BLACKDUCK, MN — Federal health inspectors found that Good Samaritan Society - Blackduck failed to test or isolate multiple residents displaying symptoms of COVID-19 and another respiratory virus, placing all 29 residents in the 172 Summit Avenue West facility at risk during a June 2024 inspection.
Residents With COVID Symptoms Left Without Testing or Isolation
The inspection, completed on June 13, 2024, documented that Good Samaritan Society - Blackduck did not implement transmission-based precautions or testing for four residents — identified as R4, R23, R22, and R15 — who were displaying COVID-19 symptoms. In addition, two residents confirmed to have human metapneumovirus (HMPV), a contagious respiratory illness, were also not placed under proper isolation precautions in a timely manner.
Transmission-based precautions are a foundational element of infection control in congregate care settings. When a nursing home resident develops respiratory symptoms such as cough, fever, or shortness of breath, established Centers for Disease Control and Prevention (CDC) guidelines call for immediate isolation from other residents, diagnostic testing, and the use of personal protective equipment by staff entering the resident's room. These steps are not optional — they represent the baseline standard of care designed to prevent a single case from becoming a facility-wide outbreak.
In a nursing home environment, the consequences of delayed action can escalate rapidly. Older adults, particularly those with chronic conditions common among long-term care residents, face significantly higher rates of hospitalization and death from respiratory infections like COVID-19 and HMPV. A failure to isolate symptomatic individuals allows viral particles to spread through shared spaces, during routine care activities, and via staff members who move between rooms throughout their shifts.
Untrained Staff Member Left in Charge of Infection Prevention
Inspectors traced the root of the facility's infection control breakdown to a critical staffing and oversight gap. The facility's director of nursing (DON) had been responsible for the infection prevention program but had been away from the facility on intermittent leave. Responsibility was delegated to a registered nurse identified as RN-A, who formally took over the program in June 2024.
However, RN-A received no formal training for her new role beyond the standard annual in-service training required of all staff and the CDC's online Nursing Home Infection Preventionist Training course. During an interview with inspectors on June 13, the DON confirmed that RN-A "had not been provided training but had the ability to call the DON with questions."
The facility's own corporate infection preventionist lead told inspectors she was unaware that the DON had been absent for an extended period or that RN-A had taken over infection prevention duties. RN-A did not appear on the corporate office's list for specialized training. Between January 1 and June 13, 2024, communication between the corporate infection preventionist and the facility covered only employee illness and vaccination topics — not resident illness tracking, isolation protocols, or guidance on outbreak response.
Federal regulations require that a facility's designated infection preventionist be "qualified by education, training, experience, or certification" and have "completed specialized training in infection prevention and control." The CDC's Nursing Home Infection Preventionist Training is designed specifically for individuals running infection prevention programs and covers core activities of effective programs, recommended practices to reduce pathogen transmission, healthcare-associated infections, and outbreak investigation tools. Simply completing this online course without hands-on mentorship or facility-specific training does not prepare a nurse to independently manage an active infection prevention program — particularly during a period of active respiratory illness among residents.
Administrator Acknowledged "Disconnect" in Oversight
During an interview with inspectors at 1:14 p.m. on the day of the inspection, the facility administrator acknowledged the gap. He stated he was aware the DON had been on intermittent leave and that infection prevention duties had been passed to RN-A. He told inspectors that an infection prevention dashboard was presented at quality assurance meetings and that, because of this, he "assumed all the required infection prevention tasks were completed as expected."
However, the administrator admitted there was "no plan or process to ensure RN-A received training and/or support in her new role." He described a "disconnect between where RN-A was in her understanding of infection prevention and where RN-A really was."
This acknowledgment is significant. Quality assurance dashboards can reflect data that has been entered, but they do not verify that underlying surveillance, testing, and isolation protocols are being carried out correctly. Without direct oversight, competency checks, or a formal training plan for the new infection preventionist, the facility had no mechanism to catch failures before they placed residents at risk.
Why Timely Infection Tracking Matters in Nursing Homes
The inspection cited the facility under F-tag 880, which addresses the requirement to establish and maintain an infection prevention and control program, and F-tag 882, which covers the qualifications and training of the designated infection preventionist. Both citations were classified at the level of minimal harm or potential for actual harm, affecting many residents.
Respiratory illness surveillance in nursing homes involves daily monitoring of residents for new symptoms, documenting trends, and acting on established thresholds that trigger testing and isolation. When this tracking system breaks down, a facility loses its ability to detect an emerging outbreak in its earliest and most controllable stage. By the time multiple residents are visibly symptomatic, the window for effective containment has already narrowed considerably.
HMPV, the virus confirmed in two of the facility's residents, is particularly relevant in long-term care. It spreads through respiratory droplets and contact with contaminated surfaces, and it can cause severe lower respiratory tract infections in older adults. Like COVID-19, it requires prompt isolation of confirmed and suspected cases to prevent transmission to vulnerable individuals who may not yet be showing symptoms.
Facility Required to Submit Correction Plan
Good Samaritan Society - Blackduck was required to submit a plan of correction to address the deficiencies identified during the inspection. The full inspection report, including all cited deficiencies and the facility's response, is available through the Centers for Medicare & Medicaid Services. Residents' families and members of the public can contact the facility directly or the Minnesota state survey agency for additional information regarding corrective actions taken.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Blackduck from 2024-06-13 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.