Good Samaritan Society - International Falls

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 29, 2022

  Based on interview and document review, the facility failed to The facility failed to provide adequate supervision by appropriately trained staff when a home maker (HM-A) staff assisted a resident, not utilizing care planned interventions and resulting in a fall with fracture. This had the potential to affect all residents in the facility that required assistance from staff for ambulation. In addition, the facility failed to implement care planned interventions for 1 of 3 residents (R3). The immediate jeopardy began on 6/20/22, when an unlicensed/non-certified (HM-A) staff assisted R1 to the bathroom while not utilizing care planned interventions resulting in a fall with fracture. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 4:00 pm. […]

• Actual harm, isolatedF689Jan 19, 2024

  Based on interview and document review the facility failed to ensure adequate supervision to reduce the risk of falls for 1 of 3 residents (R1) who had a history of falls with serious injury. This resulted in actual harm for R1 who fell and sustained a laceration to her head and a subdural hematoma (pool of blood between the brain and its outermost covering). In addition, the facility failed to develop a sustainable plan for ongoing supervision. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified severe cognitive impairment and indicated she was dependent on staff for transfers. The MDS indicated R1 did not have a fall since the prior assessment. R1's care plan dated 10/29/23, identified a communication problem related to dementia and a self care deficit. […]

• No harm, potential for more than minimal, widespreadF838Nov 25, 2024

  Based on interview and document review the facility failed to review and update the facility assessment to incorporate the minimal staff requirements; and all resources and conditions to care for the resident populations. This had the potential to affect all 50 residents who resided in the facility. Findings include: The Facility assessment dated [DATE], identified the need to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The assessment listed resident count, activities of daily living (ADL) assistance needed, behavioral symptoms and active diagnoses. The facility utilized an interdisciplinary approach to meet the needs of residents across all shifts, including nights and weekends. […]

• No harm, potential for more than minimal, widespreadF867Nov 25, 2024

  Based on interview and document review, the facility failed to develop action plans for identified areas of monitoring and failed to identify and implement at least one process improvement project (PIP) This had the potential to affect all 50 residents who resided in the facility. Findings include: The Quality Assurance, Action Committee Meeting Minutes dated 7/11/24, identified the team had reviewed the following topics: -infection control. -emergency operation plan and facility assessment. […]

• No harm, potential for more than minimal, widespreadF880Nov 25, 2024

  Based on observation, interview and document review, the facility failed to develop and implement an infection control surveillance plan for identifying, tracking, monitoring and/or reporting infections and communicable disease along with a monthly analysis; and failed to conduct COVID-19 testing of staff and residents per Centers for Disease Control (CDC) guidelines. In addition, the facility failed to implement enhanced barrier precautions (EBP) for 1 of 1 resident (R205) reviewed with pressure ulcers; and failed to wear a mask during a peripherally inserted central catheter (PIIC) line dressing change for 1 of 1 resident (R206) reviewed with a PIIC. These deficient practices had the potential to affect all 50 residents residing in the facility. […]