Good Samaritan Society - Blackduck

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and document review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect pressure ulcer staging for 1 of 3 residents (Resident R1) reviewed with pressure ulcers.Findings include:Resident R1's admission Record indicated she admitted to the facility on [DATE REDACTED]. Resident R1's diagnosis included dehydration, Parkinson's disease, anxiety and weakness. Resident R1's Braden Scale for Predicting Pressure Sore Risk dated 10/16/25, indicated a score of 13, which indicated moderate risk.Resident R1's Wound Data Collection dated 10/16/25 at 5:15 p.m., identified an unstageable decubitus (a type of skin injury caused by prolonged pressure on the skin, which restricts blood flow and can lead to tissue damage and death) ulcer on the left buttock that measured 3 centimeters (cm) x .75 cm. Surrounding skin pink and intact. Wound bed 100% granulation tissue (described as being red and moist, with a bumpy or granular appearance due to new capillary buds, fibroblasts, and collagen), which indicated a stage III pressure ulcer. Wound margins were intact and pink.Resident R1's Wound Data Collection dated 10/16/25 at 5:24 a.m., identified a wound (no description)

on the left iliac crest (the curved area on the sides of the hip bones of the pelvic girdle) that measured 3.5 cm x 1 cm x .75 cm. Drainage present on dressing, surrounding tissue intact and tunneling (a chronic wound with an opening that extends into a narrow passageway or channel beneath the skin's surface) present. Wound characteristic not completed. Drainage amount indicated moderate, color indicated purulent (white, yellow, green, brown, or sometimes pink-tinged).Resident R1's Wound RN (registered nurse) assessment dated [DATE REDACTED] at 5:32 a.m., indicated an unstageable pressure ulcer to the left buttock, present on admission. The assessment indicated, continue with current plan of treatment.Resident R1's Wound Data Collection dated 10/22/25 at 8:09 a.m., identified a stage I pressure ulcer (the earliest stage of a pressure injury, characterized by reddened, unbroken skin that does not turn white when pressed) to the left buttock that measured 3 cm x .35 cm. Wound characteristics indicated 100% granulation tissue. Surrounding tissue identified as macerated (softened, wrinkled tissue due to moisture) and reddened. RN to assess change in wound status.Resident R1's Wound Data Collection dated 10/22/25 at 11:50 a.m., identified a wound on the coccyx (the final bone at the bottom of the spine) that measured 2.5 cm x 1 cm. Description was left blank. Wound characteristics indicated 100% granulation tissue. Surrounding tissue macerated and reddened. RN to assess change in wound status.Resident R1's Wound RN assessment dated [DATE REDACTED] at 3:40 p.m., identified a non-pressure related wound on the iliac crest. Tissue loss indicated full thickness loss (a severe wound that extends through all layers of the skin and into underlying structures like fat, muscle, tendon, or bone).

Physician was notified regarding wound status, requesting wound consult.Resident R1's Wound RN assessment dated [DATE REDACTED] at 3:42 a.m., identified an unstageable pressure ulcer on the left buttock. During interview on 10/31/25 at 11:55 a.m., RN-B indicated she was new to her role and stated when coding the MDS, she looked at the nursing data collection. RN-B said the data collection she looked at said Resident R1 had an unstageable pressure ulcer on admission which was why she coded it that way. RN-B said there were some issues with the facilities wound charting.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

voiding pattern and continence and implement toileting program if needed. During interview on 10/31/25 at approximately 1:00 p.m., the director of nursing (DON) acknowledged Resident R1 did not have a baseline care plan and stated the initial care plan was done with assessments and said the nurses can click buttons to add interventions to the care plan. The DON said the nurses must not have clicked the buttons on the assessments to link to the care plan. The DON stated after the initial care plan the MDS coordinator, RN-B completed the care plans.Facility policy Care Plan dated 12/2/24, indicated the baseline care plan includes instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care. The policy indicated each resident will have and individualized, person-centered, comprehensive care plan to include measurable goals and timetables directed toward achieving and maintaining the residents optimal medical, nursing, physical and functional needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument and review of physician orders.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/31/2025

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

related to deconditioning. The care plan indicated Resident R3 required the use of a mechanical lift for transfers and required assistance from staff for bed mobility and toileting. The care plan directed staff to check every two to three hours for incontinence. The care plan further identified an alteration in skin integrity related to reduced physical mobility and directed staff to assist to turn and reposition frequently during the day and at 12:00 a.m. and 4:00 a.m., use of a pressure reducing mattress and protective boots at night.Resident R3's Braden Scale for Predicting Pressure Ulcers dated 9/24/25, identified a score of 12 which indicated high risk.Resident R3's Wound RN assessment dated [DATE REDACTED], identified a stage I pressure ulcer on the sacrum that measured 1 cm x 1 cm. The wound was described as an open area.Resident R3's, Wound Data Collection dated 10/24/25. identified an open area on the coccyx that measured 1 cm x .5 cm. No drainage or bleeding identified.

Surrounding tissue pink and intact. Wound bed 100% epithelialized (a newly formed layer of epithelial cells that regenerates to cover a wound surface, typically appearing translucent and lighter in color), indicating a stage II pressure ulcer. Wound margins or surrounding skin indicated it was denuded (skin that had the first protective layer removed). Resident R1's medical record lacked evidence of wound assessments between 10/2/25 and 10/24/25.During interview on 10/31/25 at 10:27 a.m., licensed practical nurse (LPN)-A said Resident R3 normally did not have a lot of skin issues but said currently they had been monitoring a little pressure sore

on his coccyx. LPN-A said she had seen it a few weeks ago and it was the size of a dime.During interview

on 10/31/25 at 11:55 a.m., RN-B said we have some issues with our wound charting. RN-B said the goal was to set aside a day each week to have two nurses look at the wounds, but it had not been implemented yet. 10/31/25 at approximately 1:00 p.m., the director of nursing (DON) said if a wound was observed, staff should complete the data collection form and an RN should complete the assessment if the initial assessment was completed by an LPN. The DON sated the facility did not have a process for regular wound rounds. The DON further stated nurses were supposed to complete skin checks weekly on bath day and acknowledged Resident R3's skin checks were not being completed.Facility Policy Skin Assessment Pressure Ulcer Prevention and Documentation Requirements dated 4/6/25, indicated if a pressure ulcer was identified, the RN should record the type of wound and the degree of tissue damage on the Wound RN Assessment. The licensed nurse records the location, area, measurements and the ulcer/wound characteristics on the Wound Data Collection assessment. Pressure ulcers should be evaluated at least weekly.

Event ID:

Facility ID:

If continuation sheet