Good Samaritan Society - Specialty Care Community

was informed of and participated in treatment decisions regarding psychotropic medications, including

residents (R41) reviewed for psychotropic medication use.Findings include:R41's quarterly Minimum Data Set (MDS) dated [DATE], identified R41 had severe cognitive impairment and required assistance with activities of daily living (ADL's). R41's diagnoses included non-traumatic brain dysfunction (impaired brain function not caused by a physical injury), Alzheimer's disease (a progressive brain disorder affecting memory and thinking abilities), stroke (damage to the brain caused by interrupted blood flow), and non-Alzheimer's dementia (a decline in memory and cognitive function not caused by Alzheimer's disease).

The MDS further indicated R41 had experienced two or more falls since admission.R41's physician orders dated 4/7/26, identified an order for risperidone, a psychotropic medication, which had been initiated on 1/29/26, when R41 was admitted to the facility.Review of R41's electronic medical record (EMR) failed to identify documentation that informed consent for the psychotropic medication had been obtained from the resident and/or resident representative prior to the medication being initiated.

Further review identified the consent had been obtained after the medication was started.

During an interview on 6/4/26, at 12:26 p.m., RN Case Manager (CM)-C stated psychotropic medication consents were obtained upon admission and reviewed with the resident and/or family member. CM-C reviewed R41's EMR and stated she was unable to locate the consent in the EMR, so she contacted the family on 6/2/26 and obtained verbal consent over the phone. CM-C stated the consent form was important to ensure the resident and/or family agreed with the medications being administered and understood the associated risks and benefits of the medication.

During an interview on 6/4/26 at 12:59 p.m., the director of nursing (DON) stated consent should have been obtained when the medication order was received, either upon admission if the resident was admitted on the medication or when a new psychotropic medication was initiated.

The DON stated the consent should have been signed by the resident or the resident's family member prior to administration of the medication.

Review of the facility's Psychotropic Medications Policy, reviewed/revised 12/09/2025, identified residents and/or their family or legal representative were to be notified when psychotropic medications were initiated or when residents were admitted on psychotropic medications.

The policy further identified the Permission for Use of Psychotropic Medications (GSS #478) consent form was required to be completed and signed for the use of psychotropic medications.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

minimal harm Nursing Home Resident [NAME] of Rights (RBOR) was displayed for residents, visitors, and staff to review.

This had the potential to affect all 88 residents currently residing in the facility, as well as all

displayed in a locked glass case right off the main entrance, near the elevators, which lacked the date of print. A facility combined RBOR was posted next to the entrance of the therapy room, just off the main lobby, which was dated 11/16. On 6/2/26 at 2:15 p.m. the administrator stated she was unaware any changes made to the RBOR form and was unaware of the need to obtain and post the updated version.

The facility policy, Posting Information, Social Services-Rehab/Skilled, revised 12/23/25, identified all residents residing in the facility had the right to be aware of a certain location where information concerning it's [the facility] operation, as well as their [the residents] right of appeal and advocacy.

The policy indicated it was the responsibility of the location [facility] to keep this information posted in a visible place, accessible to all residents, whether ambulatory or in a wheelchair, and to keep it updated at all times. A listing of the required information to be posted in this location included the Resident's Rights for Skilled Nursing Facilities.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

agencies.

minimal harm Based on observation, interview, and record review, the facility failed to ensure all recent facility survey results were posted in an accessible location for residents, staff, and visitors.

This had the

include: On 6/2/26 at 10:13 a.m., a review was completed of the facility survey binder, located on a table on the side wall of the lobby. A review of the binder was completed to ensure all surveys from the last recertification, completed 2/14/25, and subsequent follow up surveys (including complaint investigations and their findings) were available for review.

Upon review of the documentation, it was noted that the binder lacked information from the following complaint investigations surveys completed on 12/31/25, 4/2/26, 4/8/26 and 5/15/26.On 6/2/26 at 2:16 p.m. the administrator reviewed the survey binder and acknowledged the above listed survey results were lacking in the binder.

Administrator stated the survey results in the binder were to reflect the survey results of the past three years.

Administrator stated this was important, so the results were available for residents, visitors, and family members to review if they wished to do so.

The facility policy, Posting Information, Social Services-Rehab/Skilled, revised 12/23/25, identified all residents residing in the facility had the right to be aware of certain location information concerning its [facility's] operation, as well as their [the residents] right of appeal and advocacy.

The policy indicated it was the responsibility of the location to keep this information posted in a visible place, accessible to all residents, whether ambulatory or in a wheelchair, and to keep it updated at all times. A list of the required information to be posted included the most recent federal or state survey (CMS Form #2567) and, if applicable, plans of correction.

limited to receiving treatment and supports for daily living safely.

observation and interview the facility failed to maintain a broda chair (a specialized brand of

long-term, comfortable sitting) in good repair for 1 of 1 resident (R40) reviewed who utilized a broda chair.Findings include:F40's quarterly Minimum Data Set (MDS) dated [DATE], indicated R40 had moderate cognitive impairment and was dependent on staff for activities of daily living (ADLs). R40's diagnoses included anemia, dementia, Huntington's disease, anxiety, depression and bipolar disorder.

On 6/3/26 at 3:13 p.m. R40's broda chair was observed with four cracks on head rest cushion, the cracks were vertical on the cushion about six inches in length with the inner foam visible in the cracks.

Cushioning on right side of R40's head was observed to have several cracks of varying length with inner foam visible in the cracks.

Cushioning on left side of R40's head was observed to have an area of about eight inches by 6 inches of cracks with a diagonal jagged crack about seven inches in length with an area below about 6 inches by five inches of cracks, foam was visible in all cracked areas.

The upper corners of the left side cushion with stuffing and foam observed sticking out.

Follow up observation on 6/4/26 at 11:22 a.m. indicated R40 continued to be placed in the broda chair with cracked cushions with inner foam and stuffing visible.

When interviewed on 6/4/26 at 11:28 a.m. certified nursing assistant (CNA)-C stated when equipment was broken or in poor repair, they were to complete a maintenance work order or inform hospice if the resident was on hospice for the equipment to be repaired or replaced. CNA-C stated were not aware R40's broda had cracked cushions When interviewed on 6/4/26 at 11:31 a.m. registered nurse (RN)-C stated R40 wore a helmet that had probably caused cracks in the cushions of the broda chair and due to R40 being on hospice they would have to be notified the broda chair cushions required repair or replacement. RN-C stated they were not aware if hospice was informed of the broda chair condition.

When interviewed on 6/4/26 at 11:40 AM clinical care manager (CM)-B stated they had noticed several chairs that needed repair or replacement but had not yet informed hospice of the need. CM-B stated the concern with cracked cushions was infection control and the cushions could not be cleaned appropriately.

When interviewed on 6/4/26 at 12:53 p.m. director of nursing (DON) stated the expectation was for equipment to remain in good repair, maintenance requests or update to hospice was expected to be completed in a timely manner to ensure cleanliness and infection control was maintained.

Facility policy regarding resident equipment was requested, however, none was provided.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

consultant pharmacist had not returned the call.

During an interview on 6/4/26 at 12:59 p.m., director

resident refused the monitoring, staff should allow time, reapproach the resident, and, if the resident

DON stated staff would not expect blood pressure readings to be exactly the same in all three positions.

During an interview on 6/4/26 at 1:16 p.m., CM-C stated the facility did not have anything in place for monitoring psychotropic medication side effects. CM-C stated there was no documentation of side effect monitoring for residents receiving psychotropic medications and acknowledged there probably should have been documentation so staff would know whether the medication was having a negative effect on the resident.

During an interview on 6/4/26 at 1:29 p.m., DON stated documentation for monitoring medication side effects was something the facility was just beginning to implement.

DON stated the facility had begun reviewing medication side effects during morning meetings. DON stated side effect monitoring was important so staff would know whether residents were experiencing adverse effects from psychotropic medications.The facility's Psychotropic Medications - Rehab/Skilled policy, reviewed/revised 12/9/25, identified that each resident's drug regimen must be free from unnecessary medications, including medications used without adequate monitoring or in the presence of adverse consequences that indicate the dose should be reduced or discontinued.

The policy required ongoing monitoring throughout the administration of psychotropic medications, including continued mood and behavior documentation to evaluate the medication's effect on behaviors, monitoring for medication side effects, and monitoring for effectiveness and potential adverse consequences.

The policy further directed nursing staff to document side effects, notify the physician and family/legal representative when side effects occurred or worsened, and complete ongoing assessments to evaluate resident response to psychotropic medications.

The policy also required the reduction committee to review psychotropic medications at least every three months, including evaluation of target symptoms, medication effectiveness, and any medication-related adverse consequences experienced by the resident during the previous quarter.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

bed-hold policies.

involuntary transfer/discharge to a resident and/or resident representative prior to transfer to

include:R100's clinical record identified R100 was transferred from the facility to a sister facility on 8/22/25.Review of R100's electronic health record (EHR) failed to identify documentation that the resident and/or resident representative received written notice of the involuntary transfer/discharge prior to the transfer.

The record failed to identify documentation of a Notice of Involuntary Discharge (NOID), notification of appeal rights, evidence of notification to the resident and/or resident representative, documentation of attempted contact with resident and/or resident representative, or notification to the Ombudsman program regarding the discharge.

During an interview on 6/4/26 at 11:01 a.m., Social Worker (SW)-A stated when residents were discharged , the facility typically issued a Notice of Medicare Non-Coverage (NOMNC), discussed appeal rights, reviewed discharge information with the resident, coordinated communication with outside providers, and arranged transportation if needed. SW-A stated that for facility-initiated discharges, options were reviewed with the resident and discharge planning was discussed. SW-A stated she was aware there had been months of discussions involving the Ombudsman program and regional staff regarding R100 and issues related to unpaid bills. SW-A further stated she knew a great deal of information leading up to the discharge but did not know all of the events surrounding the discharge. SW-A confirmed there was no documentation regarding attempts to contact the resident's daughter or documentation related to discharge planning. SW-A stated the Administrator ultimately took over management of the discharge process.

During an interview on 6/4/26 at 11:26 a.m., the Administrator stated R100 was transferred to the facility's sister facility on 8/22/25 and the resident's long-term care needs continued to be met.

The Administrator stated notice of the discharge had been relayed to the resident; however, she could not provide documentation or evidence supporting that notification.

The Administrator further acknowledged there were missing pieces in the discharge record and confirmed she could not locate documentation of the required discharge notice.

During an interview on 6/4/26 at 11:35 a.m., the Ombudsman stated she had discussed R100's discharge with the facility on 9/18/25 and informed facility staff that the required discharge process had not been followed.

The Ombudsman stated she was unable to find evidence that a Notice of Involuntary Discharge had been issued, evidence that the resident and/or resident representative had been notified, or evidence of attempts to contact the resident representative regarding the discharge.

The Ombudsman further stated there was no documentation supporting these actions and confirmed the Office of Ombudsman for Long-Term Care had not received notification of the discharge.The facility's Discharge and Transfer - Rehab/Skilled, Therapy & Rehab policy, reviewed 1/15/26, required that before a resident was transferred or discharged , the facility notify the resident and resident representative in writing of the transfer/discharge and the reason for the move using the Notification of Transfer or Discharge (GSS #223A) or other state-required form.

The policy further required the facility provide information regarding appeal rights and assistance with obtaining and completing an appeal form. A copy of the transfer/discharge notice was required to be sent to the Office of the State Long-Term Care Ombudsman.

For transfers related to non-payment, the policy required at least 30 days' advance notice before the transfer or discharge occurred.

The policy also required the facility to provide and document sufficient preparation, orientation, and discharge planning to ensure a safe and orderly transfer or discharge.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

Status Assessment (SCSA) following discharge from hospice services, for 1 of 1 resident (R111)

Manual identified enrollment in hospice services and discharge from hospice services as events that may constitute a significant change in status requiring completion of a Significant Change in Status Assessment.Findings include:R111's most recent Minimum Data Set (MDS) assessment identified diagnoses which included chronic obstructive pulmonary disease (COPD; a chronic lung disease that makes breathing difficult) and chronic respiratory failure (a condition in which the lungs are unable to adequately exchange oxygen and carbon dioxide).

The MDS further identified R111 received hospice services.R111's clinical record identified hospice services were discontinued on 5/11/26.Review of R111's electronic health record (EHR) on 6/4/26 identified documentation continued to reflect R111 was receiving hospice services, including on the resident profile and care plan, despite hospice services having ended on 5/11/26.During interview on 6/4/26 at 9:27 a.m., nursing assistant (NA)-E stated R111 was on hospice services and confirmed care plans were primarily updated by the nurse manager.During interview on 6/4/26 at 9:33 a.m., licensed practical nurse (LPN)-B stated R111 had been on hospice services and had graduated from hospice. LPN-B stated the facility had held a care conference regarding the possibility of restarting hospice services; however, R111 did not meet hospice criteria.During interview on 6/4/26 at 12:32 p.m., registered nurse case manager (CM)-C stated R111 was discharged from hospice after a hospitalization on 5/10/26 and was scheduled to be discharged from hospice on 5/11/26. CM-C reviewed the EHR and confirmed it continued to identify R111 as receiving hospice services. CM-C stated the record should have been updated to accurately reflect the resident's current status. CM-C further stated she completed the Significant Change in Status Assessment on 6/3/26 after the surveyor requested information regarding the resident's hospice discharge.During interview on 6/4/26 at 12:59 p.m., Director of Nursing (DON) stated hospice discharges generated notifications to administration staff and required updates to the resident's care plan and clinical record.

The DON stated documentation was typically received from the hospice agency at discharge and confirmed a Significant Change in Status Assessment should have been completed following the hospice discharge.

The DON stated it was important for the record to accurately reflect the resident's current status and care needs in real time.During interview on 6/4/26 at 1:29 p.m., MDS nurse (RN)-E reviewed the resident's assessment history and stated the Significant Change in Status Assessment was completed on 6/3/26.

Review of the facility's MDS assessment history confirmed a Significant Change in Status Assessment was not completed until 6/3/26, approximately three weeks after R111's discharge from hospice services on 5/11/26.

Review of the facility's MDS 3.0 (Minimum Data Set) RAI policy, revised 10/27/25, identified when a significant change in a resident's status was identified, staff were to notify the social worker, RN coordinator, or designated employee so a timeline could be established and communicated to interdisciplinary team members.

The policy further required documentation of the significant change in the PN-MDS, notification of the interdisciplinary team through the MDS/Care Plan Notification process, and completion of the Significant Change MDS in accordance with the Resident Assessment Instrument (RAI) Manual requirements and timelines.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

left for signature.

The note left for family was to provide nursing staff with consent and were then

the care plan to reflect the use of the camera.

On 6/4/26 at 10:55 a.m. registered nurse/clinical manager (CM)-B stated she was not working at the facility when the cameras were put into place.

Both R1 and R122 had involved family members who had requested cameras to be put into use. CM-B stated signage was posted on the door to alert staff and visitors of the use of the camera. CM-B stated she had not completed the care plan process with R1 and R122.

The facility policy, Electronic Monitoring in Resident/Client/Patient Rooms-Enterprise, date reviewed/revised 5/18/26, initially referred to a separate policy: Photography and Video Imaging, Patient, Visitor, Workforce Member-Enterprise.

This policy is broken by states which allows this monitoring.

The document reflects for Minnesota, residents or, under certain circumstances, their authorized resident representative, may conduct electronic monitoring in a resident's room or private living space after certain conditions are met (such as written consent and notification, including that of any roommate).

The procedure identified the electric monitoring device may be used by the resident, or their authorized representative if appropriate, after requirements have been met.

This includes review of information required, and signature of a consent to allow such use.

The procedure directs staff to have signs posted to inform staff/visitors of use.

The policy lacks indication regarding placing the information in the care plan, or subsequent documentation in follow up regarding ongoing use of the video camera.

A review of the policy, Photography and Video Imaging, Patient, Visitor, Workforce Member-Enterprise, date reviewed/revised 5/18/26, was completed and also reviewed the perimeters in which this was allowed, along with consent required for use.

The facility policy, Care Plan-R/S, LTC, Therapy and Rehab, date reviewed/revised 12/1/25, indicated that each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs.

The policy stated further: This plan of care will be modified to reflect the care currently required/provided for the resident.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

practice were followed during administration of crushed medications for 1 of 2 residents (R68)

dated [DATE], identified R68 as exhibiting severe cognitive deficit and was identified as requiring assist with all aspects of activities of daily living (ADLs-dressing, grooming, bathing, and toileting).

R6's medical diagnoses included aphasia (difficulty with speaking), anemia (a low blood count of red blood cells or hemoglobin), hypertension (high blood pressure) and non-Alzheimer's dementia (a condition which may cause alteration in thoughts, cognition, and behavior).R68's admission Profile printed 6/4/26, indicated R68 had diagnoses of generalized muscle weakness.R68's Care Plan revised 2/23/26, indicated R68 had limited physical mobility related to history of a stroke with right side weakness and received antiplatelet therapy. R68's care plan identified an order in place for a texture modified diet.

The care plan lacked indication prior to 6/3/26. R28 was okay to have crushed meds.During a medication observation on 6/3/26 at 7:31 a.m. R68 was given the following medications were crushed together and mixed with applesauce and given orally: Clopidgrel 75 mg one tablet; Senexon S 500 mg/8.6 mg one tablet; and Amlodipine 10 mg one tablet.

Registered nurse (RN)-B stated R68's medications were crushed and mixed together with applesauce for R68. RN-B stated this was able to be completed as it was ordered by the provider.On 6/3/26 at approximately 10:00 a.m., DON stated all medications which required crushing were to have an order in place. DON stated this was important to assure medications were able to be crushed based on timed release status, protective coating, etc. DON stated she was unaware if there were orders in place for R68, however, affirmed medications were not to be crushed without provider orders.R68's progress notes were reviewed and identified on 6/3/26 at 12:46 p.m., an order was received from the provider that it was okay to crush meds due to history of stroke and seizure.A review of R68's cumulative orders lacked indication of authorization to crush medications prior to 6/3/26.The facility policy, Medications: Crushing-AL, R/S, LTC, date reviewed/revised 1/29/26 identified the attending provider must be aware of the need to crush medications so that the appropriate form of the medication can be ordered.

The policy further states best practice would be to separately crush each medication and separately administer each medication with food.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

Review of the EHR identified the facility obtained R91's blood pressure on a weekly basis; however, the record failed to identify blood pressure monitoring was completed to determine whether R91's blood pressure exceeded the ordered parameter of greater than 150 and whether administration of the PRN medication was indicated.

The record further failed to identify documentation the facility evaluated the ongoing need for the medication or whether the ordered blood pressure parameter was ever met.

During an interview on 6/4/26 at 9:41 a.m., licensed practical nurse (LPN)-B reviewed R91's physician orders and stated R91 had an order for PRN metoprolol. LPN-B stated he believed the medication was intended for symptoms that occurred during aggressive episodes.

During an interview on 6/4/26 at 12:32 p.m., registered nurse case manager (CM)-C stated R91's family did not want R91 routinely receiving metoprolol and a decision had been made during a care conference to change the medication to PRN use. CM-C reviewed the physician order and stated the facility should have obtained clarification from the provider regarding blood pressure monitoring parameters. CM-C further stated the order should have included instructions regarding how often blood pressure readings were to be obtained and acknowledged staff should have been monitoring R91's blood pressure to determine whether the medication was indicated.During an interview on 6/4/26 at 12:59 p.m., director of nursing (DON) reviewed the physician order and stated R91's blood pressure should have been monitored and there should have been an order identifying how frequently blood pressure readings were to be obtained. DON stated staff should have followed up with the physician for clarification regarding blood pressure monitoring expectations related to the PRN metoprolol order.A facility policy regarding monitoring and administration of PRN antihypertensive medications, including blood pressure monitoring expectations and physician order clarification requirements, was requested and was not received.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

Based on observation, interview, and document review, the facility failed to assure medication labels

administration.Findings include:On 6/1/26 at 4:10 p.m., medication observation was completed with licensed practical nurse (LPN)-A during R110's medication pass. LPN-A provided R110 with quetiapine fumarate 25 mg 1/2 tablet (1/2 tablet to total 12.5 mg-milligram/a unit of measurement) at that time, however, medication label read to give 1/2 tab(let) daily and went on to direct staff to give one tablet (25 mg) at bedtime. LPN-A stated medication administration record (MAR) directed staff to give at 4:00 p.m. LPN-A stated she was unsure if the previous dosing schedule had changed. LPN-A stated the medication label should match the orders on the MAR. LPN-A stated there were stickers available to place on the prescription label to identify a change in orders but acknowledged there was no label in place.Upon review of the orders, it was noted the orders directed staff to give quetiapine fumarate 25 mg 1/2 tablet (12.5 mg) by mouth one time a day for depression at 4:00 p.m. and 25 mg by mouth one time a day for depression at 8:00 p.m.On 6/4/26 at 1:30 p.m., a review of the medication label and the prescription label was completed with the clinical manager (CM)-A.

The label directed staff to administer 1/2 tablet (12.5 mg) by mouth once daily.

Give one tablet (25 mg) at bedtime. CM-A acknowledged the label lacked indication regarding spacing of doses. CM-A stated there were stickers available to place on label to direct staff to electronic medical record. On 6/3/26 at 7:47 a.m., registered nurse (RN)-B provided R89 with the inhaler, Anoro Elipta, for one puff inhalation.

The inhaler was noted to be in a plastic tray, and lacked any labeling to include resident name, medication date of dispensing, date of expiration, or directions for use.

The inhaler was dated as opened 4/29/26.Additionally, resident was administered the following doses of insulin:Lantus Insulin (Insulin Glargine Subcutaneous Solution 100 mg/ml) 38 units sub q (within the upper level of flesh, but not into the muscle) however the label directed staff to administer 40 units sub q.

Novolog Insulin Aspart Injection 100 unit/ml 11 units, however, the label directed staff to administer nine units of insulin sub q.RN-B stated the insulin labels should have been updated by pharmacy to reflect the current doses ordered, or a sticker should have been placed on the insulin pens to reflect there was a change in orders and to refer to the EMR. RN-B stated the inhaler should remain in the original packaging until supply was depleted.On 6/4/26 at 7:58 a.m., director of nursing (DON) stated all medications should be labeled with the resident's name, name of medication, date dispensed, med dispensed, date of expiration, and directions for use. DON stated the labels on the medication card should match the instructions on the MAR. If there were changes to the orders, there were stickers which would be placed which identify directions were changed and direct staff to refer to EMR.The facility policy, Medications: Administration Including Scheduling and Medication- R/S, LTC, date reviewed/revised 3/30/26, identified with medication pass, the staff were directed to read the label on the medication container and compare with the MAR when removing the container from the supply drawer.

The policy lacked direction as to what to do if there were a discrepancy between the label and the prescription label.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

good about dating items when opened.

Facility Food-Supply Storage–Food and Nutrition Services policy dated 3/13/26 indicated foods that had been opened or prepared were placed in an enclosed container, dated, labeled and stored properly.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

other treatment.

This had the potential to impact all 88 residents who resided at the facility, as well

for the months of March, April, and May of 2026.

The documents included the total number of infections, whether facility or community acquired infections, the facility acquired infection incidence rates, and the number of multidrug resistant organisms (MDROs).

The surveillance logs further classified the types by category of infection.

The data gathered on this log included resident name, room number, infection type, signs and symptoms reported, and status (active or resolved).

The log also included the type of treatment or antibiotic, antifungal or antimicrobial in place.

The log lacked identification of completed testing (labs, chest x-ray, etc.).

Although the logs contained an area for comments, this area was not utilized for reporting any completed lab results.During interview on 6/3/26 at 2:07 p.m., the Infection Preventionist (IP), also director of nursing (DON), stated she currently used the Point Click Care electronic medical record (EMR) for surveillance tracking. IP stated the PCC EMR was able to pull data up and input the information into the Infection Surveillance Report.

The log lacked capability to pull testing and lab results into the form as they were not hyperlinked to the surveillance report. IP stated this information may be entered into the comment section, however, had not implemented this process.

The infection control surveillance log lacked tracking instances of signs and symptoms presented which were not being treated with antibiotics, antifungals, or antimicrobials.IP stated although not tracked on the surveillance log, signs and symptoms of potential illness or infections were reviewed daily Monday through Friday by running reports and reviewing the documentation based on the control f (find) feature of the progress notes.

IP stated when she reviewed the progress notes, she looked for things such as an increase or decrease in temperatures and vital signs, symptoms of cough, shortness of breath, altered respiratory status, nausea, vomiting and diarrhea.

The progress notes were also monitored for new admissions, indwelling devices, history of MDRO's, and new wounds. In addition to symptoms of illness/infection, a review of new orders was also completed.

Upon demonstrating this process for the day of interview, the report generated 99 pages.

Although the information was culled out for the day of review, this data was not recorded or compiled for subsequent review for trending of current trends of symptoms (urinary tract infections, upper respiratory symptoms, or gastrointestinal symptoms) or tracking for patterns of symptoms or trending of illnesses. IP stated she monitored the daily progress notes for symptoms of upper respiratory infections and if symptoms were noted, testing would be performed. IP stated the same process was used for symptoms of vomiting or diarrhea, and testing for c. diff (clostridium difficile). IP stated there were no formalized logs of those who were currently being monitored only and that data was captured only by running daily reports or review of individual progress notes. At the time testing was performed due to persistent symptoms, the individual would then be tracked on the suspected log.IP acknowledged the benefit of monitoring via the surveillance log signs and symptoms of infections and illness to capture any potential trends which would allow the opportunity to implement training, education, and placement of interventions to help decrease the potential for spread of illness and infection.The facility policy, Infection Prevention and Control Program, All Service Lines-Enterprise, reviewed/revised 3/25/26 identified the purpose of the infection control program was to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections.

The policy identified the surveillance system was to be implemented to provide a safe, sanitary, and comfortable environment and prevent the development and transmission of communicable diseases and infections.

245279 06/04/2026

Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

immunizations for 1 of 5 residents (R29) reviewed for immunizations.Findings include:Information on

identified various tables when each (or all) of the pneumococcal vaccinations should be obtained.

This site identified recommendations for those who had never been vaccinated for pneumococcal disease, as well as those who had started the pneumococcal process.

Additionally, the link to Influenza (Flu) site dated 9/18/25, identified everyone six months and older should get a flu vaccine every season with rare exceptions.R29's admission minimum data set (MDS) dated [DATE], included an admission date of 4/29/26, and R29 was identified as being [AGE] years of age. R29's medical diagnoses included coronary artery disease (the narrowing of arteries which decreases blood flow to the heart), hypertension (high blood pressure), and non-Alzheimer's dementia (loss of memory and other intellectual functions, affecting the ability to perform activities of daily living ADL's). R29's electronic medical record (EMR) lacked a review of current immunizations, including those which would have been received prior to admission.

This review would have included the current status on pneumococcal immunizations, as well as influenza vaccinations.Additionally, a review was completed to identify if vaccinations had been declined as evidenced by presence of a vaccine consent marked refused.

The EMR was lacking any consent for vaccination reviewed with R29 or his responsible party.During interview on 6/3/26 at 2:07 p.m., infection preventionist (IP) stated every resident's immunization status was reviewed by the admission nurse within the first 24 hours following admission. IP stated resident's immunization status was then verified via MIIC (Minnesota Immunization Information Connection-a web-based system to allowing tracking of immunizations given) by IP to assure the vaccine had not been previously given.

Once verified, the necessary immunizations were offered.

Upon review of R29's immunization tab in the EMR, IP stated R29's immunization status had not been reviewed, and the record lacked a vaccination history, or offering of vaccinations. IP stated this should have been completed at the time of admission.The facility policy, Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, Covid-19, reviewed/revised 11/8/25 identified the purpose of the immunization program was to promote the health and safety of residents/patients, employees, and visitors through protection against vaccine-preventable diseases.

The policy identified Skilled nursing facilities (SNFs) are federally required to provide education and offer any influenza, COVID-19, or pneumococcal vaccine a resident is eligible to receive.

The process identified resident were to be screened for eligibility and any contraindications to a vaccine following CDC recommendations.

The SNF was then to provide the resident and/or their legal medical decision-maker with a vaccine information sheet to educate on the risks and benefits of a vaccine the resident is eligible to receive, and document education provided in the medical record.

Once the education was provided, staff were then to obtain consent or declination for the vaccine and document in the medical record.

The facility was then to follow up with the provider for orders for vaccination and proceed with vaccination, monitoring, and documentation.

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Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422

and staff after education, and properly document each resident and staff member's vaccination

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

and/or administered in accordance with current standard of practice for 1 of 5 residents (R29) reviewed for immunizations.Findings include:A Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Guidance updated 11/4/25, indicated individuals should receive recommended COVID-19 vaccinations, including booster doses, when eligible, unless medically contraindicated or refused.

Long-term care facilities were responsible for assessing vaccination status and ensuring residents were offered recommended vaccines.R29's admission minimum data set (MDS) dated [DATE], included an admission date of 4/29/26, and R29 was identified as being [AGE] years of age.

R29's medical diagnoses included coronary artery disease (the narrowing of arteries which decreases blood flow to the heart), hypertension (high blood pressure), and non-Alzheimer's dementia (loss of memory and other intellectual functions, affecting the ability to perform activities of daily living ADL's). R29's electronic medical record (EMR) lacked a review of current immunizations, including those which would have been received prior to admission.

This review would have included the current status on Covid-19 vaccinations.Additionally, a review was completed to identify if vaccinations had been declined as evidenced by presence of a vaccine consent marked refused.

The EMR lacked any consent for vaccination reviewed with R29 or his responsible party.During interview on 6/3/26 at 2:07 p.m., infection preventionist (IP) stated every resident's immunization status was reviewed by the admission nurse within the first 24 hours following admission. IP stated resident's immunization status was then verified via MIIC (Minnesota Immunization Information Connection-a web-based system to allowing tracking of immunizations given) by IP to assure the vaccine had not been previously given.

Once verified, the necessary immunizations were offered.

Upon review of R29's immunization tab in the EMR, IP stated R29's immunization status had not been reviewed, and the record lacked a vaccination history, or offering of vaccinations. IP stated this should have been completed at the time of admission.The facility policy, Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, Covid-19, reviewed/revised 11/8/25 identified the purpose of the immunization program was to promote the health and safety of residents/patients, employees, and visitors through protection against vaccine-preventable diseases.

The policy identified Skilled nursing facilities (SNFs) are federally required to provide education and offer any influenza, COVID-19, or pneumococcal vaccine a resident is eligible to receive.

The process identified resident were to be screened for eligibility and any contraindications to a vaccine following CDC recommendations.

The SNF was then to provide the resident and/or their legal medical decision-maker with a vaccine information sheet to educate on the risks and benefits of a vaccine the resident is eligible to receive, and document education provided in the medical record.

Once the education was provided, staff were then to obtain consent or declination for the vaccine and document in the medical record.

The facility was then to follow up with the provider for orders for vaccination and proceed with vaccination, monitoring, and documentation.

245279 06/04/2026

Good Samaritan Society - Specialty Care Community 3815 West Broadway Avenue Robbinsdale, MN 55422