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Health Inspection

Good Samaritan Society - Blackduck

June 13, 2024 · Blackduck, MN · 172 Summit Avenue West
Citations 1
CMS Rating 1/5
Beds 30
Provider ID 245600
Healthcare Facility
Good Samaritan Society - Blackduck
Blackduck, MN  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)  ·  14 pages
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

GOOD SAMARITAN SOCIETY - BLACKDUCK in BLACKDUCK, MN — inspection on June 13, 2024.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF880
Minimal harm or comfortable environment and to help prevent the development and transmission of communicable diseases specific infection prevention affected

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.

245600

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BLACKDUCK, MN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GOOD SAMARITAN SOCIETY - BLACKDUCK or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.