Good Samaritan Society - Windom

In the surveyor’s words

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

• Immediate jeopardy, patternF686Jan 27, 2026

  Based 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… […]

• Immediate jeopardy, isolatedF689Sep 30, 2022

  Based on interview and document review, the facility failed to ensure comprehensive assessments were completed and interventions implemented for 1 of 3 residents (R1) who eloped from the facility into an unsafe area. This failure resulted in an immediate jeopardy (IJ) when R1 left through the facility's front door on 9/23/22 without staff knowledge, tipped his wheelchair off the curb and fell on his side onto the driveway. R1 sustained a minor injury of a scraped right knee and skin tear to his right elbow. The IJ (Immediate Jeopardy) began on 9/23/22, at 1:00 p.m. when R1 had fallen from his wheelchair (w/c) after having gone outside without staff knowledge into an unsafe area within feet of a steep decline which led directly to a river. […]

• No harm, potential for more than minimal, widespreadF868Feb 12, 2026

  Based 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). […]

• No harm, potential for more than minimal, widespreadF880Feb 12, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF880Dec 11, 2024

  Based 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. Findings include: Document titled Monthly Infection Summary August 2024, September 2024, November 2024, indicated resident name, start date, date symptoms resolved, type of infection, status, antimicrobial, infection source and surveillance of criteria met. No mapping or trending of the data was provided. On 12/11/24 at 10:32 a.m., during an interview registered nurse (RN)-B stated she was the infection nurse at the facility. […]