Good Samaritan Society - Blackduck

F-F880: Based on interview and document review, the facility failed to perform timely tracking and trending of potential infectious symptoms to prevent the spread of transmissible organisms in a timely and ongoing manner; including a failure to implement timely transmission-based precautions (TBP) and testing for respiratory illness according to the Centers for Disease Control (CDC) for 4 of 4 residents (Resident R4, Resident R23, Resident R22, Resident R15) who were displaying COVID-19 symptoms; and failed to implement timely TBP for 2 of 2 residents (Resident R12, Resident R14) who were confirmed to have human metapneumovirus (HMPV) (a respiratory illness). This had

the potential to affect all 29 residents, visitors and staff.

During a phone interview on 6/13/24 at 8:39 a.m., the facility's infection preventionist lead (IP) stated her corporate role involved creating facility policies, updating those policies, acting as a resource for facilities to interpret guidance and/or to train new infection prevention nurses to their role. The IP was aware the director of nursing (DON) was responsible for the facility's infection prevention program but was unaware the DON had been out of the facility for an extended period of time when the duties were delegated to registered nurse (RN)-A nor that RN-A had formally taken over the program in June of 2024. RN-A was not on the IP's list for training. Between 1/1/24 and 6/13/24, the IP and DON had emailed communication regarding employee illness and return to work criteria and the facility's vaccination program. The IP could not recall the facility reaching out for guidance regarding resident illness, isolation recommendations, and/or questions regarding expectations of duties.

During an interview on 6/13/24 at 8:49 a.m., with the DON and RN-A , RN-A stated the only training she had received to take over the IP program was the corporate annual inservice trainings that were required by all staff and the CDC Nursing Home Infection Preventionist Training. The DON stated that RN-A had not been provided training but had the ability to call the DON with questions.

During an interview on 6/13/24 at 1:14 p.m., the administrator stated he was aware the DON was previously responsible for the facility's infection prevention progam, and had required intermittent leave from the facility.

They had delegated infection prevention responsiblities to registered nurse (RN)-A. The administrator stated

an infection prevention dashboard was presented at the quality assurance meetings and, because of this, the administrator assumed all the required infection prevention tasks were completed as expected. However, there was no plan or process to ensure RN-A received training and/or support in her new role. The administrator stated there was disconnect between where RN-A was in her understanding of infection prevention and where RN-A really was.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 245600 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245600 B. Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Good Samaritan Society - Blackduck 172 Summit Avenue West Blackduck, MN 56630

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 The facility policy Infection Prevention and Control Program revised 10/30/23, identified the facility was to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and Level of Harm - Minimal harm or comfortable environment and to help prevent the development and transmission of communicable diseases potential for actual harm and infections.

Residents Affected - Many A. The Infection Prevention and Control Program Is developed to address facility-specific infection prevention needs and requirements identified by the facility assessment and infection control risk assessment.

B. The Infection Prevention and Control Program is reviewed annually and as needed by the Infection Preventionist, or appointed designee, to reflect nationally accepted standards of practice. The Skilled Nursing Facility has designated at least one Individual as the Infection Preventionlst, who is responsible for

the facility's Infection Prevention and Control Program. The SNF Infection Preventionist must:

a. Have primary professional training In nursing, medical technology, microbiology, epidemiology, or other related field;

b. Be qualified by education, training, experience, or certification;

c. Work at least part-time onsite at the facility; and

d. Have completed specialized training In Infection prevention and control.

The Centers for Disease Control and Prevention (CDC) Nursing Home Infection Preventionist Training updated 3/2/24, identified the course was for individuals responsible for infection prevention and control (IPC) programs in nursing homes. The specialized nursing home training covered:

- Core activities of effective IPC programs.

- Recommended IPC practices to reduce pathogen transmission.

- Healthcare-associated infections and antibiotic resistance.

- Policy and procedure templates, audit tools, and outbreak investigation tools.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 245600