Good Samaritan Society - Windom

Inspectors wroteBased on interview and document review, the facility failed to ensure the infection preventionist provided the Quality Assurance Performance Improvement (QAPI) members with employee surveillance and illness data during monthly meetings. This had the potential to affect all 56 residents. TBReview of RN-A's employee file identified she had a hire date of 8/13/25. On 8/13/25, RN-A completed a baseline screening questionnaire and was given a first step TB skin test (TBT) which was negative for TB exposure. On 8/26/25, RN-A was given her second TST, On 8/29/25, the TST site on RN-A's arm was reviewed by the tester and determined positive as it showed induration (thickened, raised skin). Employee file note entitled Regarding [name] TB testing identified an un-named staff noted:RN-A's 1st TST was negative. Second TST was reviewed at 48 and showed redness and induration. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure there was appropriate surveillance and subsequent mitigation efforts and education identified for 1 of 1 staff (registered nurse (RN)-A) who was found to be positive for Tuberculosis (TB) during routine pre-employment testing. Additionally, the facility failed to ensure employees were cleared to return to work (RTW) after illness using professional standards and appropriately surveilled for illness, for 4 of 4 months (October 2025 through January 2026) reviewed. The facility also failed to ensure 3 of 3 whirlpool tubs were cleaned and disinfected according to manufacturer's guidelines and failed to ensure 1 of 1 nebulizer (inhaled medication) treatment devices were cleaned, rinsed, and left to air dry after each medication administration. [...]

Inspectors wroteBased on interview and document review the facility failed to provide the CMS-10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to 3 of 3 (R13, R24, R40) sampled resident when they ended their Medicare Part A skilled services with days remaining.

Inspectors wroteBased on interview and document review, the facility staff failed to report allegations of potential abuse timely to the facility management for 3 of 3 residents (R7, R26, and R39) sampled.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate allegations of potential abuse for 3 of 3 (R7, R26, R39) sample residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 14 sampled resident (R26) code status was accurately reflected in all parts of the medical record.

Inspectors wroteBased on interview and document review the facility failed to identify target behaviors or symptoms for psychoactive medication for 3 of 5 (R3, R7, R26) sampled residents for monitoring.

Inspectors wroteBased on interview and document review the facility failed to notify the ombudsman of a discharge for 2 of 2 (R6, R61) sampled residents.

Inspectors wroteBased on interview and document review, the facility failed to complete and submitted a timely quarterly Minimum Data Set (MDS) assessment for 1 of 1 (R56) resident reviewed.

Inspectors wroteBased on interview and document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PAS) level I was completed accurately for 1 of 1 resident (R3) reviewed for PASARR.

Inspectors wroteBased on interview and document review, the facility failed to have an integrated care plan to coordinate and delineate what services hospice was to provide and what services the facility was to provide, to ensure oversight and services would be provided for 1 of 1 sampled resident (R5) reviewed for hospice care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R1) who had impaired hearing was provided hearing aids daily.

Inspectors wroteBased on observation, interview, and document review, the facility failed to have signage posted outside the door for 1 of 1 medication room (South) identifying oxygen canisters were stored within.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure controlled narcotic medication awaiting destruction were easily reconciled in 1 of 3 med rooms (South) to prevent potential diversion.

Inspectors wroteBased on interview and document review, the facility failed to ensure pharmacist consultant recommendations were acted upon for 1 of 5 sampled resident (R26).

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the overall medication error rate was below 5% for 2 of 25 observations resulting in an 8% medication error rate.

Inspectors wroteBased on observation, interview, and document review the facility failed to identify, comprehensively assess, monitor, and develop interventions to prevent/mitigate the risk of pressure ulcer development and/or deterioration for 4 of 4 residents (R1, R2, R3, R5). The facility's failure resulted in Immediate Jeopardy (IJ) for R1 when the facility failed to prevent and manage impaired skin integrity that progressed to bone and soft tissue infections which required hospitalization for treatment and management. The IJ began on 12/31/25 after R1's existing buttock wound(s) were documented as black and blue tissue to the buttocks, with ongoing inconsistent identification of skin integrity and without completion of comprehensive wound assessments, physician notification, or implementation of effective treatment and pressure-relieving interventions to prevent further deterioration. [...]

Inspectors wroteBased on interview and record review the facility failed to update the care plan for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide dignity 2 of 3 residents (R5, R6) who were reviewed for dignity.

Inspectors wroteBased on interview and record review the facility failed to notify the physician and resident representative regarding changes to skin integrity and treatment orders for 1 of 3 residents (R1) reviewed for change in condition.

Inspectors wroteBased on interview, and record review the facility failed to assist 1 of 3 residents (R1) who requested to be seen by the dentist.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control practices for 2 of 3 residents (R1, R5) reviewed for infection control.

Inspectors wroteBased on observation, interview, and document review the facility failed to maintain a system to analyze monthly surveillance data for trends and patterns to reduce the spread of illness, infections, control transmission of infections and communicable diseases present in the facility. This had the potential to affect all 53 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were provided care in a dignified and respectful manner for 1 of 3 residents (R13) who were observed during care interactions.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide services to restore, maintain and prevent loss of range of motion (ROM) for 1 of 1 resident (R10) reviewed for limited ROM.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow standards of care and practice for use of an indwelling catheter for 1 of 1 resident (R15) who used an indwelling catheter.

Inspectors wroteBased on interview and document review, the facility failed to ensure that in the absence of a full-time registered dietician (RD), the supervisor of nutrition and food services (SNFS) was certified to oversee nutrition and food services. This had potential to affect all 56 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure staff followed appropriate infection control practices while handling cups and silverware during food service. In addition, the facility failed to ensure pans in the kitchen were completely dry before storing to prevent bacterial growth. Further, the facility failed to ensure hairnets were accessible to staff upon entrance to the kitchen. This had potential to affect all 56 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure hand hygiene was performed when staff were observed going room to room delivering clean laundry. In addition, the facility failed to monitor risk factor testing associated with the facility water management program to prevent waterborne pathogens including Legionella (bacteria that can cause lung infection). This had potential to affect all 56 residents who resided in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure 1 of 1 resident (R31) who was observed to have medications in her room, had been appropriately assessed and deemed safe to self-administer medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for antipsychotic medications for 1 of 1 resident (R18) and for fall resulting in major injury for 1 of 1 resident (R2) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to provide timely incontinence care for 1 of 1 resident (R21) who was dependent upon staff for assistance with activities of daily living (ADL).

Inspectors wroteBased on observation, interview and document review, the facility failed to follow physician orders for compression socks for 1 of 1 resident (R35) reviewed for edema, failed to monitor, treat skin lesions for 2 of 2 residents (R35 and R55) reviewed for non-pressure related skin condition, and failed to monitor the frequency of resident bowel movements and provide intervention for 2 of 2 residents (R36 and R49) reviewed for constipation.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure range of motion program for upper and lower extremities was implemented for 1 of 2 residents (R47) reviewed who had limited range of motion.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly explain an arbitration agreement for complete understanding of the agreement upon admission, for 2 of 3 residents (R55 and R111) reviewed for binding arbitration.