Good Samaritan Society - Albert Lea

Based on observation, interview, and document review, the facility failed to ensure food stored in the refrigerators were labeled, dated and discarded properly. In addition, the facility failed to ensure pans were completely dry before storing, utensils were covered or placed in drawers, and personal items from staff were not allowed in the food prep area. These findings had the potential to affect all 69 residents who were served food from the kitchen. Findings include: During the initial kitchen tour on 5/11/26, commencing at 9:48 a.m., with the manager of nutrition and food services (MNFS)-C, the following observations were made: In a walk-in refrigerator, observed opened and dated food stored past the facility seven-day window per their policy, as well as two opened and undated containers:Facility-made strawberry frost in a hard plastic container with green cover, dated 3/19. Chopped red onion in a plastic storage bag, dated 4/25. Red grapes in a plastic storage bag, dated 10/14. There had been a cloudy whitish/grayish liquid in bag with the grapes. Chef Grade brand hard boiled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure services and assistance were provided to preserve independence for 1 of 1 residents (R44), reviewed for vision and whose vision was highly impaired. Findings include:R44's significant change Minimum Data Set (MDS) assessment, dated 4/16/26, indicated intact cognition, clear speech, was understood and able to understand. R44's vision was highly impaired, indicating he saw large print, but not regular print in newspapers/books. R44 was independent in some activities of daily living and dependent on staff for others. R44 was able to walk short distances such as to the bathroom.R44's care plan dated 11/25/25, indicated R44 had impaired visual function related to macular degeneration evidenced by moderately impaired vision. R44 would maintain optimal quality of life within limitations imposed by visual function. R44 was able to see very large print/newspaper headlines with magnifying glass and glasses; provide R44 with both. The care plan did not indicate R44 had blindness in his left eye.R44's Optometrist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review the facility failed to ensure safe operating temperature of high-temperature dish washing machine. This had the potential to affect all 73 residents, staff and visitors who may use washed equipment from the facility kitchen. Findings include: During an observation and interview on 4/23/25 at 11:42 a.m., the dietary manager (DM) stated 3 empty dish racks are sent through the dish machine prior to actual dirty dishes to ensure proper operating temperatures. Proper wash temperature should be 150-degrees and proper rinse temperature should be 180-degrees. The DM sent 3 empty dish racks through and noted the wash and rinse temperature were both approximately 140-degrees. The DM sent 3 more empty dish racks through and continued to get 140 degrees for wash and rinse. The DM stated the dish machine has a booster that increases the temperature to the proper temperature. The DM noted there was a flashing red light on the booster that normally does not flash. Temperatures are logged on log sheet. The DM noted dietary aide (DA)-A documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the facility failed to ensure appropriate personal protective equipment was used when separating soiled laundry and ensure resident's clean clothing was transported in a way to prevent dust and dirty to collect. This had the potential to impact all 73 residents who reside in the facility. Findings include: An observation on 4/21/25 at 11:38 a.m., laundry aide (LA)-A was pushing a large metal cart down the hallway. The cart contained multiple shirts that were on hangers. The clothing was uncovered. An observation on 4/22/25 at 11:20 a.m., LA-A was delivering clean resident clothing to rooms. A large metal cart with multiple hanging shifts were not covered. LA-A took off a few shirts, hung them on her arm and then took off a few more and carried those by hand into a resident room. An observation of the laundry room on 4/23/25 at 10:54 a.m., LA-A stated bins of soiled resident clothing and linens were sent down each shift. The laundry was then sorted into piles of shirts, pants, towels, sheets, blankets. The laundry was then done from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure the call light was within reach of 1 of 1 resident (R49) reviewed for falls. R49's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition and diagnoses of chronic kidney disease (CKD), altered mental status, and a history of falling. It further indicated R49 was independent with most activities of daily living (ADL) and mobility. R49's Falls Risk Tool dated 3/13/25, indicated R49 scored a 20 which was considered a high risk for falls. R49's care plan dated 3/31/25, indicated R49 was at risk for falls related to requiring stand by assist with transfers and ambulation but frequently independently transferred/walked in her room. It further included the following interventions: -Educate resident/family about safety reminders and what to do if a fall occurs. -Educate resident/family/IDT as to causes of fall. -Remind resident to call/wait for staff assistance rather than self transferring.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to provide timely incontinence care for 1 of 2 residents (R23) reviewed for activities of daily living (ADL). R23's significant change Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition and diagnoses of dementia and epilepsy. It further indicated R23 had no rejection of care behaviors, required partial to moderate assistance with toileting, was frequently incontinent of bladder, and always incontinent of bowel. R23's Care Area Assessment (CAA) dated 3/13/25 triggered for urinary incontinence due to requiring staff assistance with incontinent personal hygiene. It further indicated R23 had functional incontinence. R23's care plan dated 3/31/25, indicated had bladder incontinence related to a traumatic brain injury (TBI) as evidenced by (E/B) functional incontinence with the following interventions: -avoid food/beverages that may irritate bladder i.e., fruit juices, spicy foods, tomato based products,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review the facility failed to report an allegation of abuse timely to the State Agency for 1 of 2 residents (R2) reviewed for allegations of abuse. Findings include: A Nursing Home Incident Report (NHIR) submitted to the SA on 2/4/25 at 1:20 p.m., indicated on 2/2/25 at 9:53 p.m., R3 was found lying next to R2 in her bed. R3 may have been attempting to masturbate while in R2's bed. Submitted approximately 40 hours after the alleged incident. R2's admission Record printed 2/10/25, identified diagnoses of dementia. R2's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment with no behaviors. R2's Minnesota Vulnerable Adult assessment dated [DATE], indicates R2's vulnerabilities included inability to ambulate without a device and self-propel the wheelchair; unable to report abuse/neglect concerns; confused to person, place and/or time; forgetfulness; varied cognition; high anxiety level; disruptive; and thought or mood disorder that impair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure enhanced barrier precautions ((EBPs), an infection control intervention designed to reduce the spread of infections which employs targeted gown and glove use during high contact resident care activities) were implemented for 2 of 2 residents (R4, R6) observed with implanted medical devices. Findings include: R4 R4's quarterly Minimum Data Set (MDS) dated [DATE], indicated R4 was dependent on staff with all activities of daily living (ADLs). R4's diagnoses included multiple sclerosis, ostomy (surgical opening for his bowels), and urinary catheter. R4's infection care plan dated 4/5/24, indicated R4 required EPBs related to supra pubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) and ostomy (a surgical opening for his bowels on abdomen). Interventions directed staff to don a gown and gloves when performing high contact care activities including dressing, bathing, transferring,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure routine weekly skin assessments for impaired skin integrity for 2 of 3 residents (R1, R2) who had impaired skin integrity. Findings include: R1's Minimum Data Set (MDS) quarterly review dated 6/12/24, identified R1 had severe cognitive impairment. Diagnoses included cancer, and an open lesion with application of non-surgical dressings. R1's care plan revised on 3/21/23, indicated R1 had a potential impairment to skin integrity with a non-healing lesion on the top of his head. Interventions included to monitor location, size and treatment of skin injury, report abnormalities including failure to heal, signs/symptoms of infection, maceration, etc. to health care provider. Avoid scratching and keep hands and body parts from excessive moisture. R1's Wound Data Collection identified on 5/4/24, an initial data collection for the growth on top of R1's head. The assessment did not include wound measurements and a description of the wound. Review of R1's record did not include weekly comprehensive wound assessments for the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and document review the facility failed to maintain accurate medical records for 1 of 3 residents (R1) reviewed related to wound management. Findings include: R1's Minimum Data Set (MDS) quarterly review dated 6/12/24, identified R1 had severe cognitive impairment. Diagnoses included cancer, and an open lesion with application of non-surgical dressings. R1's care plan revised on 3/21/23, identified a potential impairment to skin integrity with a non-healing lesion on the top of his head. Interventions included to monitor location, size and treatment of skin injury, report abnormalities including failure to heal, signs/symptoms of infection, maceration, etc. to health care provider. Review of R1's progress notes included a change in skin condition that was identified on 7/8/24 however was not documented until 7/10/24. R1's progress note with a created date of 7/10/24 at 10:04 a.m. and documented effective date of 7/8/24, identified R1's family member had been notified of maggots in the wound on top of R1's head and what staff were doing for it. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure a copy of the resident advanced directive was in medical record and failed to follow the facility policy for 2 of 2 (R46 and R48) residents reviewed for advanced directives. Findings include: R46's quarterly Minimum Data Set (MDS) dated [DATE], indicated moderate cognition (able to partially understand). Diagnoses included heart failure, depression, and cerebral vascular accident (stroke). R28 had a health literacy score was not completed. R46 face sheet indicated to attempt resuscitation with use of cardiopulmonary recitation (CPR) and full treatment as needed. R46's electronic health record (EHR) banner indicated full code (to attempt life saving measures and use of CPR based on MN POLST (physician orders for life sustaining treatment)). On [DATE] at 10:09 a.m., requested R46 advance directive or supporting document form, none provided. R46's record lacked evidence a form to indicate advanced directives was included in facility record system…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review the facility failed to coordinate care with an outside health agency for the use of bilateral (both sides) lower leg splints to prevent worsening of contractures for 1 of 2 residents (R5) reviewed for position and mobility. Findings include: R5's admission Minimum Data Set (MDS) dated [DATE], identified moderately cognitively impaired, and had contractures on their right arm, and right leg related to cerebral vascular accident (CVA-stroke). R5's diagnoses included, hypertension (HTN), hyperlipidemia (HLD)(high level of lipids in the blood), CVA, venous insufficiency (poor circulation), torticollis (asymmetrical neck position), osteoporosis (OP) (weakened bones), vascular dementia (impairment of thought processes), hemiparesis (one sided paralysis of the body) from a CVA to right side, coronary artery disease (CAD), right leg ulceration (skin breakdown-wound), stiffness of the left ankle, and weakness. R5's physician orders were as follows: -Activity as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures with the use of an antipsychotic medication for 1 of 5 residents (R1) reviewed for unnecessary medications. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, received extensive assistance with activities of daily living (ADLs), and received an antipsychotic medication. R1's care plan printed 2/1/24, indicated potential for psychotropic drug adverse drug reaction (ADR's) related to daily use of psychotropic medications, and included to monitor for hypotension (low blood pressure). R1's physician orders included orders for Seroquel (antipsychotic) 75 milligram (MG) by mouth three times daily for psychotic disorder with delusions due to known physiological conditions; delusional disorders. R1's treatment administration record (TAR) from August 2023 through February 2024, directed nursing staff to monitor orthostatic blood pressures monthly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.