Good Samaritan Society - Inver Grove Heights

In the surveyor’s words

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

• Actual harm, isolatedF760Apr 9, 2024

  Based on interview and document review, the facility failed to ensure 1 of 3 (R1) residents reviewed for medication errors did not have properly transcribed orders for an antibiotic for an infected pressure ulcer. This medication error resulted in actual harm to R1 when she developed sepsis and was hospitalized . The facility implemented corrective action prior to the survey, so the deficiency was issued at past non-compliance. Findings include: Pressure Ulcer staging per the National Pressure Ulcer Advisory Panel (NPUAP): Stage 2 pressure ulcer: a partial-thickness skin loss with exposed dermis, the wound bed is viable, pink, and moist. Stage 4 pressure ulcer: a full-thickness skin and tissue loss with exposed muscle, ligament, cartilage or bone. Slough and/or eschar may be visible. […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2024

  Based on observation, interview, and document review, the facility failed to ensure final cooking temperatures were checked or obtained in a manner to reduce the risk of cross-contamination between food items prepared in the main production kitchen. This had potential to affect all 36 residents who were served the meal. Findings include: On [DATE] at 11:36 a.m., food production in the main kitchen was observed with cook (CK)-A present. CK-A placed a metallic tray filled with breadsticks into the oven and pulled out a pan which had two, foil pans on top with lasagna in them. CK-A used a spike-style thermometer to pierce the seal over the lasagna and obtain a temperature which read, 182 [F]. […]

• No harm, potential for more than minimal, widespreadF812Jan 12, 2023

  Based on observation, interview, and document review, the facility failed to ensure commercial food utensils and serving counters used in 1 of 1 main production kitchen(s) were kept in a clean, sanitary condition to reduce the risk of cross-contamination and food-borne illness. These findings had potential to affect all 28 residents, visitors, and staff who consumed food from the main production kitchen. Findings include: On 1/9/23 at 8:23 a.m., an initial tour was completed in the main production kitchen and cook (CK)-A and food service assistant (FSA)-A were present and helping to serve the breakfast meal. […]

• No harm, potential for more than minimal, widespreadF880Nov 16, 2022

  Based on observation, interview and document review, the facility failed to follow Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19 to prevent or minimize the transmission of COVID-19 for 4 of 5 residents (R2, R4, R5, R7) reviewed for transmission-based precautions (TBP). Furthermore, the facility failed to ensure a resident positive for COVID-19 (R1) remained in TBP. This had the potential to affect all 39 residents who reside in the facility. Findings include: R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 was cognitively intact and was receiving hospice care. […]

• No harm, potential for more than minimal, widespreadF886Nov 16, 2022

  Based on interview and document review, the facility failed to test staff for COVID-19 according to Centers for Medicare and Medicaid (CMS) guidance for outbreak testing requirements for 3 of 3 staff [licensed practical nurse (LPN)-A, LPN-D, and nursing assistant (NA)-E] reviewed for COVID-19 testing. This deficient practice had the potential to affect all 39 residents in the facility, all staff, and any visitors to the facility. Findings include: The CMS QSO-20-38-NH memo revised 9/23/22, directed, upon identification of a single new case of COVID-19 infection in any staff or residents, outbreak testing should begin immediately. Furthermore, the memo directed testing should be repeated every 3-7 days until no new cases are identified for 14 days. […]