiting factors for the need of ADL assistance being causes for being dependent were physical limitations such as weakness, limited range of motion, poor coordination, poor balance, visual impairment or pain. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident and/or resident representative was informed of and participated in treatment decisions regarding psychotropic medications, including failure to obtain informed consent prior to the initiation of a psychotropic medication for 1 of 5 residents (R41) reviewed for psychotropic medication use.

Inspectors wroteBased on observation and interview the facility failed to maintain a broda chair (a specialized brand of wheelchair and positioning recliner designed for individuals with limited mobility who require long-term, comfortable sitting) in good repair for 1 of 1 resident (R40) reviewed who utilized a broda chair.

Inspectors wroteBased on interview and record review, the facility failed to provide and document written notice of an involuntary transfer/discharge to a resident and/or resident representative prior to transfer to another facility, for 1 of 1 resident (R100) reviewed for transfer and discharge requirements.

Inspectors wroteBased on interview and record review, the facility failed to timely complete a comprehensive assessment after a significant change in status, including failure to complete a Significant Change in Status Assessment (SCSA) following discharge from hospice services, for 1 of 1 resident (R111) reviewed for MDS assessment requirements. The Resident Assessment Instrument (RAI) User's Manual identified enrollment in hospice services and discharge from hospice services as events that may constitute a significant change in status requiring completion of a Significant Change in Status Assessment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure professional standards of practice were followed during administration of crushed medications for 1 of 2 residents (R68) observed during medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician-ordered parameters were monitored prior to administration of an antihypertensive medication, including failure to obtain blood pressure readings to determine whether a PRN dose of metoprolol was indicated, for 1 of 1 resident (R91) reviewed for medication administration parameters.

Inspectors wroteDuring interview and record review, the facility failed to ensure all residents were offered and up to date on immunizations for 1 of 5 residents (R29) reviewed for immunizations.

Inspectors wroteBased on document review and interview, the facility failed to ensure COVID-19 immunization was offered and/or administered in accordance with current standard of practice for 1 of 5 residents (R29) reviewed for immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review. This had the potential to affect all 88 residents currently residing in the facility, as well as all staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all recent facility survey results were posted in an accessible location for residents, staff, and visitors. This had the potential to affect all 88 residents residing in the facility as well as staff and visitors.

Inspectors wroteBased on interview, observation, and document review, the facility failed to promote dignity while providing care for 1 of 3 residents (R1) reviewed who required assistance with activities of daily living.

Inspectors wroteBased on interviews, observation, and document review the facility failed to implement care plan interventions for 1 of 3 residents (R1) when staff transferred R1 with pivot transfers (technique for moving a resident from one position to another. While standing, resident moves their feet to turn toward the new surface) instead of with the Stand Aid (non-motorized device to assist a person to a standing position), as indicated in the care plan.

Inspectors wroteBased on interviews, observations, and document review the facility failed to ensure safe transfers for 1 of 3 residents (R1) who was lifted off the floor following a fall by two staff without using a Hoyer lift (mechanical lift used to transfer residents from one surface to another). In addition, two staff assisted R1 to stand from a wheelchair with a Stand Aid (non-motorized lift used to assist residents from a seated position to a standing position) without a gait belt.

Inspectors wroteBased on observation, interview, and document review the facility failed to assess, develop and implement person-centered care plans to meet the needs of 6 of 16 residents (R1, R2, R3, R5, R7 and R8) reviewed who received treatment and services related to dementia.

Inspectors wroteBased on interview and document review, the facility failed to ensure efforts to resolve a grievance for missing personal possessions was addressed, acted upon, and resolved for 1 of 1 resident (R1) whose family voiced concerns regarding missing personal property.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure foods which were a known allergen were not served or provided for 1 of 1 resident (R1) reviewed who complained about repeatedly being served such foods. This could cause an allergic reaction for R1 if she had consumed them.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents knew how to file a grievance and that grievance forms were posted in prominent locations throughout the facility for residents and resident representatives to file grievances, and anonymously if desired for 4 of 4 residents (R29, R32, R37 and R39) reviewed for grievances. This had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dishwasher temperatures were within range to ensure resident dishes were sanitized for 4 of 5 unit (Boundary Waters, Arrowhead, Lakes, Woodland) kitchenettes that housed and utilized dishwashers. In addition, the facility failed to maintain the coffee machine in a sanitary manner to prevent potential food-borne illness. These practices had the potential to affect all residents residing in these units.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 1 of 1 (R140) resident observed with medications at bedside.

Inspectors wroteDuring observation, interview, and document review the facility failed to clean and maintain residents wheelchairs for 2 of 2 residents (R3, R33).

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physican of a change in condition for 1 of 2 residents (R6) with a significant weight gain.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure pressure ulcer (PU) prevention interventions were in place for 1 of 2 residents (R66) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a urinary catheter was secured to facilitate urine flow and positioned below the bladder for 1 of 1 resident reviewed for catheter cares. ensure the proper use of a catheter for 1 of 1 resident (R68).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure beverages were served in the appropriate consistency for 1 of 1 resident (R12) reviewed for therapeutic diets.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide medication as ordered by the physician for 1 of 3 residents (R4) reviewed for pharmacy services.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment identified the facility's staffing needs based on the care needs of the resident population. This deficient practice had the potential to affect all 92 residents who resided in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline care plan was developed, within 48 hours that included goals and interventions to address resident's current needs, as required for 1 of 1 residents (R1) reviewed.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision during a meal for 1 of 1 residents (R1) reviewed, who required supervision due to swallowing disorder.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights, or another means to request assistance were accessible for 4 of 4 residents (R5, R6, R7, and R8) reviewed who were dependent on staff for mobility.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a proper assessment, care planning, and ongoing re-evaluation for the use of physical restraints for 5 of 5 residents (R4, R5, R6, R7, and R8) reviewed to ensure the imposed restraint were used to treat the resident's medical symptoms, is not used for convenience or discipline, is the least restrictive alternative for the least amount of time and document ongoing re-evaluation for the need of restraints.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat with dignity for 1 of 3 residents (R7) reviewed for resident rights. A nursing assistant (NA)-C was observed speaking to R7 in a belittling manner while providing cares.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the person-centered care plan for 2 of 4 residents (R5 and R7) reviewed to meet the resident's needs. In addition, the facility failed to complete a person-centered care plan for 2 of 4 residents (R4 and R6) to describe the residents medical needs.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide 1 of 3 residents (R3) reviewed who was unable to carry out activities of daily living (ADL's) the necessary services to maintain proper personal hygiene.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide professional standards of practice for 2 or 3 residents (R6 and R9) reviewed when residents were observed wearing two incontinence briefs placed on them at the same time.

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately assess and initiate interventions to minimize the risk for pressure ulcer development for 1 of 3 residents (R1) reviewed.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the proper temperature of food was served at breakfast on the 2nd floor WL unit. This had the potential to affect all 16 residents.

Inspectors wroteBased on interview and document review, the facility failed to report an allegation of staff to resident abuse to the state agency (SA) within two hours after the allegation was made for 1 of 3 residents (R2) reviewed for abuse when the facility reviewed a video taken by a family member.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain wheelchairs in clean and sanitary manner for 4 of 4 residents (R3, R27, R36 and R57) reviewed who utilized wheelchairs.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow standards of practice related to medication administration for 1 of 1 residents (R35) observed to receive an inhalation medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively assess to assure safety with smoking for 1 of 2 residents (R8) who was smoking outside the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate management and routine care of an indwelling urinary catheter was provided for 1 of 1 resident (R49) reviewed for catheter care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that there were accurate orders in place for oxygen (O2) usage for 1 of 1 resident (R20) reviewed for oxygen therapy.

Inspectors wroteThe facility failed to ensure the accurate administration of medications to meet resident needs for 1 of 2 (R21) reviewed for medication errors.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident's drug regimen were free of drugs used for excessive duration for 1 of 5 residents (R21) reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to properly store and label an insulin pen for 1 of 2 residents (R49) reviewed who received insulin. In addition, the facility failed to ensure medications were properly labeled with directions for use for 1 of 4 residents (R34) reviewed for eye drop storage on Arrowhead unit.

Inspectors wroteBased on interview and document review the facility failed to ensure a resident was free and protected from ongoing verbal and physical abuse by a nursing assistant (NA)-A, for 1 of 1 resident (R1) who verbalized staff abuse.